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• Ophthalmic Case Study 19

Case Study 19 - CC: Wandering Eye and Double Vision

Original Author: Rebecca Mastey

HPI: 8 year old female brought in by mother for evaluation of wandering eye and double vision. She was noted to have eye misalignment at age 1 and age 2 but exams were limited at that time. The patient had not followed with ophthalmology since then. Recently, the right eye has been wandering more frequently and has been noticed by teachers and students at school. She also gets double vision when she looks up and has adapted a slight chin up posture.

Past Ocular History: Intermittent exotropia noted at age 1 and 2

Ocular Medications: None

Past Medical History: None

Surgical History: None

Past Family Ocular History: None

Social History: Lives with parents and older sister. Normal growth and development for age.

Medications: Allegra

Allergies: NKDA, seasonal allergies

ROS: Denied headache, denied recent illness Ocular Exam

Visual Acuity (cc): OD: 20/50 +1 OS: 20/50 +3

OD: Dark 8, Light 6, Round, Risk, No APD OS: Dark 8, Light 6, Round, Risk, No APD

Extraocular Movements: OD:  -3 to supraduction, otherwise full OS: Full

Confrontational Visual Fields: OD: Full OS: Full Slit Lamp Exam:

Imaging/additional tests: Sensorimotor exam:

• Stereo: Animals 3/3, Circles 8/9
• Abnormal head position (AHP): 5-10 degree chin up

Diagnosis: Monocular elevation deficiency

Differential Diagnoses: The patient has monocular elevation deficiency (MED) in which there is a deficiency of one eye to elevate in all directions. It is likely congenital although not diagnosed until this visit due to limited exams on prior visits due to age. Other diagnoses on the differential include Brown syndrome, Duane syndrome, acquired elevation deficiency, Superior division of CN3 palsy, and congenital fibrosis of EOM. The patient history, as well as the sensorimotor exam and ductions help better understand the pattern and assist in narrowing the diagnosis to MED as the elevation deficit is the same in both abduction and adduction.

Definition: Moncular elevation deficiency (MED) is defined as a limitation of elevation in one eye with normal movements in all other gazes. The superior limitation must be similar in both abduction and adduction. MED is relatively rare. The incidence of strabismus overall is about 5% and of these patients the incidence of MED is 0.5%. It is most commonly congenital although can be acquired. MED was formerly called “double elevator palsy” referring to the two ipsilateral elevator muscles (inferior oblique and superior rectus), however, this is becoming less widely used and replaced with MED. The pathophysiology is still poorly understood but leading theories include: superior rectus paresis, inferior rectus restriction, and/or unilateral supranuclear abnormality.

Examination: MED often presents with vertical misalignment of the eyes which can cause an abnormal head posture (AHP), binocular diplopia, or amblyopia. Patients often adapt an AHP to offset diplopia that they notice. This adaptation helps the patient use both eyes together and therefore can prevent amblyopia. MED is a clinical diagnosis that is most notable on ductions and sensorimotor exam. There will be a limitation of elevation in the affected eye that is similar in all areas of upgaze. There can be ptosis and amblyopia in the affected eye although this is not required for the diagnosis. CT/MRI can rule out other etiologies since imaging is usually normal in MED.

Treatment: As with any misalignment of the eyes, any underlying refractive error should be corrected with glasses and if there is amblyopia this should be addressed as well. This patient does not have diplopia or significant misalignment in primary gaze and therefore monitoring is sufficient for now. Close monitoring for any change in these symptoms (ie worsening diplopia, worsening alignment in primary, worsening head position, or loss of stereovision) would warrant surgical intervention. Surgically, the goal would be to improve the position of the affected eye in primary gaze and increase the field of binocular vision.

How do you differentiate between MED and Brown Syndrome? b. Brown Syndrome has elevation deficit in adduction and MED has elevation deficit in adduction and abduction Correct answer is B. MED has elevation deficit that is comparable in all fields of upgaze (abduction and adduction) whereas Brown syndrome has an elevation deficit only in adduction. True or False: Patients with MED who adapt a head up posture is a sign of amblyopia This statement is false. Patients who adapt a head up posture are doing so in order to use both eyes together. This is actually a reassuring sign of fusion, preserving stereovision, and avoiding amblyopia. If the affected eye is amblyopic, the patient may not adapt a head up posture as they are not using the eyes together. Which is a suggested cause of MED? d. All the above Correct answer is D. The pathophysiology is still poorly understood and all of the above causes could be the underlying reason for MED in a given patient. If the patient warrants surgical intervention, it is especially important to try and further evaluate which of these three is the cause in order to perform the correct surgerical intervention.

References/Resources:

• Color Atlas of Strabismus Surgery: Strategies and Techniques, Third Edition, Kenneth W Wright
• Gorey, Dhiman, Thacker, et al (2015). Monocular Elevation Deficit-Simplified. Delhi Journal Of Ophthalmology. 26. 7-13. 10.7869/djo.127.
• https://eyewiki.org/Monocular_Elevation_Deficit

Case Studies

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• Open access
• Published: 28 August 2024

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

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

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

Metrics details

Introduction

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

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

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

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

Peer Review reports

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

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

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

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

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

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

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

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

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

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

The research began by posing the following questions:

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

How can these problems be addressed?

What are the solutions and suggestions from the involved stakeholders?

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

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

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

Materials and methods

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

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

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

Sampling and participant selection

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

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

Data collection tools

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

Demographic information

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

Focus group discussion

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

Spielberger anxiety scale questionnaire

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

Acceptance and satisfaction questionnaire

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

Data analysis and rigor of study

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

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

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

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

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

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

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

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

The cyclical process of action research [ 27 ]

Stage 1: Reflection

Identification of the problem.

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

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

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

Stage 2: Planning

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

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

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

Design and implementation of the blended CCE

Stage 3: Act

Cce implementation steps.

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

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

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

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

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

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

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

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

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

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

Step 2: Preparing the necessary infrastructure for conducting the exam

Software infrastructure.

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

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

Checklists and questionnaires

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

Empowerment workshops for professors and education staff

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

Student empowerment programs

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

Step 3: CCE implementation

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

In-person exam

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

Virtual exam

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

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

Step 4: Evaluation

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

Stage 4: Observation / evaluation

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

Process evaluation

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

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

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

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

Outcomes evaluation

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

Design framework and implementation for the blended Clinical Competency Examination

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

Evaluation results

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Data availability

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

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Acknowledgements

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

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

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

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

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

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Abstract: The widespread application of Artificial Intelligence (AI) techniques has significantly influenced the development of new therapeutic agents. These computational methods can be used to design and predict the properties of generated molecules. Multi-target Drug Discovery (MTDD) is an emerging paradigm for discovering drugs against complex disorders that do not respond well to more traditional target-specific treatments, such as central nervous system, immune system, and cardiovascular diseases. Still, there is yet to be an established benchmark suite for assessing the effectiveness of AI tools for designing multi-target compounds. Standardized benchmarks allow for comparing existing techniques and promote rapid research progress. Hence, this work proposes an evaluation framework for molecule generation techniques in MTDD scenarios, considering brain diseases as a case study. Our methodology involves using large language models to select the appropriate molecular targets, gathering and preprocessing the bioassay datasets, training quantitative structure-activity relationship models to predict target modulation, and assessing other essential drug-likeness properties for implementing the benchmarks. Additionally, this work will assess the performance of four deep generative models and evolutionary algorithms over our benchmark suite. In our findings, both evolutionary algorithms and generative models can achieve competitive results across the proposed benchmarks.

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Constructing a Novel Network Structure Weighting Technique into the ANP Decision Support System for Optimal Alternative Evaluation: A Case Study on Crowdfunding Tokenization for Startup Financing

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This study constructed a novel decision-making framework for startup companies to evaluate token financing options. A Network structure weighting (NSW) technique was developed and integrated with the analytic network process (ANP) to create a comprehensive assessment model. This innovative approach addressed the limitations of traditional multi-criteria decision-making methods by effectively capturing the complex interdependencies between factors influencing token financing decisions. The proposed model comprises three main steps: (1) utilizing a modified Delphi method to identify key factors affecting token financing, (2) developing the NSW technique to determine the network structure of these factors, and (3) integrating the NSW results into the ANP model to evaluate and rank the critical factors and alternatives. This study applied this framework to assess three token financing alternatives: Initial Coin Offerings (ICO), Initial Exchange Offerings (IEO), and Security Token Offerings (STO). The results indicate that STO is the optimal financing alternative for the analyzed startup scenario in token financing, followed by Initial Exchange Offerings and Initial Coin Offerings. The model identified platform fees, issuance costs, and financing success rate as the three most critical factors influencing the decision. This study contributes to both methodology and practice in FinTech decision-making. The NSW-ANP framework offers a more robust approach to modeling complex financial decisions, while the application to token financing provides valuable insights for startup companies navigating this emerging funding landscape. The proposed framework lays the groundwork for more informed and structured decision-making in the rapidly evolving field of cryptocurrency-based financing.

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1 Introduction

Due to the rise and development of Financial Technology (FinTech), as well as the enactment of the Jumpstart Our Business Startups (JOBS) in the U.S. [ 1 ], crowdfunding has become the newest financing means for enterprises in need of external funds [ 2 , 3 ]. In 2014, the total amount of funds raised through crowdfunding reached USD 16.2 billion, which was 167% higher than that of 2013 [ 4 ]. In addition, according to the statistical results of Statista Inc. (2020) [ 5 ], the total amount of alternative financing in 2020 was USD 6.1 billion, among which crowdfunding accounted for the largest market share. For this reason, it could be said that the development scale of crowdfunding in the global financial market has been rocketing.

Crowdfunding involves a number of different forms. The first form is donation-based crowdfunding, which mainly means to raise charity funds for the implementation of programs and projects. The second form is rewards-based crowdfunding, in which the investor can receive non-monetary rewards because of capital contributions. The third form is debt-based crowdfunding, in which the relevant interest arrangements between the investor and the fundraiser are determined in line with credit contracts. The fourth form is equity-based crowdfunding, in which the fundraiser uses the equities of the target company to exchange funds from the investor, while the investor receives such equities and therefore is entitled to that company’s revenues or dividends [ 6 , 7 , 8 ]. Estrin et al. [ 9 ] pointed out that equity-based crowdfunding depends mainly on the Internet or social network platforms. This fund-raising method not only reduces the transaction cost but also stands for a new business pattern under which startup companies can establish their own goodwill and provide investors with opportunities for investment. Although crowdfunding has many advantages for startup companies, risks do exist, including uncertainty of equity ownership, lack of liquidity, and damage to stockholder equity [ 10 , 11 , 12 ]. For this reason, past studies suggested that startup companies might obtain funds by offering tokens on the basis of distributed ledger technology and the immutability of blockchains. This not only could reduce the potential risks of traditional fundraising platforms but also could promote the transparency level of the relevant transactions [ 12 , 13 , 14 ]. Howell et al. [ 15 ] indicated that token financing has become one of the important sources for enterprises to raise funds through digital platforms. Presently, the development of crowdfunding tokenization mainly involves three patterns: (1) initial coin offerings (ICO), (2) initial exchange offerings (IEO), and (3) security token offerings (STO). ICO has the advantages of low cost and high speed. However, the risks of theft and fraud exist [ 15 , 16 , 17 ]. The advantages of IEO include having the business reputation of a third-party platform as a guarantee and handling the relevant transactions directly on the transaction platform. However, the possibility of the token price being manipulated cannot be ruled out [ 17 , 18 ]. The last pattern, STO, has the advantages of the highest level of safety and of being protected by the rules and regulations of regional governments. However, the high complexity of examination and verification as well as excessively low liquidity are problems that cannot be avoided [ 17 , 19 ]. The research results of past literature also show that for startup companies, the efficiency of token financing is higher than that of equity financing [ 20 ]. Furthermore, Chod et al. [ 14 ] pointed out that enterprises may take advantage of the decentralization features of token financing to make it more convenient for token investors in their project investments and reduce the cost of encouraging token investors to join the investment platforms. In this way, it is easier for entrepreneurs in raising funds.

For this reason, the utilization of token financing for the purpose of raising operation efficiency has become an important business strategy. The aforesaid three patterns of crowdfunding tokenization have their respective advantages and disadvantages, as well as potential risks. If startup companies intend to raise funds through virtual currencies, the alternatives of financing in cryptocurrency will affect the financing efficiency and lead to the capital turnover issue. Previous studies on token financing focused more on risk-return analysis [ 21 , 22 , 23 , 24 ], token rules and regulations [ 25 , 26 , 27 ], hedging of tokens [ 28 , 29 , 30 , 31 ], and prediction of price in tokens [ 32 , 33 , 34 , 35 ]. However, there is scarce evidence and a lack of applicable measurement tools in regard to assessing the optimal solution for the token financing of startup companies. Hence, algorithms for multiple criteria decision-making can be utilized for the construction of assessment models, so that the optimal solution for assessment can be reached [ 36 , 37 , 38 ]. Past studies also suggested that the optimal solution can be solved using the analytic hierarchy process (AHP) [ 38 , 39 , 40 , 41 , 42 ]. Although AHP can be used to assess the optimal solutions in different fields, it is unsuitable to use traditional AHP methods for decision-making problems in real situations. AHP is characterized by a hierarchical structure and based upon the presumption that the variables or criteria are independent from each other. Numerous problems relating to the assessment of optimal solutions and the relevant variables are correlated to or dependent on each other; as a result, complicated internal relationships cannot be solved through hierarchical or independent methods [ 43 , 44 ]. To solve this problem, Saaty [ 45 ] proposed the analytic network process (ANP), which added a feedback mechanism and interdependency to the AHP method to solve the problems of a lack of correlation and interdependency. ANP does not require the linear relationship of traditional AHP methods, which is top-down, and can establish an assessment pattern of networked relationships. Past literature has applied ANP models in the assessment of different industries, such as traffic problems [ 46 , 47 ], environment and energy assessment [ 48 , 49 , 50 ], filtration and selection of suppliers [ 51 , 52 , 53 ], and assessment of risk factors [ 54 , 55 , 56 ]. Thus, it can be seen that the problem of correlation or interdependency between criteria or variables cannot be solved effectively through AHP during decision-making, while ANP can effectively solve this problem. Although ANP can overcome the difficulties related to the presumption of independence in AHP, the ANP algorithm cannot ascertain the strength of the dependence and relationships between variables needed to generate a network structure. Previous studies addressing the network structure issue have applied deep machine learning concepts, as demonstrated by Moghaddasi et al., Gharehchopogh et al., and subsequent works by Moghaddasi et al. [ 57 , 58 , 59 , 60 , 61 ]. However, these studies primarily focused on the relationship in the Internet of Things, implicitly highlighting the challenges in applying such approaches to multi-criteria decision-making (MCDM) problems. Additionally, several studies employed the Decision-Making Trial and Evaluation Laboratory (DEMATEL) method to resolve network structures among criteria [ 62 , 63 , 64 , 65 , 66 ]. This approach offers an alternative perspective on capturing complex interrelationships within decision-making frameworks. However, the DEMATEL method has several limitations. First, the relationships derived through DEMATEL may be biased or misleading [ 67 , 68 ]. Additionally, the method faces convergence issues, as it cannot determine relationships between criteria when the data fail to converge [ 69 ]. As evident from Table  1 , there are two primary gaps in the existing literature. First, in terms of network structure methodology, while ANP, DEMATEL, and other decision-making frameworks have been proposed, they each have limitations. Second, regarding the research problem, while many studies have examined different aspects of token financing, there is a notable absence of comprehensive, quantitative decision-making frameworks specifically designed for startup companies evaluating token financing alternatives. In view of the above, this study developed a new network structure weighting (NSW) model, and then integrated NSW into ANP to remedy ANP’s shortcoming of being unable to determine the network structure. Finally, case studies were carried out to assess the optimal solution for startup companies engaging in token financing.

For the proposed NSW-ANP model, the modified Delphi method was utilized to determine the clusters and factors influencing startup companies engaging in token financing. Then, the network structure of these clusters and factors was determined based on the NSW method. Finally, the ANP model was utilized to calculate the weights of various factors and financing schemes for startup companies engaging in token financing and then sequence them to determine the optimal token financing schemes and their key factors. While ANP has been applied in various fields, this study proposed the first application of an enhanced ANP approach (integrated with NSW) to evaluate the token financing options for startups. This novel application demonstrates the versatility and effectiveness of our integrated approach in addressing complex FinTech decision-making scenarios.

This study makes significant contributions to the existing literature in both methodological innovations and novel applications. In terms of methodological advancements, we introduce a novel NSW technique that quantifies the strength of relationships between decision factors in a network structure. Furthermore, we develop an integrated NSW-ANP framework that enhances the capabilities of the traditional ANP by incorporating a more robust method for determining network relationships. With regard to novel applications, this study breaks new ground in two key areas. Firstly, we apply this integrated NSW-ANP framework to evaluate token financing options for startup companies, an area that has not been addressed using such a comprehensive decision-making approach. Secondly, this study provides the first systematic evaluation of ICO, IEO, and STO using a multi-criteria decision-making framework. This framework resolves the complex interdependencies between various factors, offering a more nuanced understanding of these emerging financing mechanisms. By combining methodological innovation with practical application in an emerging field, this study not only advances the theoretical understanding of multi-criteria decision-making processes but also provides valuable insights for practitioners in cryptocurrency-based startup financing. Academically, the new NSW-ANP model put forward in this study could be used for determining the network relationship of a research structure, and be integrated into the ANP to remedy the ANP’s shortcomings. The new integrated decision-making pattern put forward in this study also could provide valuable references for the measurement of the interdependency and correlation among variables in the assessment of the optimal solution of token financing for startup companies. Practically, the proposed framework could provide startup companies with a measurement tool containing a network structure and is valuable, so as to determine the optimal solution of token financing for startup companies introducing token financing to their businesses.

The remainder of this paper is organized as follows: Sect.  1 is the introduction, Sect.  2 describes the research method, Sect.  3 presents the case study, and Sect.  4 offers the conclusions.

2 Methodology

In this study, the clusters and factors were acquired through collecting experts’ opinions and literature reviews via modified Delphi method (MDM) as a first step. Next, the network structure of the clusters and factors was determined on the basis of the network structure weighting (NSW) method. Finally, the analytic network process (ANP) model was utilized to calculate and sequence the weightings of the various factors and financing schemes of startup companies engaging in token financing so that the most suitable token financing scheme and the key factors could be determined. The research method is presented in the following sections.

The Delphi method is an anonymous technique of decision-making by a group of experts. To solve a certain problem or find a solution for a particular future event, these experts are treated as the appraisal targets. For the final goal of reaching a stable group consensus among the experts, the group members are anonymous to each other, and particular procedures and repetitive steps are employed. The Delphi method attempts to combine the knowledge, opinions, and speculative abilities of experts in the field in an interruption-free environment. The Delphi method can be used to deduce what will happen in the future, effectively predict future trends, or reach a consensus over a certain issue [ 70 , 71 ]. This method is based upon the judgment of experts, and multiple rounds of opinion feedback are utilized to solve complicated decision-making problems. The traditional Delphi method emphasizes the following five basic principles [ 72 , 73 ]:

The principle of anonymity: All experts voice their opinions as individuals, and they remain anonymous when doing so.

Iteration: The questionnaire issuer gathers up the experts’ opinions and sends them to other experts. This step is carried out repeatedly.

Controlled feedback: In each round, the experts are required to answer pre-designed questionnaires, and the results are served as references for the next appraisal.

Statistical group responses: Comprehensive judgments are made only after the statistics of all the experts’ opinions are conducted.

Expert consensus: The ultimate goal is to reach a consensus after the experts’ opinions are consolidated.

The procedures of the Delphi method are as follows [ 74 ]:

Select the anonymous experts.

Carry out the first round of the questionnaire survey.

Carry out the second round of the questionnaire survey.

Carry out the third round of the questionnaire survey.

Consolidate the experts’ opinions and reach a consensus.

According to the modified Delphi method, Steps C and D are carried out repeatedly until a consensus is reached among the experts, and the number of experts should be between five and nine [ 75 , 76 ].

In this study, the experts’ opinions were gathered through the Delphi method and the relevant literature was discussed, so that the clusters and factors influencing startup companies engaging in token financing could be obtained.

2.2 NSW Model

This study utilized the Delphi method to collect the clusters and factors that could influence startup companies engaging in token financing schemes. In order to effectively carry out the calculation and assessment of ANP, the network structure of these clusters and factors need to be determined as a prerequisite for the subsequent filtration and selection of the optimal token financing scheme. Therefore, this study put forward the NSW method in order to acquire the relationships and the structure chart between clusters and factors. The NSW procedure is as follows:

Step 1: Collect and confirm the decision factors

The collection and confirmation of the decision factors can be realized through common tools such as literature reviews, the Delphi method, focus group interviews, and brainstorming. When decision-makers or experts need to determine n assessment factors that are consistent with the decision-making issues, the n assessment factors may be defined as \(\{ C_{1} ,C_{2} , \ldots ,C_{n} \}\) .

Step 2: Design the questionnaire

As far as the n factors determined by the decision makers or experts in Step 1 are concerned, a nine-point Likert scale can be utilized to ascertain the correlation and correlation strength between the factors. In the event of n factors, n ( n  − 1) comparisons in line with the scale need to be carried out.

Step 3: Calculate the weight of the network structure

Each expert compares and scores the decision factors. After that, all the comparison scores of the experts are used in the matrix construction and weighted calculation. The procedure is as follows:

2.2.1 Establish the Matrix of the Network Correlation and the Correlation Diagram

The correlation matrix is established as M , while \(\{ C_{1} ,C_{2} , \ldots ,C_{n} \}\) are the decision factors. If C i is influenced by C j , \(m_{ij}\) will be the scores of a quantitative judgment given by experts. On the contrary, if \(m_{ij} = 0\) , C i is not influenced by C j . The results can be shown in matrix M ( n  ×  n ) as follows:

The column aggregation and row aggregation of matrix M are:

\({\text{Column}}_{j}\) and \({\text{row}}_{i}\) , respectively, give the scores of factor j , which affects other factors, or factor j , which is influenced by other factors.

2.2.2 Define the Transition Probability Matrix

If transition matrix A is defined by the features of the Markov chain, A  = ( a ij ), as shown in Eq. ( 2 ). A is a regular Markov matrix, and the existence of stationary distribution \(x = \left( {x_{1} ,x_{2} , \ldots ,x_{N} } \right)^{T}\) satisfies Ax  =  x and \(\sum\nolimits_{i} {x_{i} = 1}\) . The characteristic value of 1 can be acquired through the characteristic vector corresponding to the characteristic value of Matrix A , or through the iteration method \(x^{0}\) , where \(x^{k + 1} = Ax^{k}\) , to obtain the characteristic value. x stands for the distribution of probabilities of the various factors being influenced when the transition number approaches infinity, and \(x_{i}\) stands for the network node score of the i th factor.

2.2.3 Calculate the Weightings of the Network Structure

According to the results described in II above, the network node score of each factor is distributed to the correlation diagram of each expert ( n experts have n correlation diagrams). Afterwards, based on the node score of factor i , the strength score of each expert’s factor i influencing other factor j goes through a standardized distribution using the correlation diagram to obtain each expert’s weighted value of the network structure, R, as shown in Eq. ( 3 ). In the end, the \(R(C_{i} ,C_{j} )\) of n experts is averaged and standardized, as shown in Eq. ( 4 ) and Eq. ( 5 ). The standardized results can then be integrated into the ANP model to assess the optimal token financing scheme for startup companies.

Saaty put forward ANP in 1996. This method is rendered through a network structure and derived from an ANP. Practically, there are many questions about decision-making assessment that are not limited to expressing their complex interrelated properties in a hierarchical and independent manner, and they are not of purely linear relationships either. Rather, these questions have a network-like structure [ 45 , 77 , 78 , 79 ]. Based on the original presumption and prerequisite of the analytic hierarchy process (AHP), Saaty [ 45 ] integrated relationship and feedback mechanisms into the AHP model to solve the problem of correlation between different principles.

Saaty pointed out that the relationships of interactive influence between clusters and elements can be analyzed in a graphic manner. Such relationships and interactive influence can be demonstrated through arrow lines [ 45 , 80 ], as shown in Fig.  1 . This network structure is crucial for understanding the fundamental difference between hierarchical and network-based decision-making models. Unlike traditional hierarchical structures, this network allows for complex interdependencies between different elements of the decision-making process. In Fig.  1 , the bidirectional arrows indicate that influence can flow both ways between clusters, reflecting real-world complexities where factors can mutually affect each other.

Source : Ref. [ 45 ]

The network structure.

According to the relationships and strengths of different factors in the aforesaid models and structure charts of ANP, a supermatrix is utilized for demonstration, as shown in Fig.  2 . This matrix is a critical component of the ANP, allowing for the quantification of relationships between all elements in the network. It is formed when the various clusters and respective factors contained in such clusters are listed on the left side and upper part of the matrix in an orderly manner. The supermatrix consists of a number of sub-matrices, which are formulated based on the eigenvectors after the comparison of different factors. In Fig.  2 , \(W_{11} ,W_{kk} , \ldots ,W_{nn}\) are the values of the eigenvectors after the comparisons and calculations.

Source : Refs. [ 45 ] [ 80 ]

The supermatrix of a network.

ANP is an algorithm based on AHP and can be divided into four steps. In Step 1, the structures are formed step by step. In Step 2, the questions are raised. In Step 3, comparisons of interdependent clusters are made in pairs and a supermatrix is formed. In Step 4, the ultimate choice and optimal scheme are selected [ 45 , 79 ].

This study apples the ANP as the foundation of our approach due to several key advantages it offers in the context of complex decision-making scenarios. First, it is well-suited for this application because it allows for the consideration of interdependencies and feedback relationships between decision factors, which is crucial in the dynamic and interconnected world of FinTech and token financing. Furthermore, it provides a structured approach to incorporating both qualitative and quantitative factors into the decision-making process. This is particularly beneficial when evaluating token financing options, as it allows us to consider both qualitative and quantitative data. Finally, it is able to prioritize alternatives based on a comprehensive set of criteria and sub-criteria. This is especially valuable when comparing different alternatives, each of which has its own unique set of characteristics and implications. ANP allows for a more comprehensive comparison than simpler decision-making tools. Among various MCDM techniques, the ANP has a superior capacity to model complex systems with intricate interdependencies. While other MCDM techniques, such as the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) and the VIseKriterijumska Optimizacija I Kompromisno Resenje (VIKOR) method, offer effective means for ranking alternatives, they exhibit limitations in accounting for the multifaceted interrelationships among criteria.

Consequently, this study employs the ANP method as the foundation for constructing an integrated decision-making model. A brief introduction of the construction program of the network process pattern is as follows:

Step 1: Confirm the research problems and network structure

Determine the targets according to features of the problems and search for decision-making clusters, as well as the factors contained in the various clusters by employing the proposed NSW method to acquire the influencing strength of the various factors; finally, draw the network structure models of the decision-making problems according to the results of NSW.

Step 2: Create pair-wise comparison matrices and priority vectors

Compare the factors in pairs. This step has two parts: the comparison of clusters (in pairs) and the comparison of factors within clusters (in pairs). The comparison of factors within clusters (in pairs) can be divided into the comparison within a particular group and comparisons among different clusters. The assessment scale of the comparison is similar to that of AHP. In addition, the eigenvectors, which are reached through the various comparison matrices, serve as the values of the supermatrix, which can be used to illustrate the interdependency and relative significance among the clusters. Equation ( 6 ) can be utilized to calculate the scores of relative significance in regard to the various clusters and factors. As for the strength of the interdependency among the clusters and among the factors, NSW can be utilized to determine the network structure (as described in Sect.  2.2 .)

Step 3: Construct the supermatrix

The supermatrix can effectively solve problems related to the interdependency among the various clusters and factors within the system (as shown in Fig.  2 ). The values of the supermatrix consist of small matrices, which include the comparison of different factors (in pairs) and the comparison of interdependent factors (in pairs). The numerical values of clusters or factors without the influence of feedback are 0, as shown in Eq. ( 7 ). In this study, it was suggested that the overall network structure could be confirmed by NSW. For this reason, the NSW results were integrated into the supermatrix for subsequent assessment and to determine the strength of the interdependency in the supermatrix, as shown in Eq. ( 8 ).

The ANP calculation process includes three matrices: the unweighted supermatrix, the weighted supermatrix, and the limit supermatrix. The unweighted supermatrix stands for the weightings of the original results of the comparison in pairs. In the weighted supermatrix, the weighted values of a particular element within an unweighted matrix are multiplied by the weighted values of the relevant clusters. In the limit supermatrix, the weighted matrix multiplies itself repeatedly until a stable state is attained. According to ANP, if supermatrix W is in an irreducible state of stability, all columns in the supermatrix will have similar vectors, indicating convergence can be attained. The ultimate weighted values of each cluster, factor, and scheme can be calculated through Eq. ( 9 ) during the convergence process.

Step 4: Evaluate the optimal alternative

Through the ANP framework and the calculations of the unweighted supermatrix, weighted supermatrix, and limit supermatrix, all the alternative schemes, as well as the ultimate values of the groups and factors, can be attained in the limit supermatrix. The ultimate results of the weighted values are then ranked to determine the optimal scheme.

3 Case Study

This study aimed to establish the network structure weighting (NSW) model by integrating NSW into the analytic network process (ANP) and establishing an assessment pattern to analyze the optimal scheme of token financing for startup companies, as well as the weighted values of clusters and factors. The consolidation-type diagram of the analytical process is shown in Fig.  3 . This integrated framework is a key innovation, that employs the Modified Delphi Method to identify relevant factors, and applies the NSW technique to determine the network structure. The results are then integrated into the ANP model for final calculations and analysis. This integrated approach addresses the limitations of traditional ANP by providing a more robust and objective method for determining network relationships. It combines the strengths of expert knowledge (through the Delphi method), systematic relationship quantification (via NSW), and comprehensive decision analysis (through ANP), resulting in a more reliable and nuanced decision-making tool for token financing. First, the modified Delphi method was utilized to calculate the clusters and factors influencing startup companies engaging in token financing. Second, the network structure of the clusters and factors was determined on the basis of the NSW method put forward in this study. Finally, the weighted values of the network structure of NSW were integrated into the ANP model to calculate the weighted values for the various factors and various financing schemes of startup companies engaging in token financing. These weighted values were then sequenced to obtain the optimal scheme and key factors of token financing. Figure  4 presents the integrated framework for evaluating token financing options. This model incorporates five main clusters: Finance, Laws and Regulations, Risk, Investor, and Online Community, each containing several specific factors. The model also includes three token financing alternatives: ICO, IEO, and STO. This structure allows for a comprehensive evaluation of token financing alternatives, considering a wide range of relevant factors. By inclusion of diverse clusters including financial considerations, as well as legal, risk-related, investor-focused, and community aspects, the proposed framework allows startup companies to make well-informed decisions based on a thorough analysis of all relevant factors.

The integration processes

The research model

Step 1: Research the problem and confirm the decision factors

Past literature has pointed out that a research framework can be established only after experts reach a consensus on the factors [ 81 , 82 ]. Regarding the assessment of multiple principals, the number of selected experts should be between five and nine [ 76 ]. Therefore, this study included three scholars and four business starters, totaling seven experts. The goal of this study was to construct a consolidation-type pattern for the optimal scheme of token financing. Taking startup companies as examples, through a literature review and utilization of the Delphi method, a total of 17 factors, five clusters, and three token financing schemes were obtained, as shown in Fig.  4 . Relevant materials of each cluster and factors are shown as follows:

The definitions and illustrations of the clusters, factors, and token financing schemes in this study are as follows:

Finance: This includes issuance costs, platform fees, and transaction costs.

Issuance costs (C1) [ 83 , 84 ]: The costs of issuing tokens in different token financing schemes (for instance, Mint), which can vary.

Platform fees (C2) [ 83 ]: The costs for different token financing schemes to be launched on platforms (for instance, the costs for the schemes to be launched in Finance).

Transaction costs (C3) [ 83 ]: The transaction costs of different token financing schemes, which can vary (for instance, service charges).

Laws and regulations: This includes the place of issuance, government policy, token security regulations, and information disclosure transparency.

Place of issuance (C4): The laws, regulations, and rules of different countries and regions, as far as the issuance of tokens is concerned.

Policies (C5): The degree of support from government authorities on token financing.

Token security regulations (C6) [ 84 ]: The relevant policies on token security.

Information disclosure transparency (C7) [ 85 ]: Policies regarding the information disclosure of enterprises that issue tokens.

Risk: This includes financing schedules, token price fluctuations, reputation, shareholding proportion, and financing success rates.

Financing schedule (C8): The length of the financing scheme. For instance, Initial Coin Offerings (ICO) take a relatively long time, while Security Token Offerings (STO) take a relatively short time.

Token price fluctuations (C9) [ 83 ]: The price fluctuations of token transactions are obvious and influence relevant financing efficiency.

Reputation (C10) [ 86 ]: The degree of the token financing scheme’s requirements for the business reputation of the enterprises. For instance, ICO requires relatively less on the business reputation of the enterprises.

Shareholding proportion (C11): The proportion of shares corresponding to the tokens, which are held by the investors.

Financing success rates (C12) [ 87 ]: The success rates of different token financing schemes for enterprises.

The investor aspect: This includes the financing objects and financing thresholds.

Financing objects (C13): The investors being sought out by enterprises engaging in token financing. For instance, ICO and Initial Exchange Offerings (IEO) focus more on private investors, while STO focuses more on professional investors.

Financing thresholds (C14): The thresholds for enterprises to engage in token financing. For instance, the threshold of STO is relatively high.

The online community aspect: This includes the online sharing of voice, online public sentiment, and online trends.

Online sharing of voice (C15) [ 88 ]: The degree of influence of investors’ preferences of network volume in different financing platforms.

Online public sentiment (C16): The degree of influence of investor sentiment in the social network platforms of different financing platforms.

Online trends (C17): The degree of influence of the tendencies on the investors in the overall environment of token financing.

Token financing schemes: These include ICO, IEO, and STO.

ICO: The development, maintenance, and exchange for the purpose of financing, using blockchain technologies and virtual tokens.

IEO: The issuance and sales of tokens through the endorsement of exchanges. It also refers to the rules under which the exchanges are responsible for knowing your customer (KYC) compliance and anti-money laundering (AML).

STO: ICO is supervised by the government. It refers to the practice of linking the assets of enterprises to tokens through securitization, as well as the sales of such assets.

Step 2: Develop the network structure models through NSW

The results acquired in Step 1 were integrated into the NSW models suggested by this study, so as to determine the network structure. The relevant procedures are as follows:

Step 2.1: Design the questionnaire

In regards to the five clusters and 17 factors obtained by the experts in Step 1, a nine-point Likert scale was utilized to determine the strength of correlation between different factors. In the event of n factors, n ( n  − 1) comparisons of the scale were carried out. Because this study referred to seven experts for the development of the network structure model, the data involved were quite complicated. The NSW procedures were illustrated in accordance with the finance clusters, as well as the three factors of issuance costs, platform fees, and transaction costs. The questionnaire design for the finance clusters is shown in Table  2 , in which 0 indicates no influence was observed, while 9 indicates the influence was of the highest level. The strength of correlation among the three factors of finance obtained through the questionnaires of the seven experts is shown in Fig.  5 . Each expert’s assessment is represented in a separate diagram, allowing for a comparison of individual perspectives. The differences in experts’ opinions highlight the subjective nature of these assessments and underscore the importance of aggregating their opinions. The generally strong correlations between factors, particularly between issuance costs and platform fees, suggest that these financial aspects are closely interrelated in token financing decisions. This visualization is crucial for understanding the foundation of our network structure, as it forms the basis for our NSW calculations.

The strength of correlation among the three factors of finance obtained through the questionnaires of the seven experts

Step 2.2: Calculate the weight of the network structure

Each expert compared the factors and scored them in terms of strength. After that, the comparison scores provided by the experts were used in the construction of the matrices and weighted calculations. First, the correlation matrices of the finance clusters, M 1 to M 7 , were established on the basis of Eq. ( 1 ) and the scores of the strength given by the seven experts, as shown below. Second, correlation matrix M was transformed into probability matrices A 1 to A 7 through Eq. ( 2 ), as shown below, and the iteration method was used n times to obtain the characteristic values (eigenvalues) of each questionnaire and factor. Third, this study calculated the weighted values of the correlation among C 1 , C 2 , and C 3 , as well as R ( C i , C j ) 1 to R ( C i , C j ) 7 , through Eq. ( 3 ), as shown in Fig.  6 . This visualization is crucial for understanding how individual expert opinions contribute to the overall network structure. The variation in weights across experts highlights the subjective nature of these assessments and the necessity to aggregate multiple expert opinions. Notably, most experts consistently assign higher weights to the relationships between issuance costs ( C 1 ) and platform fees ( C 2 ), indicating a strong perceived connection between these two factors. In the end, the ultimate weighted values of the network structure (the scores of the correlation degree) were calculated using Eq. ( 4 ) and Eq. ( 5 ). The weighted values of the network structure of the various clusters and factors are shown in Fig.  7 . Figure  7 illustrates the final network structure weights for all five clusters and their respective factors, which is the foundation for our subsequent ANP analysis. These network structure weights provide a comprehensive understanding of the relative importance and interconnectedness of various factors in token financing decisions. They serve as a crucial input for our ANP model, ensuring that the final decision-making process accurately reflects the complex realities of token financing.

The network structure weights of finance cluster’s factors by 7 experts

The network structure weights of five cluster’s factors

Upon completing the calculations, the results of the weighted values for the network structure were integrated into the ANP models to establish the comparison matrices and calculate the eigenvectors.

Step 3: Perform pair-wise comparisons of the matrices and priority vectors

The eigenvectors of the clusters and factors were calculated through the AHP processes and pairwise comparison of features of matrices. The eigenvectors of the degree of correlation between different clusters and factors were calculated through NSW. The cases in this study involved five clusters (finance, laws and regulations, risk, investor, and online community), 17 factors (issuance costs, platform fees, transaction costs, place of issuance, government policy, token security regulations, information disclosure transparency, financing schedules, token price fluctuations, reputation, shareholding proportion, financing success rates, financing objects, financing thresholds, online share of voice, online public sentiment, and online trends), as well as three schemes.

The comparison matrices (in pairs) and the geometric method were utilized to calculate the eigenvectors, while the eigenvectors for the network structure of the correlation strength scores were obtained on the basis of NSW. The eigenvectors obtained for the various comparison matrices, as well as the eigenvectors related to the correlation strength of the factors, served as the values of the supermatrix, which was used to illustrate the correlation strength and the relative importance of different clusters. The clusters might confirm the eigenvectors of the network structure through NSW, and the scores of the relative importance were calculated using Eq. ( 6 ). The results of the eigenvectors for the network structure of the various factors are shown in Step 2.2, and the comparison matrices (in pairs) and the weighted values of the five clusters are shown in Table  3 . Table 4 contains the scores for the relative importance of the various factors against the alternative schemes. In this study, Super Decision V2.0 (software) was utilized for the subsequent assessment of the ANP models. The eigenvectors of the network structure obtained through the NSW were inputted into Super Decision V2.0 to integrate NSW and ANP and assess the optimal scheme and the key factors.

Step 4: Construct the supermatrix

The eigenvectors of the relationships among the factors, as well as the eigenvectors regarding the weights of the factors to the schemes, were determined according to the results of Step 3. In Step 4, a supermatrix is established on the basis of the eigenvectors obtained in Step 3, so that the optimal scheme for startup companies engaging in token financing could be measured. During the ANP process, the ultimate weighted values of the various factors and schemes were calculated through the unweighted supermatrix, the weighted supermatrix, and the limit supermatrix. First, the calculated eigenvectors of the NSW model for the factors and pair-wise comparison matrices were utilized to establish the unweighted supermatrix. Second, the unweighted supermatrix was multiplied by the reciprocals of the weighted values of the relevant clusters to generate the weighted supermatrix. Finally, the results of the weighted supermatrix were multiplied by themselves repeatedly until a stable probability distribution was realized. This probability distribution reflected the ultimate weighted values to be reached. The various supermatrices are shown in Tables 5 , 6 , and 7 .

Step 5: Evaluate the optimal alternative

Through the supermatrix mentioned in Step 4, as well as the operation of Super Decision, the ultimate weighted values of the various factors and schemes under the consolidated NSW network structure could be obtained, as shown in Table  8 .

This study suggested the establishment of a set of network assessment procedures integrating the new NSW technique with the ANP model, in order to analyze the optimal scheme for startup companies engaging in token financing. The findings indicated a number of results. The sequence of the weighted values for the five clusters was as follows: finance (0.307) > risk (0.294) > laws and regulations (0.211) > investors (0.106) > online community (0.082). In addition, the sequence of the weighted values for the factors was as follows: platform fees (0.083) > issuance costs (0.078) > financing success rate (0.053) > government policy (0.0049) = financing schedule (0.049) > transaction costs (0.044) > financing threshold (0.040) > information disclosure transparency (0.039) > token price fluctuations (0.032) = shareholding proportion (0.032) > financing object (0.031) > reputation (0.030) > place of issuance (0.027) > token security regulations (0.026) > online share of voice (0.022) > online public sentiment (0.019) > online trend (0.014). Finally, the sequence of the optimal scheme for startup companies engaging in token financing is as follows: ICO (0.057) > IEO (0.101) > STO (0.175). STO is the optimal scheme for startup companies to engage in token financing.

4 Conclusion and Future Work

4.1 conclusion.

The rapid development of FinTech has become one of the goals of inclusive financing. Fintech, which depends on information technology to find solutions in the financial field, is becoming the mainstream future trend in the financial industry, especially in the development of new business patterns. Startup companies might find it difficult to borrow money from traditional financial institutions due to their business operation features and financial structures. For this reason, alternative financing has gradually become an important channel for startup companies to acquire financing. Token financing is a relatively new business pattern in the field of alternative financing, and it can avoid the shortcomings and problems of crowdfunding.

However, the development history of token financing is diversified and complicated. Previous studies in this field focused more on the analysis of the values of virtual currencies. Generally speaking, when startup companies are faced with the option of token financing, which is a new business pattern, they have relatively little information available for business assessments and decision making. When startup companies assess the optimal scheme for token financing, they often use multi-principle decision-making models, which can solve the problems of filtration and selection in token financing. However, multi-principle decision-making models depend heavily on the presumption that the variables (or criteria) are independent from each other. Therefore, such models might not be suitable for the assessment of decision-making problems in the real world.

ANP can be used to solve the problem of independence assumption in traditional multi-principle decision-making models. Although ANP can overcome the problem of independence assumption, it is still unable to ascertain the strength of the dependence and relationships between variables before producing a network structure. In this study, a new model, NSW, was put forward. This new model could be used to calculate the correlation between variables and generate the network structure. In addition, NSW could be integrated into ANP to generate the network structure. In the end, the assessment of the optimal scheme for startup companies engaging in token financing served as the case study. The results of this study show that finance is the most critical cluster in the assessment aspect. In other words, when startup companies intend to engage in token financing, financial issue is the first aspect to be considered. Token financing is the most up-to-date financing method in the era of FinTech, and capital turnover and financial structure are key issues during the development of startup companies. The sequence of key factors are platform fees, issuance costs, and financing success rate. Moreover, this sequence suggests that when startup companies intend to engage in token financing, the key factors are the aspect of costs and the success rate of financing. Finally, the optimal scheme for startup companies engaging in token financing is STO. After considering financial issues, costs, and relevant risks, startup companies should, based on the cost assessment and the success rate of financing, adopt STO for token financing to promote the financial efficiency of such companies.

This study proposed the NSW technique as a novel tool for validating network structures in decision-making processes and integrated NSW into the ANP model to develop a comprehensive framework for evaluating optimal token financing strategies. The contributions of this study in token-based financing include both methodological advancement and practical application. In terms of methodology, this study integrated the NSW technique with the ANP to enhance the robustness of existing frameworks in capturing complex interrelationships within decision-making processes. This innovative approach addresses limitations in traditional methods by providing a more comprehensive quantification of the strength and directionality of relationships between decision factors. As for practical application, this study presents the first comprehensive evaluation of token financing options for startup companies utilizing this advanced decision-making approach. The integrated NSW-ANP framework can be applied to ICO, IEO, and STO, thus offering valuable options for cryptocurrency-based startup financing. This systematic evaluation considers the intricate interdependencies among various factors influencing the selection of optimal financing strategies. By bridging the gap between theoretical innovation and practical implementation, this study not only advances the field of multi-criteria decision-making but also provides startup entrepreneurs and investors with a sophisticated tool for token-based financing options. Academically, this study provided a new NSW technique, as well as the application procedures to integrate NSW into ANP. This study also presented a case study of the assessment of the optimal scheme for startup companies engaging in token financing. Practically, this new framework could provide entrepreneurs of startup companies with valuable measurement tools for promoting their company’s capital turnover rate through token financing under the rapid development of FinTech.

4.2 Limitation and Future Research

While acknowledging the substantial advantages offered by our integrated framework, it is imperative to recognize its inherent limitations. The following constraints warrant further investigation and potential mitigation in future research:

The potential complexity and mathematical technique of the proposed model, which might make it challenging to implement for organizations.

The static nature of the model, which may not fully capture the decision risks of uncertainty in the cryptocurrency and token financing landscape.

At the current stage of development, the model may not comprehensively capture the effects of factor weight variations on the rankings of alternatives.

After discussing these limitations, we will outline potential directions for future research. This section will propose several avenues for extending and refining our work:

Expanding the application of the NSW-ANP method to other areas of FinTech decision-making beyond token financing.

Integration of fuzzy set theory into the NSW-ANP model to address decision uncertainty risks.

A sensitivity analysis was conducted to ascertain the effects of factor weight variations on the rankings of alternatives.

Data Availability

Not applicable.

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Lin, CY. Constructing a Novel Network Structure Weighting Technique into the ANP Decision Support System for Optimal Alternative Evaluation: A Case Study on Crowdfunding Tokenization for Startup Financing. Int J Comput Intell Syst 17 , 222 (2024). https://doi.org/10.1007/s44196-024-00643-0

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A new porosity evaluation method based on a statistical methodology for granular material: a case study in construction sand.

1. Introduction

2. relationship between the porosity and target particle number, 3. implementation of digital image processing based on particles statistical, 4. verification and evaluation of the method on target particle statistics based on digital images, 4.1. simple case for recognizing circle particles partially obstructed, 4.2. sand, test step, and calibration, 4.3. results analysis and method evaluation, 5. discussion, 6. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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• Case report
• Open access
• Published: 28 August 2024

Metastasis of malignant melanoma to urinary tract: a case report

• Takashi Ueno 1 ,
• Takumi Kiwaki 2 ,
• Hironori Betsunoh 3 ,
• Kaoru Ito 1 ,
• Takaya Murashima 1 ,
• Masato Fujii 1 ,
• Takahiro Nagai 1 ,
• Shoichiro Mukai   ORCID: orcid.org/0000-0002-1678-8619 1 ,
• Atsuro Sawada 1 &
• Toshiyuki Kamoto 1  

Journal of Medical Case Reports volume  18 , Article number:  396 ( 2024 ) Cite this article

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Introduction

Metastasis of malignant melanoma to urinary tract is reported to be rare. According to retrospective analysis of a single center study, improvement of overall survival was observed in patients with metastasis to the gastrointestinal tract that had undergone metastasectomy with curative intent. However, there is no significant evidence regarding resection for metastasis to urinary tract.

Case presentation

Case 1: an 86-year-old Japanese man was diagnosed with a small bladder tumor by computed tomography scan during post operative follow-up of malignant melanoma in the choroid of the left eye. Cystoscopy revealed black, nonpapillary tumors, suggesting metastatic malignant melanoma. Because no apparent invasive growth to muscle layer was observed by magnetic resonance imaging, transurethral resection was performed. Pathological appearance was compatible with metastatic malignant melanoma. No recurrence in urinary tract was observed; however, multiple liver metastasis was diagnosed at 3 months after surgery. Case 2: a 57-year-old Japanese man was diagnosed with right hydronephrosis due to ureteral tumor. He had a past history of subungual malignant melanoma to the left thumb 2 years prior to his visit. Right nephroureterectomy was performed, and pathological evaluation revealed metastatic malignant melanoma. He revisited 2 years later due to dysuria, and a large bladder tumor was revealed by ultrasound. Cystoscopy showed black-colored nonpapillary tumor, suggesting malignant melanoma. Total cystectomy was recommended; however, the patient withheld consent. Therefore, we performed transurethral resection. The resulting pathological finding was compatible with metastatic malignant melanoma without invasion to muscle layer. He remained free from local recurrence and metastasis for 22 years after surgery.

We successfully performed metastasectomy for bladder and ureteral metastases without recurrence in the urinary tract. Long recurrence-free survival was observed in case 2. Complete resection for metastasis of malignant melanoma may have the potential to improve survival.

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Malignant melanoma commonly occurs in the skin and metastasizes to lymph nodes (42–59%), lungs (18–36%), and liver (14–20%) [ 1 ]. Although bladder metastasis of malignant melanoma is reported in 14–22% of autopsy cases [ 2 ], clinically apparent cases reported in the English-language literature accounted for 31 cases, suggesting that metastatic lesions to the urinary tract are difficult to detect while patients are alive because they are less likely to exhibit symptoms [ 3 , 4 , 5 ]. Here, we report two cases of malignant melanoma metastasizing to urinary tract that were successfully treated with surgical intervention.

An 86-year-old Japanese man underwent left-eye enucleation due to malignant melanoma of the choroid 4 years prior to his visit. After surgery, computed tomography (CT) scan was performed every 6 months to screen for metastasis, with the most recent contrast CT scan revealing a small tumor in the bladder with weak enhancement (Fig.  1 A). The patient was then referred to our department, where cystoscopy was performed. The examination showed two black, nonpapillary tumors on the anterior wall of the bladder measuring approximately 5 mm and less than 1 mm, respectively (Fig.  1 B). Cytology of the urine was negative. MRI revealed small tumor showing high intensity on T1WI and low intensity on T2WI at anterior bladder wall without apparent invasive growth into the muscle layer (Fig.  1 C). Since the size of the tumors was small and less likely to invade the muscle layer, we decided to perform transurethral resection of bladder tumor (TUR-Bt). In the surgery, we incised the bladder mucosa from approximately 1 cm away from the tumors. Histological examination revealed proliferation of atypical cells with rounded hyperchromatic nuclei and intracytoplasmic melanin granules with a nodular appearance at the submucosal layer (Fig.  1 D, E). Immunohistochemically, the tumor cells were positive for Melan A and HMB-45 (Fig.  1 F). The appearance was similar to primary melanoma (data not shown) and compatible with metastasis of malignant melanoma. No apparent muscular invasion was observed.

Clinical and pathological appearance of case 1. Sagittal imaging of contrast computed tomography (nephrogenic phase) is shown ( A ). A small tumor with weak enhancement is suggested on the anterior side of the bladder. Cystoscopic appearance shows two nonpapillary black tumors ( B ). The bladder tumor shows high intensity in T1 weighted image (left), low intensity in T2 weighted image (right). No apparent muscle invasion is revealed in T2 weighted image of magnetic resonance imaging examination ( C ). Histological findings are shown ( D – F ). Atypical cells with intracytoplasmic melanin granules proliferate in the submucosal layer ( D , E ). The tumor cells are positive for Melan A (counterstaining with Giemsa, F )

The patient recovered without postoperative events. Three months after TUR-Bt, multiple liver metastases were discovered on CT scan. Since genetic analysis revealed no mutation in BRAF , treatment by immune checkpoint inhibitor was considered. However, the patient chose best supportive care without additional medical treatment. The general condition remained stable without recurrence in urinary tract at 6 months after surgery.

A 57-year-old Japanese man visited a private clinic with the chief complaint of right abdominal discomfort. Ultrasound examination revealed right hydronephrosis. Because CT scan suggested that the hydronephrosis was due to ureteral tumor (Fig.  2 A), the patient was referred to our department. The patient had undergone surgical intervention for subungual malignant melanoma to the left thumb 2 years prior to his visit. Retrograde pyelography showed complete obstruction of upper ureter, and the obstructed portion was matched to the ureteral tumor diagnosed by CT scan. Although urine cytology was negative, CT scan findings were compatible with ureteral carcinoma; therefore, we performed right nephroureterectomy. The resected specimen showed yellow–white and partially black colored pedunculated tumor to the upper ureter, and no satellite tumors were evident in the urinary tract (Fig.  2 B). Pathological findings showed submucosal proliferation of polygonal to spindle-shaped cells with oval to irregular-shaped nuclei and intracytoplasmic melanin granules (Fig.  2 C). The tumor cells were positive for Melan A and HMB-45, prompting a diagnosis of ureteral metastasis of known malignant melanoma. The patient recovered without postoperative event. A month after surgery, full-body radiological examination by CT scan, MRI, and bone scintigraphy was performed. Results revealed no apparent metastasis. Two years later, the patient revisited with a complaint of dysuria. Ultrasound and CT scan showed bladder tumor measuring approximately 4 cm in diameter (Fig.  2 D), and cystoscopy revealed black-colored nonpapillary tumor, suggesting malignant melanoma (Fig.  2 E). Because the tumor was large and invasion could not be ruled out, we recommended total cystectomy; however, the patient withheld consent. Therefore, we performed transurethral resection of bladder tumor (TUR-Bt). Pathological diagnosis of the resected specimens was compatible with malignant melanoma similar to the previously resected ureteral tumor (Fig.  2 F–H). Fortunately, no apparent invasion to muscle layer was observed, and the patient remained free from local recurrence and metastasis for 22 years after TUR-Bt.

Clinical and pathological appearance of case 2. Contrast computed tomography (early phase) reveals solid mass with weak enhancement in the upper ureter ( A , white arrow). Macroscopic appearance (cutting surface) of resected right kidney and the ureter is shown ( B ). Yellow–white and partially black colored pedunculated tumor in the upper ureter (yellow arrow). Contrast computed tomography (excretory phase) shows large bladder tumor ( D ), and cystoscopy reveals black-colored nonpapillary tumor ( E ). Histological appearances of ureteral tumor ( C ) and bladder ( F – H ) show submucosal proliferation of polygonal to spindle-shaped cells with oval nuclei and intracytoplasmic melanin granules. The tumor cells were positive for Melan A

Secondary bladder neoplasms have been reported to represent 2–3% of all malignant bladder tumors; however, the majority of these spread directly from adjacent organs, including colon, prostate, rectum, and cervix [ 6 , 7 ]. In metastatic secondary bladder neoplasm, the most common primary site is stomach (4.3% of all secondary bladder neoplasms), followed by skin (3.9%), lung (2.8%), and breast (2.5%) [ 6 , 7 , 8 ]. The most common histological type of secondary bladder neoplasm has been reported to be adenocarcinoma, with malignant melanoma being less common. However, a higher incidence of bladder metastasis of malignant melanoma was reported in autopsy cases. Sheehan et al . analyzed 5200 autopsy cases and reported 21 cases of metastatic bladder tumors, with 8 of these (38%) being metastatic malignant melanomas [ 9 ]. Bates reported as a possible reason for the frequency of secondary tumors to urinary and male genital tracts being higher in autopsy cases that autopsy cases were more likely to have disseminated disease [ 10 ]. In addition, sampling bias toward unusual lesions and convenience of observation by autopsy for outer layer of hollow organ were discussed with the conclusion that it is simpler to diagnose secondary neoplasia at autopsy than on the basis of biopsy.

Metastatic malignant melanoma of the bladder is typically reported to present as asymptomatic macroscopic hematuria and diagnosed by cystoscopy and histopathological features considered with clinical history of previous melanoma. Diagnostic criteria to determine whether malignant melanoma of the bladder is a primary tumor include (1) absence of any previous skin lesions, (2) absence of cutaneous malignant melanoma, (3) absence of primary visceral malignant melanoma, (4) absence of recurrence pattern showing consistency with the primary tumor diagnosis, and (5) atypical melanocytes at the tumor margin upon microscopic examination [ 9 ]. In our two cases, each patient had an apparent past history of primary melanoma, and the bladder tumor was pathologically compatible with primary tumor. Therefore, we diagnosed metastatic malignant melanoma of the bladder in both cases.

Ureteral metastasis of malignant melanoma is extremely rare. To the best to our knowledge, this is the ninth case report [ 11 , 12 , 13 , 14 ]. In addition, malignant melanoma occurred in the bladder metachronously. Because the tumor was located in the submucosal region (not the superficial region), metastasis was considered rather than intraluminal seeding from ureteral melanoma. Although all tumors were located in the submucosal area, no apparent muscle invasion was observed. Therefore, the tumors were completely resected without local recurrence.

When distant multiple metastases are discovered in patients with malignant melanoma, surgical intervention may be less indicated. However, complete resection may have the potential to improve overall survival (OS) in some cases. Deutsch et al . reported the patients with abdominal visceral metastases undergoing surgical resection had superior overall survival compared with patients treated with medical agents only, including new agents (18 months versus 7 months; P  < 0.001) [ 15 ]. The study included 366 cases with metastasis in the gastrointestinal tract, 697 cases in the liver, 138 cases in the adrenal glands, 38 cases in the pancreas, 109 cases in the spleen, and 305 cases with multiple sites. Patients with metastasis to the gastrointestinal tract undergoing complete curative resection had the greatest benefit from metastasectomy (median OS of 64 months). However, no apparent benefit for OS was observed in patients receiving palliative surgery. The study included a large number of cases and yielded significant results; however, a limitation is that it was a retrospective analysis. Further prospective study is recommended to clarify the significance of metastasectomy.

Although there was no metastasis in another organs at surgery (complete metastasectomy was performed in this period), liver metastasis appeared at 3 months after TUR-Bt in case 1. On the other hand, long-term disease control (22 years) was observed in case 2 by complete resection. According to literature, complete curative metastasectomy may have benefit for patient survival, especially in metastasis to gastrointestinal tract; however, there was no evidence of metastasectomy in patients with metastasis to urinary tract. Therefore, accumulation and analysis of the cases with urinary tract metastasis will be necessary to clarify the benefit of metastasectomy.

On contrast CT scan, metastatic melanoma usually manifested as hyper vascular mass [ 16 ]. MRI showed high intensity on T1WI and low intensity mass on T2WI [ 17 ]. In our cases, weak enhancement was observed by contrast CT scan in both cases. In addition, MRI appearance of the bladder tumor on MRI was consistent with that of conventional malignant melanoma in case 1. Although no reports described the specific appearance of metastasis to genitourinary systems, appearance in the current cases was similar to that of metastasis to other organs. MRI may be useful in developing a differential diagnosis for bladder metastasis because common urothelial carcinoma revealed iso-intensity on T1WI and iso- to slightly high-intensity compared with the muscle layer on T2WI [ 17 , 18 ].

As follow-up, imaging examination at every 3–12 months for 2 years, then every 6–12 months for another 3 years was recommended for patients with stage IV NED with cutaneous melanoma [ 19 ]. Screening for metastasis was performed by CT scan at every 6 months in case 1, and bladder metastasis manifested as small tumors. Postoperative (after nephroureterectomy) follow-up was insufficient in case 2, and larger bladder melanoma was found, suggesting the significance of sufficient follow-up by routine imaging examination.

Metastatic malignant melanoma to the urinary tract has been reported as a rare secondary tumor. We successfully performed metastasectomy for bladder and ureteral metastases without local recurrence. In addition, long recurrence-free survival was observed in case 2. Complete resection for metastasis of malignant melanoma may have significant potential to improve survival.

Availability of data and materials

The supporting data and materials for this report are available on request from the corresponding author.

Abbreviations

Computed tomography

Magnetic resonance imaging

Transurethral resection of bladder tumor

No evidence of disease

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Acknowledgements

The authors thank Ms. Miyuki Akino of the Department of Urology, Faculty of Medicine, University of Miyazaki, for her assistance with ethical protocols.

We did not receive financial support for this study.

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Department of Urology, Faculty of Medicine, Miyazaki University, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan

Takashi Ueno, Kaoru Ito, Takaya Murashima, Masato Fujii, Takahiro Nagai, Shoichiro Mukai, Atsuro Sawada & Toshiyuki Kamoto

Department of Pathology, Faculty of Medicine, Miyazaki University, Miyazaki, Japan

Takumi Kiwaki

Department of Urology, Dokkyo Medical University, Tochigi, Japan

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TU drafted the manuscript, performed the examination, observation, and approved the final version of the manuscript. HB, KI, TM, MF, and TN performed examinations, surgery, and cared for the patient and approved the final version of the manuscript. TK (Takumi Kiwaki) diagnosed and reviewed the pathological specimens and approved the final version of the manuscript. SM, AS, and TK (Toshiyuki Kamoto) drafted the report and contributed the final version of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Shoichiro Mukai .

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Ueno, T., Kiwaki, T., Betsunoh, H. et al. Metastasis of malignant melanoma to urinary tract: a case report. J Med Case Reports 18 , 396 (2024). https://doi.org/10.1186/s13256-024-04716-8

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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• Case Study Evaluation Approach
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A case study evaluation approach can be an incredibly powerful tool for monitoring and evaluating complex programs and policies. By identifying common themes and patterns, this approach allows us to better understand the successes and challenges faced by the program. In this article, we’ll explore the benefits of using a case study evaluation approach in the monitoring and evaluation of projects, programs, and public policies.

Table of Contents

Introduction to Case Study Evaluation Approach

The advantages of a case study evaluation approach, types of case studies, potential challenges with a case study evaluation approach, guiding principles for successful implementation of a case study evaluation approach.

• Benefits of Incorporating the Case Study Evaluation Approach in the Monitoring and Evaluation of Projects and Programs

A case study evaluation approach is a great way to gain an in-depth understanding of a particular issue or situation. This type of approach allows the researcher to observe, analyze, and assess the effects of a particular situation on individuals or groups.

An individual, a location, or a project may serve as the focal point of a case study’s attention. Quantitative and qualitative data are frequently used in conjunction with one another.

It also allows the researcher to gain insights into how people react to external influences. By using a case study evaluation approach, researchers can gain insights into how certain factors such as policy change or a new technology have impacted individuals and communities. The data gathered through this approach can be used to formulate effective strategies for responding to changes and challenges. Ultimately, this monitoring and evaluation approach helps organizations make better decision about the implementation of their plans.

This approach can be used to assess the effectiveness of a policy, program, or initiative by considering specific elements such as implementation processes, outcomes, and impact. A case study evaluation approach can provide an in-depth understanding of the effectiveness of a program by closely examining the processes involved in its implementation. This includes understanding the context, stakeholders, and resources to gain insight into how well a program is functioning or has been executed. By evaluating these elements, it can help to identify areas for improvement and suggest potential solutions. The findings from this approach can then be used to inform decisions about policies, programs, and initiatives for improved outcomes.

It is also useful for determining if other policies, programs, or initiatives could be applied to similar situations in order to achieve similar results or improved outcomes. All in all, the case study monitoring evaluation approach is an effective method for determining the effectiveness of specific policies, programs, or initiatives. By researching and analyzing the successes of previous cases, this approach can be used to identify similar approaches that could be applied to similar situations in order to achieve similar results or improved outcomes.

A case study evaluation approach offers the advantage of providing in-depth insight into a particular program or policy. This can be accomplished by analyzing data and observations collected from a range of stakeholders such as program participants, service providers, and community members. The monitoring and evaluation approach is used to assess the impact of programs and inform the decision-making process to ensure successful implementation. The case study monitoring and evaluation approach can help identify any underlying issues that need to be addressed in order to improve program effectiveness. It also provides a reality check on how successful programs are actually working, allowing organizations to make adjustments as needed. Overall, a case study monitoring and evaluation approach helps to ensure that policies and programs are achieving their objectives while providing valuable insight into how they are performing overall.

By taking a qualitative approach to data collection and analysis, case study evaluations are able to capture nuances in the context of a particular program or policy that can be overlooked when relying solely on quantitative methods. Using this approach, insights can be gleaned from looking at the individual experiences and perspectives of actors involved, providing a more detailed understanding of the impact of the program or policy than is possible with other evaluation methodologies. As such, case study monitoring evaluation is an invaluable tool in assessing the effectiveness of a particular initiative, enabling more informed decision-making as well as more effective implementation of programs and policies.

Furthermore, this approach is an effective way to uncover experiential information that can help to inform the ongoing improvement of policy and programming over time All in all, the case study monitoring evaluation approach offers an effective way to uncover experiential information necessary to inform the ongoing improvement of policy and programming. By analyzing the data gathered from this systematic approach, stakeholders can gain deeper insight into how best to make meaningful and long-term changes in their respective organizations.

Case studies come in a variety of forms, each of which can be put to a unique set of evaluation tasks. Evaluators have come to a consensus on describing six distinct sorts of case studies, which are as follows: illustrative, exploratory, critical instance, program implementation, program effects, and cumulative.

Illustrative Case Study

An illustrative case study is a type of case study that is used to provide a detailed and descriptive account of a particular event, situation, or phenomenon. It is often used in research to provide a clear understanding of a complex issue, and to illustrate the practical application of theories or concepts.

An illustrative case study typically uses qualitative data, such as interviews, surveys, or observations, to provide a detailed account of the unit being studied. The case study may also include quantitative data, such as statistics or numerical measurements, to provide additional context or to support the qualitative data.

The goal of an illustrative case study is to provide a rich and detailed description of the unit being studied, and to use this information to illustrate broader themes or concepts. For example, an illustrative case study of a successful community development project may be used to illustrate the importance of community engagement and collaboration in achieving development goals.

One of the strengths of an illustrative case study is its ability to provide a detailed and nuanced understanding of a particular issue or phenomenon. By focusing on a single case, the researcher is able to provide a detailed and in-depth analysis that may not be possible through other research methods.

However, one limitation of an illustrative case study is that the findings may not be generalizable to other contexts or populations. Because the case study focuses on a single unit, it may not be representative of other similar units or situations.

A well-executed case study can shed light on wider research topics or concepts through its thorough and descriptive analysis of a specific event or phenomenon.

Exploratory Case Study

An exploratory case study is a type of case study that is used to investigate a new or previously unexplored phenomenon or issue. It is often used in research when the topic is relatively unknown or when there is little existing literature on the topic.

Exploratory case studies are typically qualitative in nature and use a variety of methods to collect data, such as interviews, observations, and document analysis. The focus of the study is to gather as much information as possible about the phenomenon being studied and to identify new and emerging themes or patterns.

The goal of an exploratory case study is to provide a foundation for further research and to generate hypotheses about the phenomenon being studied. By exploring the topic in-depth, the researcher can identify new areas of research and generate new questions to guide future research.

One of the strengths of an exploratory case study is its ability to provide a rich and detailed understanding of a new or emerging phenomenon. By using a variety of data collection methods, the researcher can gather a broad range of data and perspectives to gain a more comprehensive understanding of the phenomenon being studied.

However, one limitation of an exploratory case study is that the findings may not be generalizable to other contexts or populations. Because the study is focused on a new or previously unexplored phenomenon, the findings may not be applicable to other situations or populations.

Exploratory case studies are an effective research strategy for learning about novel occurrences, developing research hypotheses, and gaining a deep familiarity with a topic of study.

Critical Instance Case Study

A critical instance case study is a type of case study that focuses on a specific event or situation that is critical to understanding a broader issue or phenomenon. The goal of a critical instance case study is to analyze the event in depth and to draw conclusions about the broader issue or phenomenon based on the analysis.

A critical instance case study typically uses qualitative data, such as interviews, observations, or document analysis, to provide a detailed and nuanced understanding of the event being studied. The data are analyzed using various methods, such as content analysis or thematic analysis, to identify patterns and themes that emerge from the data.

The critical instance case study is often used in research when a particular event or situation is critical to understanding a broader issue or phenomenon. For example, a critical instance case study of a successful disaster response effort may be used to identify key factors that contributed to the success of the response, and to draw conclusions about effective disaster response strategies more broadly.

One of the strengths of a critical instance case study is its ability to provide a detailed and in-depth analysis of a particular event or situation. By focusing on a critical instance, the researcher is able to provide a rich and nuanced understanding of the event, and to draw conclusions about broader issues or phenomena based on the analysis.

However, one limitation of a critical instance case study is that the findings may not be generalizable to other contexts or populations. Because the case study focuses on a specific event or situation, the findings may not be applicable to other similar events or situations.

A critical instance case study is a valuable research method that can provide a detailed and nuanced understanding of a particular event or situation and can be used to draw conclusions about broader issues or phenomena based on the analysis.

Program Implementation Program Implementation

A program implementation case study is a type of case study that focuses on the implementation of a particular program or intervention. The goal of the case study is to provide a detailed and comprehensive account of the program implementation process, and to identify factors that contributed to the success or failure of the program.

Program implementation case studies typically use qualitative data, such as interviews, observations, and document analysis, to provide a detailed and nuanced understanding of the program implementation process. The data are analyzed using various methods, such as content analysis or thematic analysis, to identify patterns and themes that emerge from the data.

The program implementation case study is often used in research to evaluate the effectiveness of a particular program or intervention, and to identify strategies for improving program implementation in the future. For example, a program implementation case study of a school-based health program may be used to identify key factors that contributed to the success or failure of the program, and to make recommendations for improving program implementation in similar settings.

One of the strengths of a program implementation case study is its ability to provide a detailed and comprehensive account of the program implementation process. By using qualitative data, the researcher is able to capture the complexity and nuance of the implementation process, and to identify factors that may not be captured by quantitative data alone.

However, one limitation of a program implementation case study is that the findings may not be generalizable to other contexts or populations. Because the case study focuses on a specific program or intervention, the findings may not be applicable to other programs or interventions in different settings.

An effective research tool, a case study of program implementation may illuminate the intricacies of the implementation process and point the way towards future enhancements.

Program Effects Case Study

A program effects case study is a research method that evaluates the effectiveness of a particular program or intervention by examining its outcomes or effects. The purpose of this type of case study is to provide a detailed and comprehensive account of the program’s impact on its intended participants or target population.

A program effects case study typically employs both quantitative and qualitative data collection methods, such as surveys, interviews, and observations, to evaluate the program’s impact on the target population. The data is then analyzed using statistical and thematic analysis to identify patterns and themes that emerge from the data.

The program effects case study is often used to evaluate the success of a program and identify areas for improvement. For example, a program effects case study of a community-based HIV prevention program may evaluate the program’s effectiveness in reducing HIV transmission rates among high-risk populations and identify factors that contributed to the program’s success.

One of the strengths of a program effects case study is its ability to provide a detailed and nuanced understanding of a program’s impact on its intended participants or target population. By using both quantitative and qualitative data, the researcher can capture both the objective and subjective outcomes of the program and identify factors that may have contributed to the outcomes.

However, a limitation of the program effects case study is that it may not be generalizable to other populations or contexts. Since the case study focuses on a particular program and population, the findings may not be applicable to other programs or populations in different settings.

A program effects case study is a good way to do research because it can give a detailed look at how a program affects the people it is meant for. This kind of case study can be used to figure out what needs to be changed and how to make programs that work better.

Cumulative Case Study

A cumulative case study is a type of case study that involves the collection and analysis of multiple cases to draw broader conclusions. Unlike a single-case study, which focuses on one specific case, a cumulative case study combines multiple cases to provide a more comprehensive understanding of a phenomenon.

The purpose of a cumulative case study is to build up a body of evidence through the examination of multiple cases. The cases are typically selected to represent a range of variations or perspectives on the phenomenon of interest. Data is collected from each case using a range of methods, such as interviews, surveys, and observations.

The data is then analyzed across cases to identify common themes, patterns, and trends. The analysis may involve both qualitative and quantitative methods, such as thematic analysis and statistical analysis.

The cumulative case study is often used in research to develop and test theories about a phenomenon. For example, a cumulative case study of successful community-based health programs may be used to identify common factors that contribute to program success, and to develop a theory about effective community-based health program design.

One of the strengths of the cumulative case study is its ability to draw on a range of cases to build a more comprehensive understanding of a phenomenon. By examining multiple cases, the researcher can identify patterns and trends that may not be evident in a single case study. This allows for a more nuanced understanding of the phenomenon and helps to develop more robust theories.

However, one limitation of the cumulative case study is that it can be time-consuming and resource-intensive to collect and analyze data from multiple cases. Additionally, the selection of cases may introduce bias if the cases are not representative of the population of interest.

In summary, a cumulative case study is a valuable research method that can provide a more comprehensive understanding of a phenomenon by examining multiple cases. This type of case study is particularly useful for developing and testing theories and identifying common themes and patterns across cases.

When conducting a case study evaluation approach, one of the main challenges is the need to establish a contextually relevant research design that accounts for the unique factors of the case being studied. This requires close monitoring of the case, its environment, and relevant stakeholders. In addition, the researcher must build a framework for the collection and analysis of data that is able to draw meaningful conclusions and provide valid insights into the dynamics of the case. Ultimately, an effective case study monitoring evaluation approach will allow researchers to form an accurate understanding of their research subject.

Additionally, depending on the size and scope of the case, there may be concerns regarding the availability of resources and personnel that could be allocated to data collection and analysis. To address these issues, a case study monitoring evaluation approach can be adopted, which would involve a mix of different methods such as interviews, surveys, focus groups and document reviews. Such an approach could provide valuable insights into the effectiveness and implementation of the case in question. Additionally, this type of evaluation can be tailored to the specific needs of the case study to ensure that all relevant data is collected and respected.

When dealing with a highly sensitive or confidential subject matter within a case study, researchers must take extra measures to prevent bias during data collection as well as protect participant anonymity while also collecting valid data in order to ensure reliable results

Moreover, when conducting a case study evaluation it is important to consider the potential implications of the data gathered. By taking extra measures to prevent bias and protect participant anonymity, researchers can ensure reliable results while also collecting valid data. Maintaining confidentiality and deploying ethical research practices are essential when conducting a case study to ensure an unbiased and accurate monitoring evaluation.

When planning and implementing a case study evaluation approach, it is important to ensure the guiding principles of research quality, data collection, and analysis are met. To ensure these principles are upheld, it is essential to develop a comprehensive monitoring and evaluation plan. This plan should clearly outline the steps to be taken during the data collection and analysis process. Furthermore, the plan should provide detailed descriptions of the project objectives, target population, key indicators, and timeline. It is also important to include metrics or benchmarks to monitor progress and identify any potential areas for improvement. By implementing such an approach, it will be possible to ensure that the case study evaluation approach yields valid and reliable results.

To ensure successful implementation, it is essential to establish a reliable data collection process that includes detailed information such as the scope of the study, the participants involved, and the methods used to collect data. Additionally, it is important to have a clear understanding of what will be examined through the evaluation process and how the results will be used. All in all, it is essential to establish a sound monitoring evaluation approach for a successful case study implementation. This includes creating a reliable data collection process that encompasses the scope of the study, the participants involved, and the methods used to collect data. It is also imperative to have an understanding of what will be examined and how the results will be utilized. Ultimately, effective planning is key to ensure that the evaluation process yields meaningful insights.

Benefits of Incorporating the Case Study Evaluation Approach in the Monitoring and Evaluation of Projects and Programmes

Using a case study approach in monitoring and evaluation allows for a more detailed and in-depth exploration of the project’s success, helping to identify key areas of improvement and successes that may have been overlooked through traditional evaluation. Through this case study method, specific data can be collected and analyzed to identify trends and different perspectives that can support the evaluation process. This data can allow stakeholders to gain a better understanding of the project’s successes and failures, helping them make informed decisions on how to strengthen current activities or shape future initiatives. From a monitoring and evaluation standpoint, this approach can provide an increased level of accuracy in terms of accurately assessing the effectiveness of the project.

This can provide valuable insights into what works—and what doesn’t—when it comes to implementing projects and programs, aiding decision-makers in making future plans that better meet their objectives However, monitoring and evaluation is just one approach to assessing the success of a case study. It does provide a useful insight into what initiatives may be successful, but it is important to note that there are other effective research methods, such as surveys and interviews, that can also help to further evaluate the success of a project or program.

In conclusion, a case study evaluation approach can be incredibly useful in monitoring and evaluating complex programs and policies. By exploring key themes, patterns and relationships, organizations can gain a detailed understanding of the successes, challenges and limitations of their program or policy. This understanding can then be used to inform decision-making and improve outcomes for those involved. With its ability to provide an in-depth understanding of a program or policy, the case study evaluation approach has become an invaluable tool for monitoring and evaluation professionals.

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15.7 Evaluation: Presentation and Analysis of Case Study

Learning outcomes.

By the end of this section, you will be able to:

• Revise writing to follow the genre conventions of case studies.
• Evaluate the effectiveness and quality of a case study report.

Case studies follow a structure of background and context , methods , findings , and analysis . Body paragraphs should have main points and concrete details. In addition, case studies are written in formal language with precise wording and with a specific purpose and audience (generally other professionals in the field) in mind. Case studies also adhere to the conventions of the discipline’s formatting guide ( APA Documentation and Format in this study). Compare your case study with the following rubric as a final check.

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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Case Study Research Method in Psychology

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On This Page:

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

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 that are currently occurring in his or her everyday life.

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

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.

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.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is 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.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. 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.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

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

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

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 Anna O , 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.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

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.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

What is Case Evaluation?

When two parties have gotten wrapped up in a dispute and one party would like to resolve the situation without litigation, but the other is resistant, it may be beneficial to try using case evaluation. Case evaluation will often reevaluate the stubborn party’s position and help wrap up the case in a way that can make both parties happy.

Understanding the case evaluation can help determine whether a case is a good candidate for the process. While it is not a guarantee, it is an alternative dispute resolution process. It can resolve the dispute outside of a trial and help the parties move forward. Suppose one is trapped in a dispute or litigation that is not moving forward. In that case, case evaluation may be an excellent way to push the case toward settlement rather than unnecessary litigation.

Defining Case Evaluation :

Case evaluation is an intervention process for cases either before they are filed or shortly after. The process may be completed based on an agreement of the parties or by the order of a judge. In a case evaluation, a neutral party not involved in the case looks over the case shortly after it is filed and evaluates it for each party’s strengths, weaknesses, and the possibility of success.

The neutral is usually an attorney that understands the subject matter and can make an unbiased evaluation of the case for the parties, balancing their interests and the court’s interests to settle and clear up backlogged cases. Depending on the state and parties’ wishes, the evaluation may happen either by written submissions or by oral presentation to the neutral.

After reviewing the case, the neutral will evaluate each side’s strengths while also highlighting and discussing the weaknesses the case has. This presentation aims to help the parties decide the likelihood of success should they continue.

Common characteristics of the case evaluation include:

• Confidential :   The evaluation of the case between the neutral and the parties will usually be confidential. The neutral will not share the discussions that take place within the evaluation with the judge or anyone else apart from the parties. However, if necessary, the parties should discuss this between themselves and the neutral.  
• Neutrality:  The process will be neutral. The evaluator will approach the parties’ dispute without bias. Neither party should have sway over the neutral, and they should not take sides but merely present the strengths and weaknesses of each case with their prediction for the outcome of the case. This helps to ensure that the parties’ positions are treated and considered fairly.
• Opinion:  The neutral will present an opinion to the parties. This will happen after the parties have presented their evidence and the neutral has had a chance to review everything. This opinion can help guide the parties in their decisions moving forward. 
• Discussion:  The parties and the neutral will usually meet to discuss the case or the opinion presented by the neutral. This discussion will usually include the neutral sharing their thoughts on the merits of the case, and the parties consider the case as well as potential settlement agreements .  
• Non-Binding:  The evaluator cannot decide the case or force the parties to agree or follow the evaluator’s decision. The process exists only to provide the parties with a chance to hear about the potential outcome of their case, reevaluate their positions, or discuss a settlement. The opinion created by the evaluator is not binding . It cannot influence the case’s outcome, which is why it should not be shared with anyone involved.  
• Collaborative: Once the neutral provides their evaluation of the case, the parties can collaborate and decide whether a settlement may be acceptable. The parties may be more willing to work together after they have a better grasp on their case. This is not always the case after a neutral present their opinion. Still, it can be a good starting point for further discussions.  

This is a brief overview of the more formal process that many courts have implemented to help clear backlogged calendars. In addition, there are a variety of ways that parties may choose to participate in case evaluation. 

It is becoming more popular for a single party to meet with an evaluator and present their case and examine the strengths and weaknesses of their case, along with the other party’s defenses. While this is not as thorough of a process, it can help a party determine if the litigation is worth the risk. 

The Role of the Neutral:

To understand the process, even more, it can be helpful to examine the role of the neutral. Within a case evaluation , the neutral, or panel of neutrals, will take all of the evidence and arguments presented and determine the strengths and weaknesses of each party’s position while predicting the outcome of a trial on the case.

The neutral is not there to help the parties decide about a settlement or encourage them to do so. Instead, the neutral is there merely to evaluate the case and show the parties the path the case may take moving forward.

Reasons to Use Case Evaluation:

The reasons that the parties may choose case evaluation will differ with each case. Still, some common themes run throughout the cases that end up in front of an evaluator. If any of these reasons ring true for a case, the parties may benefit from the neutral evaluation and the insight it brings. Some common reasons to send a case to evaluation include:  

• They think the case could settle. Courts and the legal system are often incredibly overwhelmed by the number of cases that need to be tried at any given time. This is why many judges will encourage settlement. Suppose a case is filed and a judge sees the potential for settlement early. In that case, they may recommend to neutral evaluation to encourage the parties to move towards a settlement. Additionally, the parties may see the benefit in having an evolution for settlement purposes.  
• The parties need an unbiased and accurate opinion of the case.  Parties to a legal dispute often see their case in a very optimistic way. This is normal and often necessary for parties to recover what they are entitled to. However, optimism can occasionally drive the parties to have unrealistic expectations for the case, and it may stop any fruitful conversation or accurate work. The evaluator may be able to reign in the parties’ expectations and paint an accurate picture of the possible results of the trial may be. This could lead to settlement discussions or a trial with fewer disputes than initially stated.  
• There is a stubborn party.  Evaluators will often see one party with a clear path forward and another party that believes they are entitled to more than they are, slowing resolution. In a similar fashion to the realistic picture above, The neutral may help the stubborn party come to terms with the potential outcome and reach an agreement that seemed impossible.  
• The parties contracted for it.  Contracting parties may agree to submit any disputes that arise to a neutral before a case is filed. This clause can be included in a contract and enforced when a contractual dispute arises. This requires that the parties submit a good faith and accurate representation to the neutral so that the neutral has the most accurate picture of the dispute before they present their evaluation. This can stop disputes from reaching litigation in the first place.  
• The parties agree to submit it post-dispute.  Parties may also agree to submit the case to early neutral evaluation after a dispute arises. All parties must agree to submit their dispute to the evaluator, meaning that it cannot be forced unilaterally. Again, the parties must present a good-faith representation of their case so the neutral can make an accurate evaluation. 

If a case needs a set of outside eyes looking at the evidence to help the parties fully understand the outcomes and possible weaknesses a case may have, it is always a good idea to have that third-party evaluator look at it.

Particular Cases:

While most civil cases would benefit from some form of neutral evaluation, certain cases may be particularly successful after undergoing case evaluation:

• Child Custody :  Parties seeking to establish or modify child custody orders may benefit from case evaluation because an unbiased evaluation of the positions can assist this process. The parties are often strongly fueled by emotion, and a neutral’s opinion can help provide an accurate portrayal of the case.
• Divorce :  Similar to child custody cases, case evaluation, can often help the parties see an accurate picture of what the court would award. And may help them to protect their interests rather than relying on their emotion and anger to drive them forward.  
• Contracts:  Contracts can include an agreement to submit a dispute to early neutral evaluation, as mentioned above. Contract cases often have a step-by-step evaluation of case, so having a neutral evaluate the case early on can save time for the case and provide clarity about the strength of the claim.  

While these types of cases are often particularly suited for evaluation as a whole, that does not mean that every child support or family law case will undergo evaluation. 

Additionally, it is not an exclusive list. Many cases will benefit from an evaluation, even if they do not fit in one of these categories .

Advantages of Case Evaluation:  

There are several important advantages of case evaluation. These include:

• Expertise:  The neutral can be appointed or chosen based on their knowledge about the subject matter of the dispute . This can both ensure the parties are confident that the neutral is competent and that the evaluation is fair and understanding of any unique challenges.  
• Focus:  There are often many aspects of a case that can distract the parties from the most critical parts of the case. Emotions often drive the parties to focus on more minor points of lesser importance. An evaluation can help the parties adjust their focus to the most critical aspects of their case, which can provide new insights and a more straightforward path to success in the case.
• Confidential:  Because the entire process is confidential, it allows the parties to speak freely, knowing that nothing will be shared publicly or in court. This can help encourage settlement and help the parties feel like their entire story was presented.
• Neutral:  The neutral evaluator’s opinion can help the parties feel that their case has real value. It also helps them understand the value of the other party’s case.  
• Voluntary:  Because the parties are choosing to participate in the evaluation and choosing to settle or continue in the case after, the parties are often more forthcoming in the process and can see value in the chance to learn more about their case.
• Chance to Settle Early:  Case evaluation gives the parties a chance to come together and hear the strengths and weaknesses of both cases. Then have the opportunity to discuss a settlement before the parties spend too much on attorneys and court fees.  

Case evaluation can help the parties gain a deeper understanding of their position and the likely outcome of the case. Doing so can bring clarity to the parties, even if an agreement is not reached .

Disadvantages of Case Evaluation:

There are also disadvantages to case evaluation that can impact the accessibility or necessity of the process and must be considered. These include:

• Cost: Because the process is voluntary, there is no guarantee that the case will be resolved after the evaluation . The evaluation may add costs on top of other litigation costs .
• Stress: When the process does not provide a settlement or clarification for the parties, it can feel like wasted time and stress for something that was not fruitful.
• Refusal: Sometimes, a party will hear that their case is not strong but still refuse to settle it. This can drag out the process of resolving the case and keep the parties in a state of limbo where they know what will likely happen but cannot act on it.

Case evaluation can be beneficial in many cases to clarify and understand the outcome and help encourage settlement between the parties. For many, case evaluation is not an initial idea when alternative dispute resolution is necessary. Still, it may help encourage the parties to find an outcome that benefits them and moves the case forward.

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• Volume 21, Issue 1
• What is a case study?
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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

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

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What is it?

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

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

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

Benefits and limitations of case studies

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

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

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

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

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

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

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

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

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

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

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

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

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

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

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

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

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Qualitative Research: Case study evaluation

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• Peer review
• Justin Keen , research fellow, health economics research group a ,
• Tim Packwood a
• Brunel University, Uxbridge, Middlesex UB8 3PH
• a Correspondence to: Dr Keen.

Case study evaluations, using one or more qualitative methods, have been used to investigate important practical and policy questions in health care. This paper describes the features of a well designed case study and gives examples showing how qualitative methods are used in evaluations of health services and health policy.

This is the last in a series of seven articles describing non-quantitative techniques and showing their value in health research

Introduction

The medical approach to understanding disease has traditionally drawn heavily on qualitative data, and in particular on case studies to illustrate important or interesting phenomena. The tradition continues today, not least in regular case reports in this and other medical journals. Moreover, much of the everyday work of doctors and other health professionals still involves decisions that are qualitative rather than quantitative in nature.

This paper discusses the use of qualitative research methods, not in clinical care but in case study evaluations of health service interventions. It is useful for doctors to understand the principles guiding the design and conduct of these evaluations, because they are frequently used by both researchers and inspectorial agencies (such as the Audit Commission in the United Kingdom and the Office of Technology Assessment in the United States) to investigate the work of doctors and other health professionals.

We briefly discuss the circumstances in which case study research can usefully be undertaken in health service settings and the ways in which qualitative methods are used within case studies. Examples show how qualitative methods are applied, both in purely qualitative studies and alongside quantitative methods.

Case study evaluations

Doctors often find themselves asking important practical questions, such as should we be involved in the management of hospitals and, if so, how? how will new government policies affect the lives of our patients? and how can we cope with changes …

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What is Case Study Analysis? (Explained With Examples)

Oct 11, 2023

Case Study Analysis is a widely used research method that examines in-depth information about a particular individual, group, organization, or event. It is a comprehensive investigative approach that aims to understand the intricacies and complexities of the subject under study. Through the analysis of real-life scenarios and inquiry into various data sources, Case Study Analysis provides valuable insights and knowledge that can be used to inform decision-making and problem-solving strategies.

1°) What is Case Study Analysis?

Case Study Analysis is a research methodology that involves the systematic investigation of a specific case or cases to gain a deep understanding of the subject matter. This analysis encompasses collecting and analyzing various types of data, including qualitative and quantitative information. By examining multiple aspects of the case, such as its context, background, influences, and outcomes, researchers can draw meaningful conclusions and provide valuable insights for various fields of study.

When conducting a Case Study Analysis, researchers typically begin by selecting a case or multiple cases that are relevant to their research question or area of interest. This can involve choosing a specific organization, individual, event, or phenomenon to study. Once the case is selected, researchers gather relevant data through various methods, such as interviews, observations, document analysis, and artifact examination.

The data collected during a Case Study Analysis is then carefully analyzed and interpreted. Researchers use different analytical frameworks and techniques to make sense of the information and identify patterns, themes, and relationships within the data. This process involves coding and categorizing the data, conducting comparative analysis, and drawing conclusions based on the findings.

One of the key strengths of Case Study Analysis is its ability to provide a rich and detailed understanding of a specific case. This method allows researchers to delve deep into the complexities and nuances of the subject matter, uncovering insights that may not be captured through other research methods. By examining the case in its natural context, researchers can gain a holistic perspective and explore the various factors and variables that contribute to the case.

1.1 - Definition of Case Study Analysis

Case Study Analysis can be defined as an in-depth examination and exploration of a particular case or cases to unravel relevant details and complexities associated with the subject being studied. It involves a comprehensive and detailed analysis of various factors and variables that contribute to the case, aiming to answer research questions and uncover insights that can be applied in real-world scenarios.

When conducting a Case Study Analysis, researchers employ a range of research methods and techniques to collect and analyze data. These methods can include interviews, surveys, observations, document analysis, and experiments, among others. By using multiple sources of data, researchers can triangulate their findings and ensure the validity and reliability of their analysis.

Furthermore, Case Study Analysis often involves the use of theoretical frameworks and models to guide the research process. These frameworks provide a structured approach to analyzing the case and help researchers make sense of the data collected. By applying relevant theories and concepts, researchers can gain a deeper understanding of the underlying factors and dynamics at play in the case.

1.2 - Advantages of Case Study Analysis

Case Study Analysis offers numerous advantages that make it a popular research method across different disciplines. One significant advantage is its ability to provide rich and detailed information about a specific case, allowing researchers to gain a holistic understanding of the subject matter. Additionally, Case Study Analysis enables researchers to explore complex issues and phenomena in their natural context, capturing the intricacies and nuances that may not be captured through other research methods.

Moreover, Case Study Analysis allows researchers to investigate rare or unique cases that may not be easily replicated or studied through experimental methods. This method is particularly useful when studying phenomena that are complex, multifaceted, or involve multiple variables. By examining real-world cases, researchers can gain insights that can be applied to similar situations or inform future research and practice.

Furthermore, this research method allows for the analysis of multiple sources of data, such as interviews, observations, documents, and artifacts, which can contribute to a comprehensive and well-rounded examination of the case. Case Study Analysis also facilitates the exploration and identification of patterns, trends, and relationships within the data, generating valuable insights and knowledge for future reference and application.

1.3 - Disadvantages of Case Study Analysis

While Case Study Analysis offers various advantages, it also comes with certain limitations and challenges. One major limitation is the potential for researcher bias, as the interpretation of data and findings can be influenced by preconceived notions and personal perspectives. Researchers must be aware of their own biases and take steps to minimize their impact on the analysis.

Additionally, Case Study Analysis may suffer from limited generalizability, as it focuses on specific cases and contexts, which might not be applicable or representative of broader populations or situations. The findings of a case study may not be easily generalized to other settings or individuals, and caution should be exercised when applying the results to different contexts.

Moreover, Case Study Analysis can require significant time and resources due to its in-depth nature and the need for meticulous data collection and analysis. This can pose challenges for researchers working with limited budgets or tight deadlines. However, the thoroughness and depth of the analysis often outweigh the resource constraints, as the insights gained from a well-conducted case study can be highly valuable.

Finally, ethical considerations also play a crucial role in Case Study Analysis, as researchers must ensure the protection of participant confidentiality and privacy. Researchers must obtain informed consent from participants and take measures to safeguard their identities and personal information. Ethical guidelines and protocols should be followed to ensure the rights and well-being of the individuals involved in the case study.

2°) Examples of Case Study Analysis

Real-world examples of Case Study Analysis demonstrate the method's practical application and showcase its usefulness across various fields. The following examples provide insights into different scenarios where Case Study Analysis has been employed successfully.

2.1 - Example in a Startup Context

In a startup context, a Case Study Analysis might explore the factors that contributed to the success of a particular startup company. It would involve examining the organization's background, strategies, market conditions, and key decision-making processes. This analysis could reveal valuable lessons and insights for aspiring entrepreneurs and those interested in understanding the intricacies of startup success.

2.2 - Example in a Consulting Context

In the consulting industry, Case Study Analysis is often utilized to understand and develop solutions for complex business problems. For instance, a consulting firm might conduct a Case Study Analysis on a company facing challenges in its supply chain management. This analysis would involve identifying the underlying issues, evaluating different options, and proposing recommendations based on the findings. This approach enables consultants to apply their expertise and provide practical solutions to their clients.

2.3 - Example in a Digital Marketing Agency Context

Within a digital marketing agency, Case Study Analysis can be used to examine successful marketing campaigns. By analyzing various factors such as target audience, message effectiveness, channel selection, and campaign metrics, this analysis can provide valuable insights into the strategies and tactics that contribute to successful marketing initiatives. Digital marketers can then apply these insights to optimize future campaigns and drive better results for their clients.

2.4 - Example with Analogies

Case Study Analysis can also be utilized with analogies to investigate specific scenarios and draw parallels to similar situations. For instance, a Case Study Analysis could explore the response of different countries to natural disasters and draw analogies to inform disaster management strategies in other regions. These analogies can help policymakers and researchers develop more effective approaches to mitigate the impact of disasters and protect vulnerable populations.

In conclusion, Case Study Analysis is a powerful research method that provides a comprehensive understanding of a particular individual, group, organization, or event. By analyzing real-life cases and exploring various data sources, researchers can unravel complexities, generate valuable insights, and inform decision-making processes. With its advantages and limitations, Case Study Analysis offers a unique approach to gaining in-depth knowledge and practical application across numerous fields.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology 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 many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point 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, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its 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 or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights 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 individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

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 denied her the opportunity to learn a language at critical points in her development.

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

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

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

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 use depends on the unique characteristics of the situation and the case itself.

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:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

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 you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

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.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

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?

Need More Tips?

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

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

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, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

The Case Study Handbook, Revised Edition by William Ellet

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HOW TO ANALYZE EVALUATION SCENARIO CASES

A n evaluation scenario in a case typically portrays a situation in which a deeper understanding of a subject—such as a person, team, product or service, company, country, strategy, or policy—is necessary before any critical decisions or actions can be taken. This deeper understanding comes from an evaluation, often of the worth, value, performance, effectiveness, outcome, or consequences (for example, of a decision that has been made) of the subject. Usually the main character of the case is responsible for the evaluation, but it is also possible for the main character to be the subject of the evaluation.

Evaluations are ubiquitous in the real world. Reviews of movies, books, musical and dramatic ...

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5 Essentials Of An Effective Legal Case Assessment

• Author(s): Rahul Ranjan
• Publication Date: March 21, 2023

Contents of this Post

A legal case assessment is an essential step in any legal proceeding, whether civil or criminal. It involves evaluating the strengths and weaknesses of a case, identifying critical legal and factual concerns, and determining a relevant course of action to achieve the client’s objectives. A practical legal case assessment involves a comprehensive understanding of the law, the facts, and the problems you must overcome.

Several key factors can make or break a case. These essentials are critical to the success of any legal matter, and they can help attorneys determine whether they have a strong chance of winning. This article will discuss the five essentials of a practical legal case assessment.

Understand The Relevant Issues In The Case

While several factors can influence case assessment, the factual grounds of the case are essential. Successful case evaluation involves a comprehensive understanding of the relevant facts to assist the client in making an informed decision regarding settlement, mediation, arbitration, or litigation. A profound grasp of the facts allows counsel to offer the client options rather than proactively outlining consequences.

The legal counsel should conduct internal investigations and interviews to gather all documentary evidence and testimonial corroboration to obtain the client’s version of each critical declaration or representation. It’s crucial for lawyers not only to collect but also to verify data. Fortunately, technological advancement has made it possible to conduct online case evaluations through sites like TruLaw .

After filling out a straightforward case evaluation form, the team will employ extensive legal criteria to determine whether your case holds water and connect you with the right lawyer.

Determine Whether Claims And Defenses Are Viable

An attorney must be sure whether the case has any legitimacy basis and, if so, identify practical defenses. This process necessitates an examination of essential statutory and case law, as well as the appropriate verdict form and jury instructions. Additionally, the lawyer must outline and clarify the findings for the client in detail.

The legal counsel should provide the client with an in-depth explanation and outline of the following details:

• All plausible claims
• All possible counterclaims that may arise
• All defenses, as well as any third-party claims
• An estimation of the expenses in pursuing potential claims, counterclaims, and defenses

The lawyer should explain to the client in great detail all the relevant aspects of the case, such as the potential claims, counterclaims, defenses , and third-party claims, along with an estimate of the associated costs.

To facilitate this, the legal counsel may find it beneficial to construct a proof matrix that identifies all the elements of each claim or defense, including the witnesses, documentary evidence, and possible evidentiary objections and responses.

Know The Adversary

When evaluating a case, the legal counsel must conduct legal research and gather relevant information, such as opposing counsel, the court, opposing parties, and the potential jury pool. This data can be obtained from publicly available sources and consulting with other practitioners in the relevant community.

When researching opposing counsel, they should focus on their litigation history, reputation, and financial stability, including their tendency to settle early or partner with other counsel. By using all this information, legal counsel can assess the risk tolerance, goals, and primary concerns of all parties affected by the litigation, including the company, its insurers, partners, and internal business clients. By analyzing these factors and setting out competing priorities, legal counsel can comprehensively evaluate a case and position it for a favorable and cost-effective outcome.

Make A Plan

Developing a plan involves creating a strategy for proceeding with the case based on the strengths and weaknesses identified. Attorneys must produce a logical and persuasive argument to convince the judge or jury of their client’s position.

To develop a case plan, attorneys must consider various factors, including legal issues, evidence, and potential arguments from the opposing side. They must prepare to create a range of discussions and strategies and be able to adapt their approach as the case evolves.

Mock Trial And Survey

Law departments and outside counsel may develop biases in interpreting the facts, the law, and their responses to certain aspects of a case. Therefore, the view of an impartial third party can be valuable for an initial assessment of the case. Mock trials are a practical means of achieving this, allowing for the following:

• The acquisition of an outsider’s perspective
• An accurate assessment of whether the case is trial-ready
• The evaluation of potential jurors’ reactions
• The assessment of damages

Jury consultants typically handle mock trials, followed by a survey of jurors to determine which themes and witnesses were deemed most valid. While mock trials and surveys are the most effective ways of obtaining a third-party perspective, they’re usually conducted late in the case, often done just before the trial. It is regrettable because mock trials can uncover gaps in the case.

Effective legal case assessment is essential for success in any legal matter. It thoroughly analyzes the facts, evidence, and legal issues involved in the case and the adversaries. An excellent legal case assessment includes an evaluation of the strengths and weaknesses of both sides as well as efficient strategizing during the litigation process. Overall, an excellent legal case assessment can ensure that the case proceeds seamlessly, leading to a positive outcome for the client.