Case studies are in essence external detailed investigations of an individual, group or an institution. (MODULE R14.QUALITATIVE RESEARCH) As a method it enables the researcher to uncover and explore variables and factors that each individual case study reveals -- and this in turn adds to the overall perception and understanding of the topic or issue under investigation. Case studies also differ from more statistical and quantifiable methods of inquiry in that "…the focus of attention is the individual case and not the whole population of cases" (MODULE R14.QUALITATIVE RESEARCH).
From a more philosophical viewpoint, the case study is more open-ended and less dependent on a research methodology that focus on a limited or "bounded system." A central aspect of this method is that content and case studies have the particular advantage of focusing on any system or issue in its natural context or habitat. (MODULE R14.QUALITATIVE RESEARCH)
The case study method can be effectively employed in the following scenario. An elderly diabetic has problems with his diet and this is related to a lack of knowledge and information. These issues are also linked to the problem of an inadequate support system. As has been referred to, diet is an important aspect of self-management. "Diet and exercise are the cornerstones of diabetic treatment at all ages" ( Wallace).
The research question that might be posited in this case is to what extent are a patient's dietary and management problems related to a number of other social and external issues and variables, such as the interaction between the support system and an adequate knowledge base? These and other factors are all interrelated and impinge on the understanding of the problems that the elderly patient may be experiencing.
In this case a quantitative research methodology would only be able to reveal some the variables and their interrelationships and would probably not expose the more subtle linkages between them. On the other hand, a case study approach would be a more effective and appropriate methodology to implement in the attempt to understand the interaction of variables that could effect the management of the problem in terms of understanding the individual situation in all its detail. As one study using this methodology found, "…some patients felt undersupported." The study also suggests that by using the case study method one is able to "… assess in more detail the relationships between people's appetite for knowledge, their actual knowledge, and their satisfaction with knowledge levels" (Abbott and Gunnell, 2004).
3. 4. Ethnographic and postmodern approaches
A modern trend is the "postmodern "interpretation of healthcare. The term postmodern is a complex and much debated term, a discussion of which is outside the parameters of this paper. Simplistically stated, the postmodern approach refers most commonly to a wide-ranging 'deconstruction' or radical analytic interrogation of the way those social norms, values and 'master narratives' construct the world in which we live. The deconstructive aspect of postmodernism is the attempt to unravel the layers of bias and prejudice that obscure a clear view of reality.
In terms of the present discussion on management and the elderly diabetic person, the most appropriate qualitative method to use is the ethnographic method. In a postmodern context the management of the diabetic patient should be examined from the point-of-view of the hidden biases and presuppositions that might be active and which may impede adequate management methods and procedures. The question that could be asked in this research situation is as follows: is the view of the elderly diabetic patient affected in any negative sense by presuppositions and biases that are not blatantly obvious? In other words, the broadest context should be taken into account.
The ethnographic method refers to a from of intensive and participatory research that focuses on "…the sociology of meaning through close field observation of sociocultural phenomena" ( Young, 2004). Typical ethnographic research deals with an investigation of the community and often the researcher enters into the community as a participant in order to gain an understanding of the social factors and variables in play.
Using the ethnographic model of qualitative research the researcher can interrogate and investigate the social and psychological context of the elderly diabetic patient, particularly in the institutional environment. This method is the most appropriate to use when there are wider concerns that involve a total understanding of the overall social and cultural context that affects any management decisions and protocols .
An interesting study that illustrates aspects of this qualitative methodology is, Are we stereotyping our elderly patients? By Maggie Young (2004). Young addresses the question of ageism and the way that nurse and staff may be guilty of various forms of discrimination that adversely affect patient treatment and management.
The research by Young involves four case studies and found that in all cases there were indications of discrimination and ageism towards the elderly diabetic patients; which tended to undermine not only the quality of the treatment and management but also the patients sense of self-worth and identity.
The cases all concerned elderly patients with diabetes who had been "…. allocated by the DSN to group insulin education because of the urgency of starting insulin therapy" ( Young, 2004). In each instance evidence of false assumptions and discrimination were found. " In each case the DSN's assumptions about the individual's ability to assimilate information in a group setting proved wrong. The case studies suggest that the ability to learn new skills is not necessarily influenced by age or intelligence" ( Young, 2004).
In essence the above study refers to the biases and assumptions that are part of the social context and which can be a factor in influencing the efficacy of the management and treatment processes of these patients. In this situation the case studies are related to the wider social and institutional context in a broad normative analysis. It was found that the attitudes of professional nursing staff could be 'deconstructed' and revealed as harboring prejudicial views and opinions that would adversely affect treatment. It is also obvious that this broad and interrogative technique is intended to be subjective and is in essence an extension of the more limited case study method. It is also obvious that the quantitative methodologies would not be able to achieve these results, which depend on subjective immersion in the environment under study.
In conclusion, the above discussion demonstrates the value of various qualitative methodologies in the nursing profession and in relation to understanding and dealing with diabetic management issues among the elderly. What is also evident is that certain qualitative methods are more appropriate in certain situations. For instance, the choice of an in-depth interview or a case study would depend on factors relating to the aims and intentions of the research. What should also be pointed out is that in many cases researchers find that a combination of qualitative and quantitative research methodologies can be extremely effective in understanding and dealing with certain healthcare issues.
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