Case study research involves drawing on multiple sources of evidence to understand a semi-bounded phenomena (i.e., knowledge translation) within its real life context (i.e., long-term care). This approach relies on multiple sources of evidence  and frequently employs both quantitative and qualitative methods. As case study legitimizes an eclectic, pragmatic approach to the conduct of research we will be drawing on three complementary methodologies; ethnography (data collection methods), grounded theory (analysis and theory development), and participatory action research (working with site participants to develop site specific approaches to data collection).
The research objectives require descriptive and explanatory case study work in order to describe how organizational context influences knowledge translation in long-term care settings. However, data about cause and effect relationships are also required in order to explain which causes produce which effects in relation to knowledge translation . In order to fully illuminate the research questions and assist in explanation building and transferability of findings, multiple cases will be included.
The Promoting Action on Research Implementation in Health Services (PARIHS) framework is the theoretical framework underpinning TREC [33–35]. The framework has been theoretically and empirically developed to represent the interplay and interdependence of the many factors influencing the successful translation of knowledge into practice; explained by a function of the relation between evidence, context and facilitation [5, 12, 34].
The framework, which underpins TREC as a whole, is particularly relevant to this study because:
It will provide a conceptual guide for mapping the contextual factors influencing knowledge translation in long-term care settings at various levels.
Understanding the role of organizational context in knowledge translation is the main purpose of this study. Both the conceptual framework and methodological approach will acknowledge and value the role of organizational context and its component parts (e.g., culture, leadership, evaluation) in knowledge translation.
It facilitates the gathering of individual (e.g., practitioner and resident) experiences, as well as appreciating the fit with the broader context of care delivery.
Method triangulation will be used to enhance the credibility and transferability of the conclusions drawn from the data. The unique characteristics of the different data collection methods will allow a more comprehensive understanding of organizational context and knowledge translation to emerge. Data collection methods will be used within each study site. While the data collection methods will be the same in the comprehensive and focused case study sites, comprehensive case study site data collection will be more in-depth than the focused sites by virtue of the fact that a greater amount of time will be spent in the sites.
Cases – definition
A 'case' is being defined as a particular long-term care setting and the 'embedded units'  – knowledge translation practices in relation to falls, pain management, behavior management, and skin care. In this way, knowledge translation activities and behaviors will be studied in the real life of the practice context and their impact more easily evaluated.
Comprehensive case studies (n = 3) will be conducted in each of Alberta, Saskatchewan, and Manitoba over a six-month period. This will involve up to one month spent conducting information sessions to familiarize staff with the purpose and procedures of the study. This will be followed by approximately one month in each facility for intensive observation and interview data collection. In month three, the researchers will undertake preliminary data analysis, and then in month four they will return to the field to confirm emerging findings through interviews. The process of data analysis will be repeated in month five, and the researchers will again return to the field in month six to verify their findings through group discussions with staff in naturally-occurring meetings. During months four to six the researchers will also undertake document analysis. The total amount of time the researchers spend in the field will be a maximum of six months. We will re-enter the sites a year later to observe any changes in organizational context. This will involve up to one month of non-participant observation and interviews with selected individuals identified by the researchers as key informants (phase one is currently underway).
Focused case studies will be conducted in selected settings to allow elaboration of emerging themes about the relationship between the organizational context within long-term care facilities and knowledge use in practice. Data collection in these sites will occur over two to four months and will comprise one month spent conducting information sessions to familiarize staff with the purpose and procedures of the study. This will be followed by up to one month of non-participant observation and interviews, which will then be followed by interviews with staff and possibly family members.
A primary source of data will be non-participant observation in the long-term care facility, including observation in resident care areas and at a variety of meetings. General observations within units of the facility will provide a description of the daily work patterns that provide the organizational context for knowledge use. At the onset of phase one (the comprehensive case studies) the research associates will spend at least one month in each facility to observe natural activities, practices, and interactions among staff and residents. Relevant meetings will also be attended. In phase two (the more focused case studies) non-participant observation will take place over a shorter period.
These general observations will be broadly guided by Spradley's  nine dimensions of observation, which include: space, actors, activities, objects, acts, events, time, and goals and feelings. Particular attention will be paid to observing knowledge use with respect to indicator conditions: falls, pain, dementia behaviors, and quality of life. These indicators were identified by our decision-making partners as priority areas for long-term care facilities in Western Canada and will also be examined using numerical data in project one . The team is also interested in focusing on skin care practice, which during preliminary data collection in sites also appears to be an important indicator. Observations will be recorded in researcher field notes that will subsequently be transcribed and imported into a qualitative data management/analysis software program.
In addition, formal and informal interviews will be conducted with key informants to clarify factors in the setting that may be influencing knowledge use and characterizing context. Interviews will take place with key informants at various levels of the organization. These interviews will be conducted using interview guides that elicit views on key elements of organizational context (e.g., resources, organizational structure, leadership, team work). The actual format of the interviews will be tailored to the individual being interviewed. For example, the director of the facility will be an important informant on how various historical/critical events (e.g., implementation of new policies in the health region) have influenced knowledge use in practice. They will also be important sources of information about governance and resources, such as budgetary issues including pay and incentives, access to training opportunities for frontline staff, the status of information and knowledge management systems in the facility, and mechanisms for providing individuals' and groups' feedback on their performance. Frontline managers will be important sources of data with respect to teamwork issues on their unit, such as division of labor, pressure groups, and relationships between groups (e.g., day and night staff). Individual healthcare aides will also be interviewed to elicit their understanding of 'how things are done around here,' or the context of their unit and work shift for knowledge use. The questions to be posed to the managers will be driven by issues identified in the organizational literature as to the important influences on knowledge use in practice. On the other hand, the development of the interview guide for the healthcare aides will evolve as on-site observations are made to ensure that the questions asked will be framed in the language currently in use on their particular unit(s). During the first month of data collection, informal discussions will be undertaken simultaneously with the non-participant observation, which will enable any issues that arise in observation to be explored in more depth during formal interviews.
Documents will also be an important source of data. Documents that describe the organizational structure and staffing patterns will be summarized and described in field notes. Written policies and procedures, particularly with respect to the indicator conditions (falls, pain, dementia behavior, quality of life, skin care), will be gathered and analyzed to determine the knowledge products available for use in the facility. Informal materials, such as postings on bulletin boards, kardexes where information about care plans for individual residents often reside, and materials found in the staff resource room will be recorded in field notes. Where appropriate and with the consent of the facility, digital photographs of the physical layout of the unit or facility (not including residents, visitors, or staff) will be taken to provide information about the physical environment/context. The actual use of such documents on a daily basis as care is provided and as critical incidents occur, will also be recorded in the written field notes. Document data collection will take place on an ongoing basis during field visits.
To better understand the effect of knowledge use within each of the facilities on the 'customer' of care, three family caregivers who regularly visit their loved one in the nursing home will be approached to participate in the study. These family caregivers will be selected with the guidance and recommendation of the unit manager, or if a caregiver expresses an interest in being involved during periods of observation. The family caregivers will be asked to take part in an interview in which we will explore their experiences and perspectives of being a caregiver in the particular facility. If this approach appears to be workable, then one interview will be conducted in each of the focused case studies with three family members. These interviews will provide another dimension for development of the theory.
Finally, after the major period of observation and interviewing is complete in phase one, and the data analysis has revealed major themes about elements of organizational context that influence knowledge use in practice, a focused discussion with staff members at naturally occurring meetings will be conducted. The intent is to present the themes along with their definitions and some descriptive examples so that the participants can comment on their perceptions of the accuracy of the interpretation made by the investigators. This is an important last step to provide for clarification, verification, and elaboration of the themes. Over a period of time, this process will evolve so that the participants in the final discussion groups during phase two will be providing feedback on the most evolved version of the theory, allowing for in-depth discussion of the circumstances under which certain factors are more or less influential in knowledge use. This process will also allow the investigators to truly embed the emerging theory in the language that is actually used within long-term care facilities to describe knowledge use in practice, thereby aiding in the dissemination and clarity of the findings for all levels of staff in these organizations.
Training for research associates
We are conscious of the need to provide relevant training and support for the qualitative fieldworkers. The leaders of the project will ensure that each person involved in the data collection process (primarily the research associates):
Is confident in designing interview and focus group schedules.
Can undertake content analysis of interview and focus group data.
Is aware of the ethics and sensitivities of conducting observation in practice settings.
Can take good field notes and analyze them.
Can interview and run focus groups effectively.
Is aware of the need for project management skills.
Can communicate the results of the analysis of qualitative data in written and verbal form.
Can work effectively as a team member with the other research associates and investigators.
The project leaders are experienced in the teaching and practice of these methods and have access to training materials to support the proposed approach. In addition, the research associates will receive technical training in the use of data management and communication systems (Nvivo, Elluminate, and the web-based learning management system) to facilitate the conduct of the project.
Consistent with case study methods, each case is regarded as a 'whole study' in which convergent evidence is sought and then considered across multiple cases. As such, a pattern-matching logic, based on explanation-building will be used as a data analysis framework . This strategy will allow for an iterative process of analysis across sites and will enable an explanation about organizational context and knowledge use to develop over time. It will be important to ensure that data analysis reflects the variety of data sources and the potential insight that each could offer in meeting the aims of this study. Therefore, data from each site will be analyzed within the data set to derive key themes, and then these themes will be considered in conjunction with the findings from the other data sources. Additionally, analysis will be conducted within sites and then, in order to enable conclusions to be drawn for the study as a whole, findings will be summarized across sites to assist in explanation and theory building. Data will be managed in NVivo .
The analysis process necessarily involves significant interaction between the investigators and the research associates who are actually making the observations and conducting the interviews. A plan has been developed to ensure that this interaction is timely, regular, and purposeful. To provide for multiple perspectives on the meaning of the data and how to label and define emerging themes, a key feature of this type of interpretive analysis is to provide for several individuals to read and interpret the field notes and interviews along with the individuals who have done the data collection. The investigators involved in this study all have significant previous experience in this analysis approach, and will ensure that data collection remains focused on defining the emerging explanation of how organizational context influences knowledge use. In this way, data collection continues only to the point of theoretical 'saturation' (that is, dense and rich explanation) so as to reduce burden to participants in the study.
Ethical approval for this project has been obtained from the appropriate university ethics boards: Universities of Alberta, Calgary, Manitoba, Saskatchewan, and Regina. Relevant operational approvals will be obtained accordingly.
Access to sites
Access to sites was described above. Sites are free to withdraw at any stage of the research.
Participation is voluntary. Consent will be negotiated at several levels. First, the facility itself will be asked to consider the request for their inclusion in the study, and written consent to make general observations in designated areas and to analyze written documents will be requested from the official authorities of the facility. Second, a principle of consent by exclusion will be followed when observing in general resident care areas. That is, the consent of staff on each shift where observations will take place will be verbally negotiated; anyone who is not comfortable with being included will not be observed. No families, residents, or staff will be observed without their consent. Third, staff will be told that at any time they can ask to see the notes that the observer is recording if they wish to, so that they can clarify any inaccuracies, or they may ask that the observer stop recording. All such requests will be respected. No observations will occur in residents' rooms, but observations of residents will occur in common areas, such as hallways and lunch rooms. In any case where observations may occur in common areas, we will negotiate this with staff and residents (if able) or family if not. Printed material in the form of brochures and posters will be available for residents, visitors, and staff to explain the study's purposes and data collection approaches.
Written consent will be obtained for individual interviews. These consents will be negotiated in advance, and a convenient time will be arranged for the interview to occur in a quiet, non-threatening setting. Our experience from feasibility testing in project one  has been that the healthcare aides find the process of informed consent to be positive.
Participants in this project will not be anonymous to the frontline data collectors. In addition, audio-recordings may contain information that enables identification of the participants. All audio-recordings will be stored centrally on a secure server and will remain identifiable by codes assigned by the researchers. Back-up copies of audio-recordings will be stored on computer disks, which will be kept in a locked cabinet. Code legends will be stored securely and separately from the audio-recorded data. De-identification will occur at the point of transcription and the process by which this occurs will be decided upon by the TREC data committee and project investigators, in consultation with the research associates. All transcriptionists will sign a confidentiality oath and all data in this study will be held confidentially.
This study and the observations are being conducted in settings with vulnerable populations, i.e., long-term care residents. During the course of the observational work investigators, research associates and/or staff may observe instances of unsafe or unethical practice. If they arise, we will deal with these situations on a case-by-case basis in accordance with professional guidelines and facility procedures.
We will negotiate, and be flexible with, the times of data collection so as to avoid any untoward impact on the operations of the facility. As a token of our appreciation, we will provide the facility with refreshments and participating staff with a token gift (e.g., a coffee certificate).