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The multiple case study design is a valuable qualitative research tool in studying the links between the personal, social, behavioral, psychological, organizational, cultural, and environmental factors that guide organizational and leadership development. Case study research is essential for the in-depth study of participants' perspectives on the phenomenon within its natural context. Rigorously designed management and leadership case studies in the extant literature have a central focus on individual managers' and leaders' stories and their perceptions of the broader forces operating within and outside their organizations.

This is a comprehensive methodology book exploring the multiple case study design with step-by-step and easily accessible guidelines on the topic, making it especially valuable to researchers, academics, and students in the areas of business, management, and leadership.

Chapter 1 | 6 pages, a refresher on the philosophical foundations of academic research, chapter 2 | 6 pages, research methodologies, chapter 3 | 3 pages, the role of theory in qualitative research, chapter 4 | 6 pages, how does the novice researcher design a multiple case study, chapter 5 | 5 pages, the advantage of the multiple case study design for management researchers, chapter 6 | 6 pages, applying data collection methods in multiple case study research, chapter 7 | 9 pages, the data analysis process for multiple case study research, chapter 8 | 3 pages, extending theory with multiple case study design, chapter 9 | 7 pages, incorporating multiple case design and methodologies into teaching and professional practice, chapter 10 | 9 pages, writing and publishing multiple case study research, chapter 11 | 2 pages, concluding thoughts.

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Forum Qualitative Sozialforschung / Forum: Qualitative Social Research (FQS)

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Home > JCPS > Vol. 15 (2022) > No. 2

Journal of Counselor Preparation and Supervision

A systematic approach to multiple case study design in professional counseling and counselor education.

Charmayne R. Adams , University of Nebraska at Omaha Follow Casey A. Barrio Minton , University of Tennessee Follow Jennifer Hightower , Idaho State University Follow Ashley J. Blount , University of Nebraska at Omaha Follow

Document Type

Case study, multiple case study, qualitative research, research design, counseling

Subject Area

Counseling, Counselor Education, Higher Education Counseling, Mental Health Counseling, Rehabilitation Counseling, School Counseling

Case study research is a qualitative methodology that allows researchers to explore complex phenomena in a structured way, that is rigorous and provides an enormous amount of depth. Three scholars are credited with major contributions to the case study literature: Merriam (1998), Stake (1995/2006), and Yin (1994). The purpose of this paper is to explore case study design for use in the counseling profession. The authors provide instruction on the case study scholars, data collection, analysis, and reporting for both single and multiple case study research designs. Finally, implications for student counselors, counselor educators, and counseling professionals are provided.

Methodology: Multiple-Case Qualitative Study

First Online: 01 July 2021

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Feng Ding 2

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This longitudinal multiple-case study is qualitative in nature, with data collection lasting for more than a year. As this study set out to understand the experiences, feelings, emotions, conceptions, and understanding of students about their experiences, a qualitative research approach was adopted to “identify issues from the perspective of” the participants, and to study them in a natural setting (Hennink et al., 2011, p. 9).

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Ding, F. (2021). Methodology: Multiple-Case Qualitative Study. In: First Year in a Multilingual University. Springer, Singapore. https://doi.org/10.1007/978-981-16-0796-7_3

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Research Guides

Multiple Case Studies

Nadia Alqahtani and Pengtong Qu

Description

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

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

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

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

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

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

Key Research Books and Articles on Multiple Case Study Methodology

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

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

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

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

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

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

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

Recent Dissertations Using Multiple Case Study Methodology

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

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

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

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

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

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

Multiple Case Studies Copyright © 2019 by Nadia Alqahtani and Pengtong Qu is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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The Multiple Case Study Design Methodology and Application for Management Education

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Most organizations today operate in volatile economic and social environments and qualitative research plays an essential role in investigating leadership and management problems. This unique volume offers novice and experienced researchers a brief, student-centric research methods text specifically devoted to the multiple case study design. The multiple case study design is a valuable qualitative research tool in studying the links between the personal, social, behavioral, psychological, organizational, cultural, and environmental factors that guide organizational and leadership development. Case study research is essential for the in-depth study of participants' perspectives on the phenomenon within its natural context. Rigorously designed management and leadership case studies in the extant literature have a central focus on individual managers' and leaders' stories and their perceptions of the broader forces operating within and outside their organizations. This is a comprehensive methodology book exploring the multiple case study design with step-by-step and easily accessible guidelines on the topic, making it especially valuable to researchers, academics, and students in the areas of business, management, and leadership.

Daphne Halkias is Professor and Distinguished Research Fellow at École des Ponts Business School in Paris, France. Michael Neubert is Associate Professor in Business and Management Studies and a Member of the Academic Council at UIBS in Zurich, Switzerland. Paul W. Thurman is Professor of Management and Analytics at Columbia University's Mailman School of Public Health, New York, USA. Nicholas Harkiolakis is on the Faculty of the School of Technology at Northcentral University, San Diego, California, USA.

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Distinguishing case study as a research method from case reports as a publication type

The purpose of this editorial is to distinguish between case reports and case studies. In health, case reports are familiar ways of sharing events or efforts of intervening with single patients with previously unreported features. As a qualitative methodology, case study research encompasses a great deal more complexity than a typical case report and often incorporates multiple streams of data combined in creative ways. The depth and richness of case study description helps readers understand the case and whether findings might be applicable beyond that setting.

Single-institution descriptive reports of library activities are often labeled by their authors as “case studies.” By contrast, in health care, single patient retrospective descriptions are published as “case reports.” Both case reports and case studies are valuable to readers and provide a publication opportunity for authors. A previous editorial by Akers and Amos about improving case studies addresses issues that are more common to case reports; for example, not having a review of the literature or being anecdotal, not generalizable, and prone to various types of bias such as positive outcome bias [ 1 ]. However, case study research as a qualitative methodology is pursued for different purposes than generalizability. The authors’ purpose in this editorial is to clearly distinguish between case reports and case studies. We believe that this will assist authors in describing and designating the methodological approach of their publications and help readers appreciate the rigor of well-executed case study research.

Case reports often provide a first exploration of a phenomenon or an opportunity for a first publication by a trainee in the health professions. In health care, case reports are familiar ways of sharing events or efforts of intervening with single patients with previously unreported features. Another type of study categorized as a case report is an “N of 1” study or single-subject clinical trial, which considers an individual patient as the sole unit of observation in a study investigating the efficacy or side effect profiles of different interventions. Entire journals have evolved to publish case reports, which often rely on template structures with limited contextualization or discussion of previous cases. Examples that are indexed in MEDLINE include the American Journal of Case Reports , BMJ Case Reports, Journal of Medical Case Reports, and Journal of Radiology Case Reports . Similar publications appear in veterinary medicine and are indexed in CAB Abstracts, such as Case Reports in Veterinary Medicine and Veterinary Record Case Reports .

As a qualitative methodology, however, case study research encompasses a great deal more complexity than a typical case report and often incorporates multiple streams of data combined in creative ways. Distinctions include the investigator’s definitions and delimitations of the case being studied, the clarity of the role of the investigator, the rigor of gathering and combining evidence about the case, and the contextualization of the findings. Delimitation is a term from qualitative research about setting boundaries to scope the research in a useful way rather than describing the narrow scope as a limitation, as often appears in a discussion section. The depth and richness of description helps readers understand the situation and whether findings from the case are applicable to their settings.

CASE STUDY AS A RESEARCH METHODOLOGY

Case study as a qualitative methodology is an exploration of a time- and space-bound phenomenon. As qualitative research, case studies require much more from their authors who are acting as instruments within the inquiry process. In the case study methodology, a variety of methodological approaches may be employed to explain the complexity of the problem being studied [ 2 , 3 ].

Leading authors diverge in their definitions of case study, but a qualitative research text introduces case study as follows:

Case study research is defined as a qualitative approach in which the investigator explores a real-life, contemporary bounded system (a case) or multiple bound systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information, and reports a case description and case themes. The unit of analysis in the case study might be multiple cases (a multisite study) or a single case (a within-site case study). [ 4 ]

Methodologists writing core texts on case study research include Yin [ 5 ], Stake [ 6 ], and Merriam [ 7 ]. The approaches of these three methodologists have been compared by Yazan, who focused on six areas of methodology: epistemology (beliefs about ways of knowing), definition of cases, design of case studies, and gathering, analysis, and validation of data [ 8 ]. For Yin, case study is a method of empirical inquiry appropriate to determining the “how and why” of phenomena and contributes to understanding phenomena in a holistic and real-life context [ 5 ]. Stake defines a case study as a “well-bounded, specific, complex, and functioning thing” [ 6 ], while Merriam views “the case as a thing, a single entity, a unit around which there are boundaries” [ 7 ].

Case studies are ways to explain, describe, or explore phenomena. Comments from a quantitative perspective about case studies lacking rigor and generalizability fail to consider the purpose of the case study and how what is learned from a case study is put into practice. Rigor in case studies comes from the research design and its components, which Yin outlines as (a) the study’s questions, (b) the study’s propositions, (c) the unit of analysis, (d) the logic linking the data to propositions, and (e) the criteria for interpreting the findings [ 5 ]. Case studies should also provide multiple sources of data, a case study database, and a clear chain of evidence among the questions asked, the data collected, and the conclusions drawn [ 5 ].

Sources of evidence for case studies include interviews, documentation, archival records, direct observations, participant-observation, and physical artifacts. One of the most important sources for data in qualitative case study research is the interview [ 2 , 3 ]. In addition to interviews, documents and archival records can be gathered to corroborate and enhance the findings of the study. To understand the phenomenon or the conditions that created it, direct observations can serve as another source of evidence and can be conducted throughout the study. These can include the use of formal and informal protocols as a participant inside the case or an external or passive observer outside of the case [ 5 ]. Lastly, physical artifacts can be observed and collected as a form of evidence. With these multiple potential sources of evidence, the study methodology includes gathering data, sense-making, and triangulating multiple streams of data. Figure 1 shows an example in which data used for the case started with a pilot study to provide additional context to guide more in-depth data collection and analysis with participants.

An external file that holds a picture, illustration, etc.
Object name is jmla-107-1-f001.jpg

Key sources of data for a sample case study

VARIATIONS ON CASE STUDY METHODOLOGY

Case study methodology is evolving and regularly reinterpreted. Comparative or multiple case studies are used as a tool for synthesizing information across time and space to research the impact of policy and practice in various fields of social research [ 9 ]. Because case study research is in-depth and intensive, there have been efforts to simplify the method or select useful components of cases for focused analysis. Micro-case study is a term that is occasionally used to describe research on micro-level cases [ 10 ]. These are cases that occur in a brief time frame, occur in a confined setting, and are simple and straightforward in nature. A micro-level case describes a clear problem of interest. Reporting is very brief and about specific points. The lack of complexity in the case description makes obvious the “lesson” that is inherent in the case; although no definitive “solution” is necessarily forthcoming, making the case useful for discussion. A micro-case write-up can be distinguished from a case report by its focus on briefly reporting specific features of a case or cases to analyze or learn from those features.

DATABASE INDEXING OF CASE REPORTS AND CASE STUDIES

Disciplines such as education, psychology, sociology, political science, and social work regularly publish rich case studies that are relevant to particular areas of health librarianship. Case reports and case studies have been defined as publication types or subject terms by several databases that are relevant to librarian authors: MEDLINE, PsycINFO, CINAHL, and ERIC. Library, Information Science & Technology Abstracts (LISTA) does not have a subject term or publication type related to cases, despite many being included in the database. Whereas “Case Reports” are the main term used by MEDLINE’s Medical Subject Headings (MeSH) and PsycINFO’s thesaurus, CINAHL and ERIC use “Case Studies.”

Case reports in MEDLINE and PsycINFO focus on clinical case documentation. In MeSH, “Case Reports” as a publication type is specific to “clinical presentations that may be followed by evaluative studies that eventually lead to a diagnosis” [ 11 ]. “Case Histories,” “Case Studies,” and “Case Study” are all entry terms mapping to “Case Reports”; however, guidance to indexers suggests that “Case Reports” should not be applied to institutional case reports and refers to the heading “Organizational Case Studies,” which is defined as “descriptions and evaluations of specific health care organizations” [ 12 ].

PsycINFO’s subject term “Case Report” is “used in records discussing issues involved in the process of conducting exploratory studies of single or multiple clinical cases.” The Methodology index offers clinical and non-clinical entries. “Clinical Case Study” is defined as “case reports that include disorder, diagnosis, and clinical treatment for individuals with mental or medical illnesses,” whereas “Non-clinical Case Study” is a “document consisting of non-clinical or organizational case examples of the concepts being researched or studied. The setting is always non-clinical and does not include treatment-related environments” [ 13 ].

Both CINAHL and ERIC acknowledge the depth of analysis in case study methodology. The CINAHL scope note for the thesaurus term “Case Studies” distinguishes between the document and the methodology, though both use the same term: “a review of a particular condition, disease, or administrative problem. Also, a research method that involves an in-depth analysis of an individual, group, institution, or other social unit. For material that contains a case study, search for document type: case study.” The ERIC scope note for the thesaurus term “Case Studies” is simple: “detailed analyses, usually focusing on a particular problem of an individual, group, or organization” [ 14 ].

PUBLICATION OF CASE STUDY RESEARCH IN LIBRARIANSHIP

We call your attention to a few examples published as case studies in health sciences librarianship to consider how their characteristics fit with the preceding definitions of case reports or case study research. All present some characteristics of case study research, but their treatment of the research questions, richness of description, and analytic strategies vary in depth and, therefore, diverge at some level from the qualitative case study research approach. This divergence, particularly in richness of description and analysis, may have been constrained by the publication requirements.

As one example, a case study by Janke and Rush documented a time- and context-bound collaboration involving a librarian and a nursing faculty member [ 15 ]. Three objectives were stated: (1) describing their experience of working together on an interprofessional research team, (2) evaluating the value of the librarian role from librarian and faculty member perspectives, and (3) relating findings to existing literature. Elements that signal the qualitative nature of this case study are that the authors were the research participants and their use of the term “evaluation” is reflection on their experience. This reads like a case study that could have been enriched by including other types of data gathered from others engaging with this team to broaden the understanding of the collaboration.

As another example, the description of the academic context is one of the most salient components of the case study written by Clairoux et al., which had the objectives of (1) describing the library instruction offered and learning assessments used at a single health sciences library and (2) discussing the positive outcomes of instruction in that setting [ 16 ]. The authors focus on sharing what the institution has done more than explaining why this institution is an exemplar to explore a focused question or understand the phenomenon of library instruction. However, like a case study, the analysis brings together several streams of data including course attendance, online material page views, and some discussion of results from surveys. This paper reads somewhat in between an institutional case report and a case study.

The final example is a single author reporting on a personal experience of creating and executing the role of research informationist for a National Institutes of Health (NIH)–funded research team [ 17 ]. There is a thoughtful review of the informationist literature and detailed descriptions of the institutional context and the process of gaining access to and participating in the new role. However, the motivating question in the abstract does not seem to be fully addressed through analysis from either the reflective perspective of the author as the research participant or consideration of other streams of data from those involved in the informationist experience. The publication reads more like a case report about this informationist’s experience than a case study that explores the research informationist experience through the selection of this case.

All of these publications are well written and useful for their intended audiences, but in general, they are much shorter and much less rich in depth than case studies published in social sciences research. It may be that the authors have been constrained by word counts or page limits. For example, the submission category for Case Studies in the Journal of the Medical Library Association (JMLA) limited them to 3,000 words and defined them as “articles describing the process of developing, implementing, and evaluating a new service, program, or initiative, typically in a single institution or through a single collaborative effort” [ 18 ]. This definition’s focus on novelty and description sounds much more like the definition of case report than the in-depth, detailed investigation of a time- and space-bound problem that is often examined through case study research.

Problem-focused or question-driven case study research would benefit from the space provided for Original Investigations that employ any type of quantitative or qualitative method of analysis. One of the best examples in the JMLA of an in-depth multiple case study that was authored by a librarian who published the findings from her doctoral dissertation represented all the elements of a case study. In eight pages, she provided a theoretical basis for the research question, a pilot study, and a multiple case design, including integrated data from interviews and focus groups [ 19 ].

We have distinguished between case reports and case studies primarily to assist librarians who are new to research and critical appraisal of case study methodology to recognize the features that authors use to describe and designate the methodological approaches of their publications. For researchers who are new to case research methodology and are interested in learning more, Hancock and Algozzine provide a guide [ 20 ].

We hope that JMLA readers appreciate the rigor of well-executed case study research. We believe that distinguishing between descriptive case reports and analytic case studies in the journal’s submission categories will allow the depth of case study methodology to increase. We also hope that authors feel encouraged to pursue submitting relevant case studies or case reports for future publication.

Editor’s note: In response to this invited editorial, the Journal of the Medical Library Association will consider manuscripts employing rigorous qualitative case study methodology to be Original Investigations (fewer than 5,000 words), whereas manuscripts describing the process of developing, implementing, and assessing a new service, program, or initiative—typically in a single institution or through a single collaborative effort—will be considered to be Case Reports (formerly known as Case Studies; fewer than 3,000 words).

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Qualitative case study data analysis: an example from practice

Affiliation.

1 School of Nursing and Midwifery, National University of Ireland, Galway, Republic of Ireland.
PMID: 25976531
DOI: 10.7748/nr.22.5.8.e1307

Aim: To illustrate an approach to data analysis in qualitative case study methodology.

Background: There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research.

Data sources: The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software.

Review methods: Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided. Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources.

Conclusion: By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis.

Implications for research/practice: This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Keywords: Case study data analysis; case study research methodology; clinical skills research; qualitative case study methodology; qualitative data analysis; qualitative research.

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“ You close the door , wipe your sadness and put on a smiling face ”: a qualitative study of the emotional labour of healthcare professionals providing palliative care in nursing homes in France

Benoite Umubyeyi 1 ,
Danièle Leboul 1 &
Emmanuel Bagaragaza 1

BMC Health Services Research volume 24 , Article number: 1070 ( 2024 ) Cite this article

Metrics details

Palliative care provided to frail and dying older persons in nursing homes results in intense emotions for residents and their relatives as well as for healthcare professionals. In France, scant attention has been given to how nursing home professionals manage their emotions when providing palliative care. This study analysed the emotional demands of providing palliative care in the nursing home context, the emotional strategies used by healthcare professionals to navigate such demands, and how these demands affect their emotional wellbeing.

This qualitative study used a multiple case study approach. We purposively selected nine nursing homes from three geographical provinces in France with diverse ownership statuses (public, private, associative). Individual interviews and focus group discussions were held with 93 healthcare professionals from various occupational groups employed in the participating nursing homes. Data was collected from April 2021 to September 2022 and was analysed using thematic content analysis.

Data revealed that providing palliative care to dying residents within the nursing home context results in intertwined rewarding and exhausting emotional experiences for healthcare professionals. Professionals have to utilize multifaceted emotional strategies to navigate these experiences, including suppressing and modifying emotions and distancing themselves emotionally from residents to protect themselves from emotional suffering. Participants noted a lack of formal space to express emotions. Unrecognized emotional labour undermines the wellbeing of healthcare professionals in nursing homes, whereas acknowledging emotions enhances satisfaction and gives enhanced meaning to their crucial role in resident care.

Acknowledging emotional labour as an inevitable component of providing palliative care in nursing homes is critical to supporting healthcare professional wellbeing, resilience, and retention, which may ultimately improve the quality of care for dying residents. Ensuring quality care and supporting the emotional wellbeing of nursing home professionals requires an organisational culture that considers emotional expression a collective strength-building resource rather than an individual responsibility, in hopes of shaping a new culture that fully acknowledges their humanity alongside their professional skills.

Trial registration

ClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37, Registration date: 2020-12-03.

Peer Review reports

The steady increase in the number of older persons affected by multiple and complex health needs has led to a growing number of nursing home (NH) residents worldwide spending their final moments of life and dying within these settings [ 1 ]. In turn, this trend has generated heightened attention for the necessity of integrating palliative care within the NH, an approach that has not traditionally been an area of focus [ 2 , 3 , 4 ].

The core philosophy and values of the NH are to provide a home-like environment for residents. When residents require palliative and end-of-life care, the focus shifts from supporting quality living to facilitating quality dying [ 5 ]. Such a shift is accompanied by intense emotions for residents, their relatives, and NH professionals who have had intimate interactions with residents and built strong ties and long-lasting relationships with them during the extended caregiving process. The process becomes even more emotionally laden for professionals, as they often see themselves as holding a professional caring role while also taking on the emotional work of a family member role [ 6 ]. When confronted with providing quality living while simultaneously supporting quality dying [ 5 ], NH professionals have to perform significant emotional labour to provide quality care and preserve the professional-resident therapeutic relationship, all the while maintaining their own health and emotional wellbeing [ 7 ].

In France, as in many other countries, the provision of palliative care in NHs relies heavily on a multidisciplinary staff mainly composed of nursing assistants, personal support workers, registered nurses, and other regulated professionals, under the supervision of a medical coordinator. A medical coordinator in the French nursing home context is a physician, generally with geriatric competences, who has an overall coordination and medical advisory role for nursing home and external provider team for enhanced quality care. Moreover, as elsewhere, NHs in France suffer significant staff shortages due to professional fatigue, burnout, and professional turnover [ 8 ]. The recent COVID-19 pandemic has worsened the situation in NHs, with increased COVID-19-related deaths, augmented workloads, expanded isolation, and added psychological burden among care workers [ 9 , 10 ]. There is a pressing need for NH organisations to acknowledge the emotional labour endured by healthcare professionals during the caregiving process, particularly when it involves providing palliative and end-of-life care to residents.

Current evidence has demonstrated a strong link between burnout, job satisfaction, performance, staff retention, and attrition and the emotional labour of caring [ 11 , 12 ]. When healthcare professionals have to suppress or modify their emotions, they experience dissonance between feelings and performance, which in the long term can result in emotional distress, burnout, and intention to leave the profession [ 12 , 13 ]. Other studies have noted that when emotions are freely expressed and supported, they may have a positive impact on professional-patient interpersonal relationships, staff member wellbeing, and the quality of patient care [ 14 ]. However, most studies that have explored the emotional labour involved in providing palliative care have focused on hospital, hospice, or palliative care unit settings. Rarely have these studies been conducted in NH contexts. In fact, the physical labor associated with caring in NHs and the economic aspects of the work, such as wages and scheduling, receive more attention than does emotional labour [ 15 ]. In addition, emotional intelligence is an expected competency of healthcare professionals, particularly an individual’s ability to manage their own emotions to the point that failing to do so is viewed as an individual weakness and professional failure [ 16 ]. Yet, it has been documented that the effectiveness of emotional labour depends on various factors, including the nature of the service and the organisational culture [ 13 ]. This requires situated knowledge to better understand the emotional work performed by healthcare professionals in specific contexts, such as NHs.

Emotional labour in palliative care and in nursing homes

Emotional labour has been defined as the process through which healthcare professionals suppress or change their feelings to align with organisational rules and guidelines while still conveying to others a sense of being cared for [ 17 ]. Emotional labour involves three strategies: surface acting, deep acting, and displaying genuine emotions [ 18 ]. Surface acting entails suppressing or hiding felt emotions or faking unfelt emotions to alter outwards expression. Deep acting entails a conscious attempt to modify inner feelings and felt emotions to match expected emotions [ 18 , 19 ]. Displaying genuine emotions entails the expression of natural emotions that are congruent with felt feelings without any adjustment [ 18 ]. In this study, we conceptualize emotional labour as the efforts deployed by healthcare professionals to manage their emotions when providing palliative care to NH residents.

Nurse scholars have expanded the concept of emotional labour to nursing, emphasizing the emotional component and the demand associated with caring in nursing [ 19 ]. Nurses perform emotional labour when they have to induce or suppress their feelings to align them with what is expected by their institutions to make patients feel cared for and safe, irrespective of their own actual feelings [ 20 , 21 ]. For example, when nurses are confronted with death but feel unable to facilitate a ‘good death’, they may have complex feelings of guilt and anger but may have to suppress these feelings to continue attending to patients and their relatives [ 22 , 23 ].

Emotions are inherently linked to caring, as they are essential to the development of effective and meaningful relationships with patients, their relatives, and other professionals [ 24 ]. Studies that have explored the emotional labour associated with providing palliative care highlight the complexities of the emotionally demanding experiences healthcare professionals encounter in their practice [ 6 , 23 ]. The cumulative emotional effects of grief and sadness experienced by NH professionals attending to dying individuals require them to deploy significant effort to balance the demands of the healthcare organization, the emotional needs of others, and their own wellbeing [ 23 ].

The limited available literature on emotional labour in NHs illuminates the critical influence that the physical and social environments of NHs have on shaping care providers’ emotional experiences of caring for dying residents [ 7 ]. Caring for ill, disoriented residents with aggressive behaviours as well as dying residents in their last stages of life requires NH professionals to regulate their emotions, often masking their true feelings to prioritize the emotional needs of residents and their families above their own [ 6 , 15 ]. Additionally, ethical and moral concerns that professionals face during end-of-life-care provision, such as preserving residents’ dignity, engaging in end-of-life conversations, respecting end-of-life preferences, life-prolonging treatment or treatment withdrawal, likely play a role in emotional regulation and strategies undertaken by professionals [ 23 , 25 ]. All these may affect healthcare professionals’ capacity to interact effectively with residents and co-workers, nurture their sense of self, and provide optimal care [ 7 , 22 ]. However, it is important to note that the regulation of emotions may also produce positive effects, such as facilitating caring and forming the bonds necessary to foster a home-like NH environment [ 5 , 15 ].

Despite the crucial role that emotions play in providing care in NHs, the emotional labour undertaken by NH care professionals remains an invisible aspect of job requirements [ 15 ]. Notwithstanding the critical role that healthcare professionals play in supporting quality living and quality dying for residents in the French NH context, little is known about how they manage their emotions amidst the complex situations they encounter in their practice or how they continue to provide care without jeopardizing their own emotional wellbeing. This study aimed to help fill this gap in the research by (1) analysing the emotional dimensions of providing palliative care in the NH context as well as the strategies used by healthcare professionals to manage the emotional aspects of caring for dying residents and (2) exploring the effects of emotional labour on NH professionals’ wellbeing. To this end, this study sought to answer the following research questions: (1) How do NH professionals manage the emotional demands of caring for residents requiring palliative care? (2) What effects do emotional demands have on professional-resident interactions and the emotional wellbeing of NH professionals? This study’s findings will inform NH management on strategies and interventions to not only reduce the emotional exhaustion and burnout of healthcare professionals but also improve their resilience and wellbeing at work, ensuring that they are best equipped to provide optimal care to residents and their relatives.

Study overview and design

The findings presented in this manuscript originate from a broader implementation study that evaluated the effectiveness of a timely and integrated palliative care approach in 21 NH facilities in France. The initial study used a mixed-method [ 26 ] approach and was segmented into three phases: pre-implementation, implementation, and post-implementation. The current manuscript reports materials from the pre-implementation phase. A detailed methodological description of the broader study has been reported elsewhere [ 27 ]. The qualitative component of the study follows a multiple case study approach [ 28 ]. Among the aims of the qualitative study were to explore NH professionals’ experiences and quality of life at work and to understand how they navigate the emotional demands associated with providing palliative care to residents.

Participants and settings

This manuscript presents qualitative findings from nine out of the 21 NHs that participated in the broader study. The nine NHs were purposively selected to ensure a balanced sample of three NHs per geographical region (Iles de France, Nouvelle Aquitaine, Provence-Alpes-Côte d’Azur) as well as diversity in terms of ownership status (public, private, and private non-profit).

For this study, we purposively included healthcare professionals from various occupational groups employed on a fixed contract in the selected NHs. Participants had to have a minimum of five months of experience and had experience providing palliative care to residents in the same NH. Casual and non-fixed contractual professionals were excluded from the study.

Data collection

A combination of focus group discussions and individual in-depth interviews was used to collect data. This was to achieve an enhanced understanding of the phenomenon of emotional labour within a NH context by exploring views at individual and social contexts [ 29 ]. Nine focus group discussions were conducted with various healthcare professionals who provide direct care to residents. Each focus group was composed of seven to eleven professionals. Given the purpose of the study which was to explore how different professionals navigate the emotional demands of providing palliative care within a NH context, group composition brought together all professionals involved at varying degrees in providing such a type of care. However, to allow participants to share their experiences freely and to avoid any status distinction or hierarchical influence [ 30 ], professionals in the managerial roles were not included in the focus groups. They were involved in individual interviews.

Prior to data collection, a meeting was organized at each participating NH to introduce the broader interventional study to professionals and invite them to take part in the study. The focus group sessions were held at a predetermined location within the NH at a time convenient to the participants and facility and lasted between 90 and 120 min. Individual in-depth interviews were conducted with the supervisory teams, namely the nurse coordinators and medical coordinators. Each individual interview lasted approximately 45 min and was held at a time and place convenient to participants. We used the interview guide developed by the researchers for the purpose of this study (supplementary material 1). The same interview guide was used for individual and focus group discussions, with slights changes on the phrasing of questions for interviews with the management team. Focus group and individual interview questions inquired about experiences of providing palliative and end-of-life care to residents, the emotional dimensions associated with such a type of care, how professionals navigate those experiences and the perceived consequences on professional wellbeing. Examples of questions included the following: How would you describe your experience of caring for dying residents in NHs? What are the emotional aspects of providing palliative care to residents, and how do you navigate those experiences? The last author conducted most of the individual interviews and some focus group discussions, while a trained research assistant under the supervision of the last author moderated the remaining focus groups. Both hold PhD degrees and have experience in conducting qualitative interviews for health research. All interviews and focus group discussions were conducted from April 2021 to September 2022. The interviews were audio-recorded after the participants granted permission. Regular field notes were written immediately after interviews and focus groups. Data collection continued until we have gained adequate and in-depth understanding [ 31 ] of emotional experiences of providing palliative care in NH.

Data analysis

Thematic content analysis following the analytical approach of Paillé and Mucchielli [ 32 ] guided the analysis. The level of analysis was a NH, with each NH considered a case. After verbatim transcription of all the data from the nine cases, two authors (BU & DL) became acquainted with the data by rereading the transcribed interviews, examining participants’ narratives from each case separately, and then developed a list of codes. From the code list, they created a thematization journal using code subdivision, integration, and hieararchization [ 32 ]. Next, the same two authors grouped related codes from all the cases, with a third team member (BE) resolving any discrepancies between the previous analysts. At the end of this stage, a thematic tree of three themes and eight subthemes was constructed. NVivo 14 software assisted with data management and facilitated the coding process.

To ensure methodological rigor, the authors used the recommended strategies for trustworthiness of qualitative data [ 33 ]. To ensure the reliability of the findings, two analysts completed the coding of transcripts, organized peer debriefing meetings throughout the analysis, and kept a reflexive journal recording all the steps taken and decisions made. A third analyst resolved any disagreements through consensus. To ensure credibility of findings, the authors triangulated methods (individual in-depth interviews and focus groups) and collected participant perspectives from various healthcare professions (nurses, nurse assistants, personal support workers, psychologists, occupational therapists, physiotherapists, medical doctors). The writing of the manuscript followed the “consolidated criteria for reporting qualitative research (COREQ)” [ 34 ] (Supplementary material 2).

Ethical considerations

The French Committee of Protection of Person (CPP) granted ethical approval for this study (Approval number: 2020.09.06 bis_20.07.31.64318). All focus groups and interviews respected the rights of participants to choose to participate in the study through informed consent. To ensure confidentiality and anonymity of the collected data, the reporting used codes instead of names.

Demographic characteristics of participants

All NH professionals who met the inclusion criteria and who were available on the day of the focus group were included in the study. In total, 93 professionals participated, including 79 participants in nine focus groups and 14 participants in individual interviews. Tables 1 and 2 provide the detailed characteristics of the settings and demographic characteristics of participants.

Quotes from individual interviews are followed by an acronym designating the profession of the participant (for example NC for Nurse Coordinator, MedCo for Medical Coordinator) as well as the code number of the NH. Quotes from focus groups are designated by the acronym FG, followed by an acronym for the location of the NH (IDF for Ile de France, NA for Nouvelle Aquitaine, PACA for Provence-Alpes-Côte d’Azur), and the code number of the NH.

Analysis of participants’ narratives revealed three overarching themes related to the emotional dimensions of providing palliative care in NHs: (1) intertwined emotionally rewarding and challenging experiences; (2) multifaceted emotional strategies; and (3) switching between emotional engagement, detachment and exhaustion. Supplementary material 3 illustrates the generation of themes and subthemes with illustrative quotes.

Theme 1. Intertwined emotionally rewarding and challenging experiences

Participants’ narratives revealed two intertwined and simultaneous emotional dimensions of providing palliative care to dying residents in NHs: (1) emotionally rewarding experiences and (2) emotionally challenging experiences. The emotionally rewarding dimension of the experiences was supported by the individual professionals’ intrinsic commitment, devotion, and engagement with older persons under their care and a professional duty to provide them with the “best possible care” they deserve. On the other hand, the NH context as a place of living and of care, with its organisational constraints, rendered the experience of providing palliative care to residents emotionally challenging. Specifically, it hindered the care providers’ ability to facilitate what they perceived to be a “dignified death,” leaving them with feelings of distress, frustration, guilt, and uselessness.

Caring for dying residents: emotionally rewarding experiences

Numerous participants described working in NH as a deliberate professional choice and vocation, stemming from their sense of commitment and engagement to offer dependant older people the care they deserve. The relational dimension associated with caring for NH residents gives meaning to their work and becomes a source of pleasure, satisfaction, and self-worth, as illustrated by the following registered nurse:

“Helping older persons is my passion. I find that there is less invasive care in NHs , and there is a relationship that develops and that I enjoy” (NC , NA , 751).

For the majority of healthcare professionals, this deliberate choice to work in NHs implies that confronting death on an ongoing basis is a professional responsibility. Despite the emotional challenges that come with multiple exposures to death, the participants affirmed their commitment to confront death as part of caring for residents. They held the belief that dying is part of living and that accompanying death is a normal process that comes with caring for the living. The devotion to accompanying residents until the end was perceived by NH professionals as a rewarding experience when they felt they had fulfilled their responsibility of facilitating a dignified death:

“It feels so rewarding to see a resident dying the way they should: with dignity , respect , free of pain and with the best possible comfort. That is what we are here for” (FG , PACA , 935).

Although death is considered an expected life trajectory in NHs, participants recognized that dying older persons are often overlooked as a category of the population requiring adequate palliative care. Their perceived duty to accompany residents until the end demonstrates their commitment to ensuring that dying residents experience comfort and dignity equal to that experienced by individuals dying in settings outside the NH.

Similarly, for some residents, NH professionals are the sole individuals they can bond with at a human level and who can meet their diverse emotional needs. Participants believed their role goes beyond that of care providers. Their drive to go above and beyond and make a difference in the end-of-life trajectory of residents becomes a rewarding experience that provides a sense of pride and self-worth. The NH professionals expressed feeling honoured to be the ones to accompany residents in that ultimate moment, even if it means forgetting themselves:

“Aging comes with many losses and emotional needs: most of them do not want to be here [in the NH]; they feel abandoned by their families , they lose their autonomy over things they used to do , they need to feel cared for. Being there for them through the most important moments of their stay here is very rewarding to us. Basically , in the first place , if they are put here , it is so they do not die alone” (FG , PACA , 931). “It’s truly a phase full of emotions where everything comes out: their past traumas , their anxiety , their worries. We try to hold it together , to forget ourselves a little so we can give them what they deserve…” (FG , NA , 755).

Participants’ accounts bring to the forefront that despite the emotionally laden experience of providing palliative care in an NH context, their commitment and determination to accompany residents in their last living moments make this experience emotionally rewarding.

A living and dying space: emotionally challenging experience

Narratives from healthcare professionals emphasized the context of the NH as being initially designed to serve as a living space. Such a home-like living environment that progressively becomes a place of care and ultimately a place of dying leads to the development of close bonds between NH professionals and residents for an extended period. The emotional and physical closeness formed with residents during their stay transcends the caregiver-resident therapeutic relationship. Healthcare professionals have to navigate these different aspects of the NH and remain professional caregivers, all the while providing a home-like environment. One participant explained:

“I’m here from 8am to 8 pm; we live with them [residents]. I do not call some of them by their names anymore. I call them grandpa , grandma. By living with and caring for them for an extended period , they end up becoming like family. When they die , it breaks our hearts” (FG , PACA , 931).

Boundary-setting issues such as these make the relational dimension of care especially difficult, as NH professionals can become too close to residents, which naturally complicates the transition to end-of-life care. Accompanying death for older persons who they have accompanied for living represented a challenging transition for participants who considered residents like their own relatives, as expressed by the following medical coordinator:

“They’re not just people we care for; we live with them. These are the people for whom we’ve fought for every minute to make life worth living. Professionals look after them almost as if they were their parents. Accompanying someone who is going to die , while you have accompanied them so they can live , is in itself emotionally hard” (MedCo , IDF , 116).

Their strong emotional bond with residents became a challenge for NH professionals when discussing the residents’ end-of-life preferences and the palliative decisions that needed to be made in preparation for the end-of-life care plan. Many shared avoiding these discussions, even when residents prompted them, as they did not feel ready to engage in such emotionally charged conversations.

“Palliative care supposes that we should help them think about their death , but we are unable to do that. We are primarily a place of life , and at the end , there is always death. That’s the complexity of [providing] palliative care in NHs” (NC , NA , 753).

The experience of providing palliative care in NHs was also challenged by structural and organisational constraints such as heavy workloads, a lack of time, and unmanaged pain. As a result, some participants reported that they were unable to provide dying residents with the required relief, which caused NH professionals lingering regret even after the death of the resident.

“That resident who died last week , I would have wished to have been able to stay with them a little longer , hold their hand , put on some music , so that there is a presence , like putting life into the end of life. Unfortunately , I was not able to free myself. And it is difficult to live with such a feeling” (FG , IDF , 116).

Theme 2. Multifaceted emotional strategies

When asked how they cope with the emotional demands of providing palliative care to residents, participants highlighted a diversity of emotional strategies they deployed to protect themselves and to continue fulfilling their caring roles. These ranged from genuinely expressing their emotions to modifying and suppressing their emotions to fit the moment. Modification and suppression of emotions were cited as the most commonly used strategies as opposed to the authentic expression of emotions.

“We shed tears”, “We’ve laughed with” : genuine display of emotions

Participants used expressions such as “We cry with” , “We’ve shed tears” , “We’ve laughed with” to convey the authentic emotional strategies put in place. They genuinely expressed their emotions in situations when they felt a deep connection with residents. Most of these genuine emotional strategies occurred in the moments approaching death or following death.

“All the residents on the floor are like my family. Last time I went to see Mrs. B , when my colleague told me she was dead , I was shocked , truly shocked. It was quick. I cried all my tears. I was so sad. I was unable to continue work because I was crying” (FG , IDF , 111).

In some situations, the NH professional’s personal history prompted the authentic expression of feelings. For example, if a resident’s death mirrored the death of their own loved ones, it made it difficult for them to conceal their true feelings as they usually do. Some referred to it as not being able to pretend to have no feelings.

“I accompanied my dying father in palliative care. Every time there is a death of a resident , it echoes my father’s. We had a resident death not long ago. When I saw him , I completely broke down. I cannot pretend anymore” (FG , IDF , 117).

The authenticity of emotions also manifested through allowing oneself time to grieve the death of a resident. A participant discussed requesting a day off to grieve, but some NHs also provided space for grieving the deceased residents.

“I was truly attached to Mr G. When he died , I took a day off. Everyone else [colleagues] continued living their life… laughing. For me , I could not come to work because I was grieving his death” (FG , IDF , 116).

Other participants also recognized a need for the authentic expression of emotions and requested emotional management support for the team.

“For a resident we’d known for a long time to whom we were very attached , we felt helpless with her end-of-life care , and so we genuinely asked for help. We held a round table… , and we asked for help from an external person” (FG , NA , 751).

While some participants expressed their genuine feelings, many participants across focus groups were in favour of emotions being unnoticed and noted a lack of formalized organisational strategies to deal with emotions. Many NH professionals admitted to frequently modifying their feelings to display emotions that are “acceptable.”

“ You wipe your sadness and put a smile on your face ”: modification of displayed emotions

Some NH professionals described their emotional work as involving frequent switching between sadness and joy to respond to the needs of the moment. Many shared trying to display emotions that were not what they truly felt because the situation at hand required them to convey different, often contradictory emotions; for the participants, this constituted difficult emotional labour.

“On one hand , you’ve got one person who is dying and next to them residents who are living. It is very difficult because you have to go into the room [and] take care of someone who is dying. You are sad because you know you will not see that person again. Nevertheless , the moment you see this person for a few minutes , you have to close the door , wipe your sadness , and put a smile on your face to accompany the next-door resident with a serene face. It is difficult to manage all these emotions at the same time. In one day , you have to give contradictory feelings. You are sad for one person , but at the same time , you have to bring joy to the other resident. You have to show them a different face , and that is not easy” (FG , IDF , 117).

The modification of emotions was compounded in the NH environment for some participants who not only adopted an expression in accordance with what was expected but also tried to set limits and find the appropriate time and space for revealing their true feelings when out of the NH. Participants described this ability to emotionally detach as protective:

“The moment I remove my uniform , I immediately put a different face…. When I reach home , if I have situations that have been painful , I allow myself to be restless and sad; I vent my true feelings…” (FG , PACA , 933).

“ You become numb and move on ”: suppression of feelings

Participants discussed the organisational expectation to suppress emotions in order to continue providing effective care. In a quest to fit into institutional norms, many NH professionals who describe themselves as normally prone to showing their emotions had to learn to suppress them.

“By nature , I am a very sensitive person , but now I keep all my emotions inside of me , and at the end , it becomes difficult to unload. Here , it is not common to open up and show emotions or talk about them. We are expected to keep it to ourselves and move on” (FG , PACA , 933).

Multiple exposures to death and a lack of time and a safe space to grieve deceased residents forced NH professionals to suppress their feelings in an attempt to cope with the distress and to continue providing care to residents.

“How can you display feelings when you have four successive deaths? You become numb and move on. Tomorrow you will have another one. You pretend as if everything is fine but there is a problem…” (FG , IDF , 117).

Theme 3. Switching between emotional engagement, detachment and exhaustion

Participants reported that the emotional labour of providing palliative care in NHs results in both negative and positive consequences. The majority of NH professionals noted that the negative consequences of emotional labour resulted in an inability to provide effective care, and the lack of supportive space to express their feelings caused emotional distress, feelings of guilt, and a sense of failure and powerlessness. Some participants accepted emotions as essential to their caring role and mentioned that they give meaning to their work.

“ Everyone was satisfied ”: enhanced satisfaction and meaning of work

Only a few NHs involved in the study had formalized procedures in place to support the emotional wellbeing of their healthcare professionals. These procedures included formal debriefs, a consultation with a psychologist, and massage therapy. In the majority of the NHs, informal peer-to-peer support was mentioned. In settings where emotions are acknowledged and supported, both professionals and managers reported increased satisfaction when accompanying dying residents.

“We had a resident to whom the team was so emotionally involved. When the end was approaching , emotions were high for both professionals and the resident. We [the supervisory team] requested the intervention of the external palliative care team to introduce a third party in the relationship and gently distance the team without completely disengaging them. At the end , everyone was satisfied , and the resident was properly accompanied. It ended up being one of the memorable end-of-life care for the staff” (NC , NA , 751).

When participants believed that they gave their best up to the end and that the outcome was a peaceful death, they gained a sense of pride and accomplishment. They felt they had attained their mission, which, for many, was one of the reasons they remained working in the NH despite the stressful environment.

“On his passing , the resident was so peaceful , so were relatives. It was a real sense of satisfaction. It is the kind of end-of-life care where you feel you have done the right care and that gives you motivation to stay” (FG , NA , 753).

“ It is heart-breaking ”: a sense of guilt and powerlessness

Suppression or modification of emotions affected the wellbeing of participants as well as the care they provided to residents. Different constraints such as time pressure and competing tasks added to their frustration. Their emotional distress manifested itself as constant feelings of guilt, powerlessness, and a sense of failure for not providing adequate care to residents. One of the most common sources of guilty feelings was when the NH professionals believed that they were unable to offer a peaceful, quality presence during end-of-life moments and that the resident died alone. Dying alone was considered inhumane by participants, as they believed that residents were placed in NHs mainly to ensure they do not die alone.

“Very often you tell yourself , ‘Well , I could have been by her side , tell her a comforting word , play the music she loved , rub her forehands , make sure she had a presence… , but no , she is gone and all alone’. It is not human at all , and you carry this with you for long” (FG , PACA , 933).

Participants also expressed feeling powerless when they saw residents in pain and discomfort, and their inability to provide the required comfort to the dying residents left them with an immense sense of failure and uselessness, which negatively affected their wellbeing and their satisfaction with the work done.

“It breaks your heart to see people suffering like this and little is done about it. It’s heart-breaking to think , ‘We are here to help them , but in fact we’re not even doing that’. We are useless” (FG , NA , 755).

“ You finally give up ”: distancing and exhaustion

To protect themselves from the distress associated with multiple exposures to death and a lack of institutional support, some participants admitted that they banalized death to emotionally distance themselves from dying residents, a strategy that the NH professionals recognized as inadequate.

“We give , we give , one day we can’t take it anymore and we banalize death. We don’t see death anymore. It does not affect us any longer , it becomes a commonplace gesture , mundane. Someone dies today; you attend to the next person who will be gone tomorrow , and so forth and so on. You keep accumulating and one day you explode” (FG , IDF , 117).

Other NH professionals adopted a superficial attitude in an attempt to distance themselves and detach themselves from their true feelings. They chose to involve themselves less in the therapeutic relationship by concentrating more on carrying out instrumental and technical care and less on offering a caring and relational presence.

“I go in [the room] , I give the injection and I get out. Not because I do not want to stay , but because I am thinking of the others. I cannot stay with the one who is dying while I have 70 others who are still alive. I have to look after those who are not dying” (NC , PACA , 935).

Some participants dealt with emotionally challenging situations by refusing to accept the palliative care plan of residents with whom they had strong ties. They would ignore the team’s decisions when it involved withdrawing feeding and restricting movement and instead provide the usual care such as taking blood pressure, providing hydration, and mobilizing residents, irrespective of the futile outcome or the risk of causing more suffering. In this way, they felt more useful towards the residents.

“We had a staff meeting , and they said Mrs X was in end-of-life care…that we should avoid mobilizing her and emphasize comfort care. When I arrived in the room , I did not do anything they said. Rather , I got her up from bed , I washed her , I dressed her , I brought the wheelchair , and I was about to take her out. When the nurse coordinator arrived , she could not understand what I was doing. I was in denial. I could not believe she was dying” (FG , IDF , 116).

Several participants reported feeling emotionally strained, exhausted, and lacking the energy to accomplish their mission. Some of them even resigned or verbalized their intentions to resign from their posts. Their emotional exhaustion reportedly stemmed from an accumulation of frustration, discouragement and a lack of accomplishment, feeling incompetent, and a lack of support, which prompted them to resign rather than form a negative view of the residents and fail to deliver effective care.

“You fight , you try your best to keep going , you get discouraged and finally you give up. That is why I want to do something else. Eventually , I want to take care of people and give them what they deserve. Here , I do not give them what they deserve , which frustrates me , and I accumulate. I resigned. I would rather leave the job to someone who wants to do it the way it is done. As for me , I am going to hold onto something else. I do not want to become a bitter caregiver….” (FG , PACA , 933).

The findings from this study illustrate that providing palliative care to dying residents within the NH context exposes healthcare professionals to intertwined rewarding and exhausting emotional experiences. This emotionally demanding work results in a constant switching between feelings of pride and accomplishment on the one hand and guilt, distress, and grief on the other, and it prompts healthcare professionals to identify and distance themselves from the residents to protect themselves from emotional suffering. These findings lead to greater insights into how NH professionals navigate these emotionally laden situations to meet the needs of the residents and the NH as well as their own needs. Drawing from these important findings, our discussion focuses on three key insights from the study: (1) Caring for dying residents results in both emotionally rewarding and emotionally exhausting experiences, (2) NH professionals have to perform emotional labour to navigate the experiences associated with providing palliative care, and (3) Unrecognized emotional labour undermines the wellbeing of NH professionals.

Caring for dying residents results in both emotionally rewarding and emotionally exhausting experiences

Genuine interest in caring for frail older persons is at the heart of the engagement and commitment demonstrated by the participants in our study. Participants described becoming emotionally attached to residents they care for as “unavoidable and the right thing to do,” especially given the expected “home-like” environment of the NH. In that sense, the affective dimension of working in NH and the internal motivation of the healthcare professionals aligned and helped them navigate the emotional labour of caring for dying residents and added meaning to their work. In line with other studies, the unique characteristics of NH, where care providers and residents engage repeatedly in deep personal and intimate exchanges for an extended time, forged closer and more trusting reciprocal relationships than are typically found within acute care setting nurse-patient interactions [ 35 , 36 ].

A majority of participants recalled the emotionally rewarding experiences associated with caring for frail and dying residents. The NH professionals described accompanying residents as their professional duty and took pride in making their last days as dignified, comfortable, home-like, and respectful as possible. Moreover, accompanying residents in their final moments was considered a moral responsibility by participants. The positive experiences and feelings stemming from close and trusting relationships with residents have been recognized by previous studies as central to the emotional wellbeing of NH professionals [ 15 ]. Direct caregivers for dying residents characterize those particular moments as the rare moments they feel appreciated, noticed, and like they are making a difference in settings where they generally feel unseen [ 36 ]. In particular, our participants expressed positive emotions such as engagement, pride, accomplishment, and self-worth in situations where they felt they had achieved dignity in caring for the dying residents. This is relevant because dignity represents an essential part of caring in NHs and in palliative care [ 37 , 38 ]. These personal characteristics and intrinsic motives constitute the internal resources and resilience attributes that allow healthcare professionals to cope with distressing situations surrounding accompanying death in NHs [ 10 ]. Future interventions and training should aim to reinforce the internal resources of NH professionals with a strong focus on building resilience.

Although participants perceived caring for dying residents as a rewarding experience, when the challenging working conditions within NH hindered them from achieving their moral and professional responsibility, it turned the experience into difficult emotional labour. The current NH working environment fails to provide necessary organisational resources and subsequently creates discrepancies between the ideals held by NH professionals on what constitutes the right comfort care to provide and the current practices. Under severe labour shortages, NHs prioritize technical and task-oriented activities over relational moments [ 39 ]. However, for participants in this study, not being present to hold the hands of the dying resident left them feeling guilty of failing their moral responsibility and their professional duty. Consistent with previous studies, the NH culture was found to prioritize tasks and expect healthcare professionals to be consistently “doing something” for residents versus “being” with residents [ 13 , 40 ]. This dissonance creates the most difficult emotional challenges, moral concerns, and distress for NH professionals [ 25 ]. That perceived inability to facilitate a “good death” due to organisational constraints results in moral distress for NH professionals and complicates their grieving process [ 23 , 41 ]. Echoing this, participants in our study shared how emotionally burdensome it was to constantly feel guilty of devoting less time to the “dying resident” because they were required to attend to the “living residents” instead. NH managers and policymakers should take measures to build a culture that enables healthcare professionals to prioritize the emotional needs of residents alongside their physical care needs, as both are equally important to end-of-life care.

Professionals have to perform emotional labour to navigate the experiences associated with providing palliative care

Participants in the current study used different emotional labour strategies to navigate the rewarding and challenging aspects of caring for dying residents in the NH context. Some adopted distancing strategies, such as focusing on task-based care and mechanical actions as well as avoiding feelings and emotional involvement, while others trivialized death or denied the impending death of residents. This process of strategy switching between engagement and detachment is prevalent among palliative care professionals as a way of coping with emotional demands and preventing grief [ 13 , 23 ].

Numerous participants reported that they tended to modify their feelings by displaying emotions that were different from those they felt. For example, some noted “wiping [their] face and showing a smiley face,” while others suppressed their feelings to “become numb and move on” in an attempt to display composure in the moment and comply with institutional rules. Attempting to modify one’s felt emotions to match displayed emotions is known as deep acting, whereas displaying fake, unfelt emotions and suppressing one’s felt emotions indicates a surface acting strategy [ 18 ]. The emotional strategies used by the participants in our study are similar to those commonly used by healthcare professionals in different care contexts [ 12 ]. Particularly in the NH context, emotional labour is intensified by the long-term therapeutic relationship, as the longer the therapeutic relationship the more complicated the emotional labour [ 7 , 15 ]. Participants in our study shared that the stronger and the closer the bond with the resident, the harder it was to navigate the emotional labour associated with witnessing their suffering and providing them with end-of-life care. Debates persist on the appropriate emotional distance to take when accompanying a resident with whom the healthcare professional has formed a close bond. It is noteworthy, however, that healthcare professionals who try to convey caring while remaining emotionally detached may experience increased emotional dissonance and potentially negative effects [ 23 ]. This phenomenon resonates particularly within the NH care context, where professional boundaries are blurred and difficult to respect [ 6 ].

Some participants in this study identified the importance of safe spaces where they can freely express their emotions without faking and without feeling judged, such as spending time informally with colleagues during breaks or with relatives at home. Researchers classify this as the backstage area of emotional expression, owing to the lack of formal recognition and poor appreciation of emotional labour in practice [ 42 , 43 ]. Given the complexity of emotional labour associated with providing palliative and end-of-life care in NHs, scholars recommend more strengthened, explicit, and structured backstage areas to recognize the emotional needs of healthcare professionals and support their emotional growth and resilience [ 43 ]. Unfortunately, findings from our study reiterate the inadequate support available in the NH context for their mental and emotional wellbeing.

In a few instances, some participants in our study allowed themselves to express naturally felt emotions. The close bond they had formed with residents prompted those who adopted the genuine manifestation of feelings to view the resident’s death as a parallel of their own loved one’s death; hence, they allowed themselves to react accordingly. Some took a leave of absence to process the grief, while others requested formal support as they struggled to come to terms with the death of the resident. Studies have shown that adopting naturally felt emotions as an emotional labour strategy can protect healthcare professionals from burnout, as it allows for authenticity and empathy expressions in care [ 12 ]. Genuine emotions have also been found to support nurses in the provision of compassionate care and to inspire cooperation from less-cooperative residents [ 6 ]. In our study, however, the absence of a formal supportive space within the NH to vent emotions discouraged the genuine expression of feelings. Even in the few NHs where opportunities for emotional sharing existed through support groups and psychologist interventions, the participants were reluctant to take advantage of these opportunities. One possible explanation could be that openly expressing emotions might be seen as a sign of weakness, incompetency, and inability to respect professional boundaries. Yet, organisational studies have shown that when grief and emotional suffering are acknowledged and collectively shared as a team, emotional distress is no longer perceived as an individual weakness but rather a collective suffering that requires collective measures to address. However, this cultural shift is only possible when it is supported by the institution through the provision of time, space, and opportunity to debrief and grieve [ 44 ].

Unrecognized emotional labour undermines the wellbeing of nursing home professionals

This study revealed that the emotions experienced by professionals receive relatively little attention within the NH context. This finding supports other studies that have highlighted the invisible nature of the emotional labour endured by healthcare professionals in end-of-life and palliative care within NHs [ 7 , 15 ]. Current institutional rules reinforced by professional norms such as the self-imposed emotional strategies used by healthcare professionals implicitly discourage the open expression of emotions and position genuine displays of emotion as incompetence [ 6 ]. Considering the expression of emotions as weak and a sign of a problem to be addressed leads to emotional labour being unrecognized, professionally undervalued, and even discriminated against [ 24 ]. This is deeply problematic, as unrecognized emotional labour can lead to personal, professional, and organisational negative outcomes.

The effect of emotional labour on a healthcare professional varies depending on the frequency, intensity, diversity, and length of the needed emotional displays as well as the degree of emotional dissonance between the emotions experienced and those anticipated [ 14 ]. Evidence demonstrates that a constant mismatch between felt feelings and displayed emotions leads to emotional dissonance, an internal state of conflict that can cause healthcare professionals to experience difficulty in patient interactions, high levels of stress and burnout [ 12 ], emotional “estrangement” (p.443) [ 13 ], and increased intention to leave [ 45 ]. Consistent with these studies, participants in our study felt drained and worn out by the emotional efforts associated with caring for the dying residents. They experienced guilt and feelings of powerlessness and failure, and a significant number expressed their intention to leave the NH.

At the organisational level, studies have demonstrated that poor patient outcomes and poor quality of care, including missing care opportunities and mistreating residents, are potential negative outcomes of emotional exhaustion and unrecognized emotional labour, as well as lower levels of staff recruitment and retention [ 46 ]. In contrast, emerging evidence suggests that when institutional expectations allow and support authentic emotional expression, positive effects can result for healthcare professionals, care recipients, and the healthcare system [ 12 , 14 ].

Implications for policy, practice, and research

The findings from this study expand our understanding of the complex emotional demands associated with caring for dying residents in NHs. Caring for frail older persons requires extensive time, effort, and mental and physical energy, and it involves the interplay of physical and emotional tasks and skills [ 13 ]. These findings represent a valuable contribution to the NH care system, a system that has been predominated by instrumental-focused care. The data highlights the need for a paradigm shift toward valuing the emotional labour involved in accompanying life and death in contexts that are not palliative-care specialised. Upholding quality care alongside the wellbeing of healthcare professionals requires an organisational culture that does not separate instrumental acts from the emotional labour at the very heart of the caring profession. Instead, it requires organisational changes that result in emotional support seen as a collective routine practice that strengthens the team rather than as an individual responsibility and weakness. This will allow NH professionals to regularly share their feelings and emotions, leading to emotional openness and acceptance [ 40 ].

Regular in-service training initiatives should be put in place in NHs to equip healthcare professionals with effective emotional management skills. In particular, the nursing assistants and personal support workers in our study appeared to be most affected by the negative impact of emotional labour. These categories of professional groups require tailored training to help bridge their skill gap. Capacity building approaches such as critical companionship have been proven to equip healthcare professionals with skills on the effective use of emotions in therapeutic relationships and to allow them to reflect on the use of self in caring [ 19 ]. As a lack of institutional support and peer support discourages emotional expression, NH settings should reinforce work environments in which leadership, supervisor, and co-worker support are an integral part of routine practices.

Structural deficiencies such as inadequate staffing, heavy workloads, and competing tasks leave NH healthcare professionals with inadequate time to provide optimal care. This underpins most of the challenges healthcare professionals experience in the NH context and is a primary factor in the emotional burden they experience when they fail to provide quality palliative care to dying residents. There is a need to adapt resource allocation to the complexity of providing palliative care within NHs. Further studies are needed to design interventions that support emotional regulation while increasing the resilience and emotional intelligence of healthcare professionals in NHs.

A strength of our study was the use of individual and focus groups interviews, which enabled a comprehensive exploration of individual and group views on emotional labour of NH professionals. Including professionals involved in direct care and leaders, i.e. nurse and medical coordinators, enabled to capture a diverse set of experiences and perspectives across professional categories and roles. This study did not intend to establish the levels of influence of factors such as professional category, years of work experience, level of interaction with residents or settings characteristics on emotional labour and strategies used. This may constitute the focus of future research.

This study brought to the forefront the complex emotional labour performed by NH professionals while caring for residents requiring palliative care. The results demonstrated that emotions are an undeniable part of caring for frail and dying older persons in the context of a home-like environment; however, current NH culture discourages genuine emotional sharing and emphasizes emotional suppression. Unrecognized emotions undermine the wellbeing of healthcare professionals, leading to negative individual and organisational outcomes. Understanding and acknowledging the emotional labour of NH professionals is critical to supporting their wellbeing, resilience, and retention, and it ultimately may improve the quality of care for dying residents. The stigma surrounding the emotional labour of caring can be broken by decision makers who design healthy workplace environments that celebrate emotional transparency as a strength as well as by each and every healthcare worker who bravely displays their genuine emotions in hopes to shape a new culture that fully acknowledges their humanity alongside their professional skills.

Data availability

The datasets used in this study are available on a reasonable request from the corresponding author.

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Acknowledgements

The authors of this article sincerely thank the funders of this study cited above and the scientific committee members for their valuable support. We acknowledge the contributions of all members of the Padi-Palli team. We are also grateful to the nursing homes and professionals who participated in the study. The authors thank Professor Margaret Fitch for her valuable insights into the manuscript.

This study was supported by the French Ministry of Health and Solidarity through a call for projects PREPS (Healthcare System Performance Research Program): grant number PREPS 19–0066, by the Association des Dames du Calvaire (ADC) and by the Regional Health Agencies (Agence Régionale de Santé) of Ile de France (ARS IDF) and Provence-Alpes-Côte d’Azur (ARS PACA). The funders had no role or responsibilities in the study design, data collection, data management, analysis and interpretation, or publication of this manuscript.

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EB conceptualized and designed the study, collected and analysed the data, and revised the manuscript. BU analysed the data and drafted and revised the manuscript. DL analysed the data and revised the manuscript. All authors have reviewed and approved the final manuscript.

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Research ethics approval for this study was granted by the French Committee of Protection of Person, approval number 2020.09.06 bis 20.07.31.64318. The study is registered in the National Study Database as ID-RCB 2020-A01832-37. The use of databases and data processing were implemented in accordance with French law (“Informatique et Libertés” dated January 6, 1978 and amended June 20, 2018) and European regulations (General Data Protection Regulation - GDPR dated April 27, 2016). All participants provided their informed consent in writing before their inclusion in the study. Confidentiality was ensured using codes and pseudonyms.

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Umubyeyi, B., Leboul, D. & Bagaragaza, E. “ You close the door , wipe your sadness and put on a smiling face ”: a qualitative study of the emotional labour of healthcare professionals providing palliative care in nursing homes in France. BMC Health Serv Res 24 , 1070 (2024). https://doi.org/10.1186/s12913-024-11550-7

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Study. This longitudinal multiple-case study is qualitative in nature, with data collection lasting for more than a year. As this study set out to understand the experiences, feelings, emotions, conceptions, and understanding of students about their experi-ences, a qualitative research approach was adopted to "identify issues from the ...
Multiple Case Studies
Learn about the definition, characteristics, types, and applications of multiple case studies in education research. Find examples, books, articles, and dissertations that use this methodology.
PDF A multiple case design for the investigation of information management
The multiple-case design was the best research design for this study, as it allowed the researcher to use best practices from the two international universities in order to develop a conceptual framework for the University of Johannesburg. The major benefit of using a multiple-case design was that multiple perspectives of the individuals
The Multiple Case Study Design Methodology and Application for
A book that explains how to conduct qualitative research using the multiple case study design to investigate leadership and management problems. It provides step-by-step guidelines, examples, and tips for designing and applying the methodology in various contexts.
22 Case Study Research: In-Depth Understanding in Context
This chapter outlines the strengths, challenges, and phases of case study research, a qualitative approach that focuses on a single case or a small number of cases. It also discusses how to design, collect, interpret, report, and generalize from case study data in different contexts and fields.
Perspectives from Researchers on Case Study Design
Learn about case study research design, a flexible and comprehensive method that explores complex social phenomena from multiple perspectives. Find open-access articles on case study methods, multimodal qualitative data, mixed methods, and more.
(PDF) The case study as a type of qualitative research
Learn how to conduct and analyze a case study as a qualitative research method. Download the PDF article from ResearchGate and explore related topics.
Distinguishing case study as a research method from case reports as a
Case study research is defined as a qualitative approach in which the investigator explores a real-life, contemporary bounded system (a case) or multiple bound systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information, and reports a case description and case themes.
Qualitative case study data analysis: an example from practice
Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research. Data sources: The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a ...
The Multiple Case Study Design: Methodology and Application for
The multiple case study design is an effective qualitative research method for investigating the relationships between personal, social, behavioral, psychological, organizational, cultural, and ...
PDF A multiple qualitative case study.
A descriptive qualitative multiple case study, 13, 14 part of the 'CovPall study'; a project aiming to understand the multinational response of specialist palliative and hospice care services to the COVID-19 pandemic. 5, 6, 8, 15, 16 It was guided by the following research questions: It is made available under a CC-BY 4.0 International license.
Science of the particular: An advocacy of naturalistic case study in
Case studies can provide us with in-depth understanding of a single demarcated entity. Cases can be corporations and clinics, but are usually people. There are several approaches to case study. Naturalistic case study constitutes the science of the particular. The aim of naturalistic case study is to understand with minimum intervention the particularity of a case in its ordinary situation ...
"You close the door, wipe your sadness and put on a smiling face": a
The qualitative component of the study follows a multiple case study approach . Among the aims of the qualitative study were to explore NH professionals' experiences and quality of life at work and to understand how they navigate the emotional demands associated with providing palliative care to residents. Participants and settings

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Multiple Case Studies

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Distinguishing case study as a research method from case reports as a publication type

CASE STUDY AS A RESEARCH METHODOLOGY

VARIATIONS ON CASE STUDY METHODOLOGY

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Qualitative case study data analysis: an example from practice

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