Table 2.

Ten steps for conducting a case study

Step		Description
1	Conduct a literature review.	Follow the process of reviewing the literature: search for publications, select the publications that are more relevant for the study’s purpose, appraise them and summarise the major themes identified. Ensure that the literature review informs the formulation of the research questions.	In addition to reviewing pertinent literature on epidemiology of different cancers and healthcare in Japan, the authors reviewed issues around gender and health issues. They provided a justification for conducting the case study for uniquely addressing the topic of training sensitive healthcare examinations in Japan.
2	Formulate the research questions.	Formulate research questions that are feasible, clear, significant, ethical and connected to previous research.	To investigate SPIs’ and Japanese residents’ perceptions about the training experience in the USA, and to examine the perceived impact and acceptability of performing the learnt skills from residents and other key informants after residents returned to Japan.
3	Ensure that a case study is appropriate.	Ensure that the planned study is consistent with the four key features of case study research: In depth examination of phenomena. Naturalness. Focus on context. Use of a combination of methods.	As illustrated in table 1, the authors’ study was conducted in depth, in a natural setting, with a focus on context and using a combination of methods.
4	Determine the type of case study design.	Decide the type of case study that will be used according to Yin’s typology3: Holistic single case design. Embedded single case design. Holistic multiple case design. Embedded multiple case design.	The authors conducted an embedded single case study (see table 3).22 44–46
5	Define the boundaries of the case(s) and select the case(s).	Define the case and how it fits within its broader context. Select the case or cases that will be investigated.	The case was bounded by examining the relevant activities in the teaching institution, and the outcomes of the training in the host training institution for the trainees, instructors and clinicians who would be in a position to comment on the impact of the training.
6	Prepare to collect data.	Elaborate a case study protocol that provides a detailed description of the methods that will be used during the data collection.	The study protocol included data collection during three time periods: two initial waves of data collection in years 1 and 2 with participating residents, and a third year of follow-up data collection to assess the impact of training.
7	Collect and organise the data.	Use quantitative, qualitative or mixed methods to collect the data, depending on the research questions and the type of case study design used. Elaborate a case study database to organise the data.	The researchers implemented four data collection arms: (1) post-training evaluations from the residents and instructors; (2) follow-up semistructured interviews with residents; (3) semistructured interviews with key informants (nurses and medical assistants); and (4) a web-based questionnaire given to residents.
8	Analyse the data.	Analyse the qualitative data.3 Follow a data-driven or concept-driven approach to code the data. Search for patterns in the data and identify major themes. Analyse the quantitative data. Enter the data in a software package and run statistical analyses. Use analytical techniques suggested by Yin3: Pattern matching. Explanation building. Time-series analysis. Logic models.	The authors used a linear type of analysis logically organised by emergent themes. The authors inductively analysed the data guided by the research questions and conducted a thematic analysis. The authors conducted descriptive statistics. The specific programme used was not reported. The analytical techniques focused on pattern matching between training and skills used, and explanation for the outcomes.
9	Write the case study report.	Write a report that has the following characteristics: Provides a comprehensive description of the case. Presents the data in a concise and transparent manner. Considers the needs of its primary audience.	The researchers created a report of the findings from the resident, nurse and medical assistant participants’ reports about skill proficiency, relevance of gender and sexual health discussions, and potential for SPIs in Japan. The researchers tracked the residents’ self-reports of the number of actual sensitive examinations conducted.
10	Appraise quality.	Use quality frameworks or checklists suggested in the literature to appraise the quality of the case study.	While explicated by the authors, in accordance with recommended quality criteria, the authors conducted the research in a real-life setting, the case criteria are described, the study is about a delimited phenomenon, the authors provide relevant details about the settings, the authors employed multiple methods, the authors’ descriptions are balanced with strengths and limitations for a holistic perspective, and the authors considered the generalisability of the study. The authors did not discuss the role of reflexivity in the study.

SPI, standardised patient instructor.