management training case studies

• SUGGESTED TOPICS
• The Magazine
• Newsletters
• Managing Yourself
• Managing Teams
• Work-life Balance
• The Big Idea
• Data & Visuals
• Reading Lists
• Case Selections
• HBR Learning
• Topic Feeds
• Account Settings
• Email Preferences

What the Case Study Method Really Teaches

• Nitin Nohria

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

Alumni responses varied but tended to follow a pattern. Almost no one referred to a specific business concept they learned. Many mentioned close friendships or the classmate who became a business or life partner. Most often, though, alumni highlighted a personal quality or skill like “increased self-confidence” or “the ability to advocate for a point of view” or “knowing how to work closely with others to solve problems.” And when I asked how they developed these capabilities, they inevitably mentioned the magic of the case method.

Harvard Business School pioneered the use of case studies to teach management in 1921. As we commemorate 100 years of case teaching, much has been  written  about the effectiveness of this method. I agree with many of these observations. Cases expose students to real business dilemmas and decisions. Cases teach students to size up business problems quickly while considering the broader organizational, industry, and societal context. Students recall concepts better when they are set in a case, much as people remember words better when used in context. Cases teach students how to apply theory in practice and how to induce theory from practice. The case method cultivates the capacity for critical analysis, judgment, decision-making, and action.

There is a word that aptly captures the broader set of capabilities our alumni reported they learned from the case method. That word is meta-skills, and these meta-skills are a benefit of case study instruction that those who’ve never been exposed to the method may undervalue.

Educators define meta-skills as a group of long-lasting abilities that allow someone to learn new things more quickly. When parents encourage a child to learn to play a musical instrument, for instance, beyond the hope of instilling musical skills (which some children will master and others may not), they may also appreciate the benefit the child derives from deliberate, consistent practice. This meta-skill is valuable for learning many other things beyond music.

In the same vein, let me suggest seven vital meta-skills students gain from the case method:

1. Preparation

There is no place for students to hide in the moments before the famed “cold call”— when the teacher can ask any student at random to open the case discussion. Decades after they graduate, students will vividly remember cold calls when they, or someone else, froze with fear, or when they rose to nail the case even in the face of a fierce grilling by the professor.

The case method creates high-powered incentives for students to prepare. Students typically spend several hours reading, highlighting, and debating cases before class, sometimes alone and sometimes in groups. The number of cases to be prepared can be overwhelming by design.

Learning to be prepared — to read materials in advance, prioritize, identify the key issues, and have an initial point of view — is a meta-skill that helps people succeed in a broad range of professions and work situations. We have all seen how the prepared person, who knows what they are talking about, can gain the trust and confidence of others in a business meeting. The habits of preparing for a case discussion can transform a student into that person.

2. Discernment

Many cases are long. A typical case may include history, industry background, a cast of characters, dialogue, financial statements, source documents, or other exhibits. Some material may be digressive or inessential. Cases often have holes — critical pieces of information that are missing.

The case method forces students to identify and focus on what’s essential, ignore the noise, skim when possible, and concentrate on what matters, meta-skills required for every busy executive confronted with the paradox of simultaneous information overload and information paucity. As one alumnus pithily put it, “The case method helped me learn how to separate the wheat from the chaff.”

3. Bias Recognition

Students often have an initial reaction to a case stemming from their background or earlier work and life experiences. For instance, people who have worked in finance may be biased to view cases through a financial lens. However, effective general managers must understand and empathize with various stakeholders, and if someone has a natural tendency to favor one viewpoint over another, discussing dozens of cases will help reveal that bias. Armed with this self-understanding, students can correct that bias or learn to listen more carefully to classmates whose different viewpoints may help them see beyond their own biases.

Recognizing and correcting personal bias can be an invaluable meta-skill in business settings when leaders inevitably have to work with people from different functions, backgrounds, and perspectives.

4. Judgment

Cases put students into the role of the case protagonist and force them to make and defend a decision. The format leaves room for nuanced discussion, but not for waffling: Teachers push students to choose an option, knowing full well that there is rarely one correct answer.

Indeed, most cases are meant to stimulate a discussion rather than highlight effective or ineffective management practice. Across the cases they study, students get feedback from their classmates and their teachers about when their decisions are more or less compelling. It enables them to develop the judgment of making decisions under uncertainty, communicating that decision to others, and gaining their buy-in — all essential leadership skills. Leaders earn respect for their judgment. It is something students in the case method get lots of practice honing.

5. Collaboration

It is better to make business decisions after extended give-and-take, debate, and deliberation. As in any team sport, people get better at working collaboratively with practice. Discussing cases in small study groups, and then in the classroom, helps students practice the meta-skill of collaborating with others. Our alumni often say they came away from the case method with better skills to participate in meetings and lead them.

Orchestrating a good collaborative discussion in which everyone contributes, every viewpoint is carefully considered, yet a thoughtful decision is made in the end is the arc of any good case discussion. Although teachers play the primary role in this collaborative process during their time at the school, it is an art that students of the case method internalize and get better at when they get to lead discussions.

6. Curiosity

Cases expose students to lots of different situations and roles. Across cases, they get to assume the role of entrepreneur, investor, functional leader, or CEO, in a range of different industries and sectors. Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers.

Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders. This curiosity serves them well throughout their lives. It makes them more agile, more adaptive, and more open to doing a wider range of things in their careers.

7. Self-Confidence

Students must inhabit roles during a case study that far outstrip their prior experience or capability, often as leaders of teams or entire organizations in unfamiliar settings. “What would you do if you were the case protagonist?” is the most common question in a case discussion. Even though they are imaginary and temporary, these “stretch” assignments increase students’ self-confidence that they can rise to the challenge.

In our program, students can study 500 cases over two years, and the range of roles they are asked to assume increases the range of situations they believe they can tackle. Speaking up in front of 90 classmates feels risky at first, but students become more comfortable taking that risk over time. Knowing that they can hold their own in a highly curated group of competitive peers enhances student confidence. Often, alumni describe how discussing cases made them feel prepared for much bigger roles or challenges than they’d imagined they could handle before their MBA studies. Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people.

There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching. This quickly became apparent when case teaching was introduced in 1921 — and it’s even truer today.

For educators and students, recognizing the value of these meta-skills can offer perspective on the broader goals of their work together. Returning to the example of piano lessons, it may be natural for a music teacher or their students to judge success by a simple measure: Does the student learn to play the instrument well? But when everyone involved recognizes the broader meta-skills that instrumental instruction can instill — and that even those who bumble their way through Bach may still derive lifelong benefits from their instruction — it may lead to a deeper appreciation of this work.

For recruiters and employers, recognizing the long-lasting set of benefits that accrue from studying via the case method can be a valuable perspective in assessing candidates and plotting their potential career trajectories.

And while we must certainly use the case method’s centennial to imagine yet more powerful ways of educating students in the future, let us be sure to assess these innovations for the meta-skills they might instill, as much as the subject matter mastery they might enable.

• Nitin Nohria is a professor at Harvard Business School and the chairman of Thrive Capital, a venture capital firm based in New York.

Partner Center

Case Study Basics

What is a case study *.

A case study is a snapshot of an organization or an industry wrestling with a dilemma, written to serve a set of pedagogical objectives. Whether raw or cooked , what distinguishes a pedagogical case study from other writing is that it centers on one or more dilemmas. Rather than take in information passively, a case study invites readers to engage the material in the case to solve the problems presented. Whatever the case structure, the best classroom cases all have these attributes: (1)The case discusses issues that allow for a number of different courses of action – the issues discussed are not “no-brainers,” (2) the case makes the management issues as compelling as possible by providing rich background and detail, and (3) the case invites the creative use of analytical management tools.

Case studies are immensely useful as teaching tools and sources of research ideas. They build a reservoir of subject knowledge and help students develop analytical skills. For the faculty, cases provide unparalleled insights into the continually evolving world of management and may inspire further theoretical inquiry.

There are many case formats. A traditional case study presents a management issue or issues calling for resolution and action. It generally breaks off at a decision point with the manager weighing a number of different options. It puts the student in the decision-maker’s shoes and allows the student to understand the stakes involved. In other instances, a case study is more of a forensic exercise. The operations and history of a company or an industry will be presented without reference to a specific dilemma. The instructor will then ask students to comment on how the organization operates, to look for the key success factors, critical relationships, and underlying sources of value. A written case will pre-package appropriate material for students, while an online case may provide a wider variety of topics in a less linear manner.

Choosing Participants for a Case Study

Many organizations cooperate in case studies out of a desire to contribute to management education. They understand the need for management school professors and students to keep current with practice.

Organizations also cooperate in order to gain exposure in management school classrooms. The increased visibility and knowledge about an organization’s operations and culture can lead to subsidiary benefits such as improved recruiting.

Finally, organizations participate because reading a case about their operations and decision making written by a neutral observer can generate useful insights. A case study preserves a moment in time and chronicles an otherwise hidden history. Managers who visit the classroom to view the case discussion generally find the experience invigorating.

The Final Product

Cases are usually written as narratives that take the reader through the events leading to the decision point, including relevant information on the historical, competitive, legal, technical, and political environment facing the organization. A written case study generally runs from 5,000 to 10,000 words of text supplemented with numerous pages of data exhibits. An online raw case may have less original text, but will require students to extract information from multiple original documents, videos of company leaders discussing the challenges, photographs, and links to articles and websites.

The first time a case is taught represents something of a test run. As students react to the material, plan to revise the case to include additional information or to delete data that does not appear useful. If the organization’s managers attend the class, their responses to student comments and questions may suggest some case revisions as well.

The sponsoring professor will generally write a “teaching note” to give other instructors advice on how to structure classroom discussion and useful bits of analysis that can be included to explicate the issues highlighted in the case study.

Finally, one case may inspire another. Either during the case writing process or after a case is done, a second “B” case might be useful to write that outlines what the organization did or that outlines new challenges faced by the organization after the timeframe of the initial case study.

* Portions of this note are adapted from E. Raymond Corey, “Writing Cases and Teaching Notes,” Harvard Business School case 399-077, with updates to reflect Yale School of Management practices for traditional and raw cases.

Smart. Open. Grounded. Inventive. Read our Ideas Made to Matter.

Which program is right for you?

Through intellectual rigor and experiential learning, this full-time, two-year MBA program develops leaders who make a difference in the world.

A rigorous, hands-on program that prepares adaptive problem solvers for premier finance careers.

A 12-month program focused on applying the tools of modern data science, optimization and machine learning to solve real-world business problems.

Earn your MBA and SM in engineering with this transformative two-year program.

Combine an international MBA with a deep dive into management science. A special opportunity for partner and affiliate schools only.

A doctoral program that produces outstanding scholars who are leading in their fields of research.

Bring a business perspective to your technical and quantitative expertise with a bachelor’s degree in management, business analytics, or finance.

A joint program for mid-career professionals that integrates engineering and systems thinking. Earn your master’s degree in engineering and management.

An interdisciplinary program that combines engineering, management, and design, leading to a master’s degree in engineering and management.

Executive Programs

A full-time MBA program for mid-career leaders eager to dedicate one year of discovery for a lifetime of impact.

This 20-month MBA program equips experienced executives to enhance their impact on their organizations and the world.

Non-degree programs for senior executives and high-potential managers.

A non-degree, customizable program for mid-career professionals.

Teaching Resources Library

Case studies.

The teaching business case studies available here are narratives that facilitate class discussion about a particular business or management issue. Teaching cases are meant to spur debate among students rather than promote a particular point of view or steer students in a specific direction.  Some of the case studies in this collection highlight the decision-making process in a business or management setting. Other cases are descriptive or demonstrative in nature, showcasing something that has happened or is happening in a particular business or management environment. Whether decision-based or demonstrative, case studies give students the chance to be in the shoes of a protagonist. With the help of context and detailed data, students can analyze what they would and would not do in a particular situation, why, and how.

Case Studies By Category

• 1-800-565-8735
• [email protected]

16 Team Building Case Studies and Training Case Studies

From corporate groups to remote employees and everything in between, the key to a strong business is creating a close-knit team. in this comprehensive case study, we look at how real-world organizations benefited from team building, training, and coaching programs tailored to their exact needs.  .

Updated: December 21, 2021

We’re big believers in the benefits of  team building ,  training and development , and  coaching and consulting  programs. That’s why our passion for helping teams achieve their goals is at the core of everything we do.

At Outback Team Building & Training,  our brand promis e  is  to be  recommended , flexible,  and  fast.  Because we understand that when it comes to building a stronger and more close-knit team, there’s no one-size-fits-all formula. Each of our customers have a unique set of challenges, goals, and definitions of success. 

And they look to us to support them in three key ways:  making their lives easy by taking on the complexities of organizing a team building or training event; acting fast so that they can get their event planned and refocus on all the other tasks they have on their plates, and giving them the confidence that they’ll get an event their team will benefit from – and enjoy.

In this definitive team building case study , we’ll do a deep dive into real-world solutions we provided for our customers.

4 Unique Team Building Events & Training Programs Custom-Tailored for Customer Needs 

1. a custom charity event for the bill & melinda gates foundation  , 2. how principia built a stronger company culture even with its remote employees working hundreds of miles apart , 3. custom change management program for the royal canadian mint, 4. greenfield global uses express team building to boost morale and camaraderie during a challenging project, 5 virtual team building activities to help remote teams reconnect, 1. how myzone used virtual team building to boost employee morale during covid-19, 2. americorps equips 90 temporary staff members for success with midyear virtual group training sessions, 3. how microsoft’s azure team used virtual team building to lift spirits during the covid-19 pandemic, 4. helping the indiana cpa society host a virtual team building activity that even the most “zoom fatigued” guests would love, 5. stemcell brightens up the holiday season for its cross-departmental team with a virtually-hosted team building activity, 3 momentum-driving events for legacy customers, 1. how a satellite employee “garnered the reputation” as her team’s pro event planner, 2. why plentyoffish continues to choose ‘the amazing race’ for their company retreat, 3. how team building helped microsoft employees donate a truckload of food, 4 successful activities executed on extremely tight timelines, 1. finding a last-minute activity over a holiday, 2. from inquiry to custom call in under 30 minutes, 3. a perfect group activity organized in one business day, 4. delivering team building for charity in under one week.

We know that every team has different needs and goals which is why we are adept at being flexible and have mastered the craft of creating custom events for any specifications.  

When the  Seattle, Washington -based head office of the Bill & Melinda Gates Foundation – a world-renowned philanthropic organization – approached us in search of a unique charity event, we knew we needed to deliver something epic. Understanding that their team had effectively done it all when it comes to charity events, it was important for them to be able to get together as a team and give back  in new ways .

Our team decided the best way to do this was to create a brand-new event for the Bill & Melinda Gates Foundation which had never been executed before. We created an entirely new charitable event – Bookworm Builders – for them and their team loved it! It allowed them to give back to their community, collaborate, get creative, and work together for a common goal. Bookworm Builders has since gone on to become a staple activity for tons of other Outback Team Building & Training customers! 

To learn more about how it all came together, read the case study:  A Custom Charity Event for the Bill & Melinda Gates Foundation .

Who said hosting an impactful training program means having your full team in the same place at the same time? Principia refused to let distance prevent them from having a great team, so they contacted us to help them find a solution. Their goals were to find better ways of working together and to create a closer-knit company culture among their 20 employees and contractors living in various parts of the country. 

We worked with Principia to host an  Emotional Intelligence  skill development training event customized to work perfectly for their remote team. The result was a massive positive impact for the company. They found they experienced improved employee alignment with a focus on company culture, as well as more emotionally aware and positive day-to-day interactions. In fact, the team made a 100% unanimous decision to bring back Outback for additional training sessions.

To learn more about this unique situation, read the full case study:  How Principia Built a Stronger Company Culture Even with its Remote Employees Working Hundreds of Miles Apart .

We know that employee training that is tailored to your organization can make the difference between an effective program and a waste of company time. That’s why our team jumped at the opportunity to facilitate a series of custom development sessions to help the Royal Canadian Mint discover the tools they needed to manage a large change within their organization. 

We hosted three custom sessions to help the organization recognize the changes that needed to be made, gain the necessary skills to effectively manage the change, and define a strategy to implement the change: 

• Session One:  The first session was held in November and focused on preparing over 65 employees for change within the company. 
• Session Two:  In December, the Mint’s leadership team participated in a program that provided the skills and mindset required to lead employees through change. 
• Session Three:  The final session in February provided another group of 65 employees with guidance on how to implement the change. 

To learn more, read the full case study:  Custom Change Management Program for the Royal Canadian Mint .

When Greenfield Global gathered a team of its A-Players to undertake a massive, challenging project, they knew it was important to build rapports among colleagues, encourage collaboration, and have some fun together.

So, we helped them host an Express Clue Murder Mystery event where their team used their unique individual strengths and problem-solving approaches in order to collaboratively solve challenges.

To learn more, read the full case study:  Greenfield Global Uses Express Team Building to Boost Morale and Camaraderie During a Challenging Project .

When the COVID-19 pandemic struck, we were proud to be able to continue supporting our customers’ goals with virtual team building activities and group training sessions.

With remote work being mandated as self-quarantine requirements are enforced on a global scale, companies began seeking ways to keep their newly-remote teams engaged and ensure morale remained as high as possible.

And MyZone was no exception. When the company found themselves feeling the effects of low employee morale and engagement, they noticed a decrease in productivity and motivation.

To make matters even more difficult, MyZone’s team works remotely with employees all over the world. This physical distancing makes it challenging for them to build a strong rapport, reinforce team dynamics, and boost morale and engagement.

The company was actively searching for an activity to help bring their employees closer together during this challenging time but kept running into a consistent issue: the majority of the team building activities they could find were meant to be done in person.

They reached out to Outback Team Building and Training and we were able to help them achieve their goals with a Virtual Clue Murder Mystery team building activity.

To learn more, read the case study here:  How MyZone Used Virtual Team Building to Boost Employee Morale During COVID-19.

AmeriCorps members are dedicated to relieving the suffering of those who have been impacted by natural disasters. And to do so, they rely on the support of a team of temporary staff members who work one-year terms with the organization. These staff focus on disseminating emergency preparedness information and even providing immediate assistance to victims of a disaster.

During its annual midyear training period, AmeriCorps gathers its entire team of temporary staff for a week of professional development seminars aimed at both helping them during their term with the company as well as equipping them with skills they can use when they leave AmeriCorps.

But when the COVID-19 pandemic got underway, AmeriCorps was forced to quickly re-evaluate the feasibility of its midyear training sessions.

That’s when they reached out to Outback. Rather than having to cancel their midyear training entirely, we were able to help them achieve their desired results with four virtual group training sessions: Clear Communication ,  Performance Management Fundamentals ,  Emotional Intelligence , and  Practical Time Management .

Find all the details in the full case study:  AmeriCorps Equips 90 Temporary Staff Members for Success with Midyear Virtual Training Sessions.

With the COVID-19 pandemic taking a significant toll on the morale of its employees, Microsoft’s Azure team knew they were overdue for an uplifting event.

It was critical for their team building event to help staff reconnect and reengage with one another. But since the team was working remotely, the activity needed to be hosted virtually and still be fun, engaging, and light-hearted.

When they reached out to Outback Team Building and Training, we discussed the team’s goals and quickly identified a Virtual Clue Murder Mystery as the perfect activity to help their team get together online and have some fun together.

For more information, check out the entire case study: How Microsoft’s Azure Team Used Virtual Team Building to Lift Spirits During the COVID-19 Pandemic.

The Indiana CPA Society is the go-to resource for the state’s certified public accountants. The organization supports CPAs with everything from continuing education to networking events and even advocacy or potential legislation issues that could affect them.

But as the time approached for one of INCPAS’ annual Thanksgiving event, the Indiana CPA Society’s Social Committee needed to plan a modified, pandemic-friendly event for a group of people who were burnt out my online meetings and experiencing Zoom fatigue.

So, we helped the team with a Self-Hosted Virtual Code Break team building activity that INCPAS staff loved so much, the organization decided to host a second event for its Young Pros and volunteers.

For INCPAS’ Social Committee, the pressure to put on an event that everyone will enjoy is something that’s always on their mind when planning out activities. And their event lived up to their hopes.

For more information, check out the entire case study: Helping the Indiana CPA Society Host a Virtual Team Building Activity That Even the Most “Zoom Fatigued” Guests Would Love .

When Stemcell was looking for a way to celebrate the holidays, lift its team members’ spirits, and help connect cross-departmental teams during the pandemic, they contacted us to help host the perfect team building activity.

They tasked us with finding an event that would help team members connect, get in the holiday spirit, and learn more about the business from one another during the midst of a stressful and challenging time.

So, we helped them host a festive, virtually-hosted Holiday Hijinks team building activity for employees from across the company.

For more information, check out the entire case study: Stemcell Brightens Up the Holiday Season for its Cross-Departmental Team with a Virtually-Hosted Team Building Activity .

We take pride in being recommended by more than 14,000 corporate groups because it means that we’ve earned their trust through delivering impactful results.

We’ve been in this business for a long time, and we know that not everybody who’s planning a corporate event is a professional event planner. But no matter if it’s their first time planning an event or their tenth, we  love  to help make our customers look good in front of their team. And when an employee at Satellite Healthcare was tasked with planning a team building event for 15 of her colleagues, she reached out to us – and we set out to do just that!

Our customer needed a collaborative activity that would help a diverse group of participants get to know each other, take her little to no time to plan, and would resonate with the entire group.

With that in mind, we helped her facilitate a  Military Support Mission . The event was a huge success and her colleagues loved it. In fact, she has now garnered a reputation as the team member who knows how to put together an awesome team building event.

To learn more, read the case study here:  How a Satellite Employee “Garnered the Reputation” as Her Team’s Pro Event Planner .

In 2013, international dating service POF (formerly known as PlentyOfFish) reached out to us in search of an exciting outdoor team building activity that they could easily put to work at their annual retreat in  Whistler, B.C . An innovative and creative company, they were in search of an activity that could help their 60 staff get to know each other better. They also wanted the event to be hosted so that they could sit back and enjoy the fun.

The solution? We helped them host their first-ever  Amazing Race  team building event.

Our event was so successful that POF has now hosted The Amazing Race at their annual retreat for  five consecutive years .

To learn more, check out our full case study:  Why PlentyOfFish Continues to Choose ‘The Amazing Race’ for Their Company Retreat .

As one of our longest-standing and most frequent collaborators, we know that Microsoft is always in search of new and innovative ways to bring their teams closer together. With a well-known reputation for being avid advocates of corporate social responsibility, Microsoft challenged us with putting together a charitable team building activity that would help their team bond outside the office and would be equal parts fun, interactive, and philanthropic. 

We analyzed which of our six charitable team building activities would be the best fit for their needs, and we landed on the perfect one: End-Hunger Games. In this event, the Microsoft team broke out into small groups, tackled challenges like relay races and target practice, and earned points in the form of non-perishable food items. Then, they used their cans and boxes of food to try and build the most impressive structure possible in a final, collaborative contest. As a result, they were able to donate a truckload of goods to the local food bank.

For more details, check out the comprehensive case study:  How Team Building Helped Microsoft Employees Donate a Truckload of Food .

Time isn’t always a luxury that’s available to our customers when it comes to planning a great team activity which is why we make sure we are fast, agile, and can accommodate any timeline. 

Nothing dampens your enjoyment of a holiday more than having to worry about work – even if it’s something fun like a team building event. But for one T-Mobile employee, this was shaping up to be the case. That’s because, on the day before the holiday weekend, she found out that she needed to organize a last-minute activity for the day after July Fourth. 

So, she reached out to Outback Team Building & Training to see if there was anything we could do to help – in less than three business days. We were happy to be able to help offer her some peace of mind over her holiday weekend by recommending a quick and easy solution: a  Code Break  team building activity. It was ready to go in less than three days, the activity organized was stress-free during her Fourth of July weekend, and, most importantly, all employees had a great experience. 

For more details, check out the full story here:  Finding a Last-Minute Activity Over a Holiday .

At Outback Team Building & Training, we know our customers don’t always have time on their side when it comes to planning and executing an event. Sometimes, they need answers right away so they can get to work on creating an unforgettable experience for their colleagues.

This was exactly the case when Black & McDonald approached us about a learning and development session that would meet the needs of their unique group, and not take too much time to plan. At 10:20 a.m., the organization reached out with an online inquiry. By 10:50 a.m., they had been connected with one of our training facilitators for a more in-depth conversation regarding their objectives.

Three weeks later, a group of 14  Toronto, Ontario -based Black & McDonald employees took part in a half-day tailor-made training program that was built around the objectives of the group, including topics such as emotional intelligence and influence, communication styles, and the value of vulnerability in a leader.

To learn more about how this event was able to come together so quickly, check out the full story:  From Inquiry to Custom Call in Under 30 Minutes .

When Conexus Credit Union contacted us on a Friday afternoon asking if we could facilitate a team building event for six employees the following Monday morning, we said, “Absolutely!” 

The team at Conexus Credit Union were looking for an activity that would get the group’s mind going and promote collaboration between colleagues. And we knew just what to recommend:  Code Break Express  – an activity filled with brainteasers, puzzles, and riddles designed to test the group’s mental strength. 

The Express version of Code Break was ideal for Conexus Credit Union’s shorter time frame because our Express activities have fewer challenges and can be completed in an hour or less. They’re self-hosted, so the company’s group organizer was able to easily and efficiently run the activity on their own.

To learn more about how we were able to come together and make this awesome event happen, take a look at our case study:  A Perfect Group Activity Organized in One Business Day .

We’ve been lucky enough to work with Accenture – a company which has appeared on FORTUNE’s list of “World’s Most Admired Companies” for 14 years in a row – on a number of team building activities in the past. 

The organization approached us with a request to facilitate a philanthropic team building activity for 15 employees. The hitch? They needed the event to be planned, organized, and executed within one week. 

Staying true to our brand promise of being fast to act on behalf of our customers, our team got to work planning Accenture’s event. We immediately put to work the experience of our Employee Engagement Consultants, the flexibility of our solutions, and the organization of our event coordinators. And six days later, Accenture’s group was hard at work on a  Charity Bike Buildathon , building bikes for kids in need.

To learn more about how we helped Accenture do some good in a short amount of time, read the full case study:  Delivering Team Building for Charity in Under One Week .

Learn More About Team Building, Training and Development, and Coaching and Consulting Solutions 

For more information about how Outback Team Building & Training can help you host unforgettable team activities to meet your specific goals and needs on virtually any time frame and budget, just reach out to our Employee Engagement Consultants.  

Subscribe To Our Newsletter

And stay updated, related articles.

How to Create an Engaging And Productive Virtual Internship Program

How to Develop an Employee Volunteer Training Program

The 15 Best Teamwork Examples to Implement at Work Today

 From corporate groups to remote employees and everything in between, the key to a strong business is creating a close-knit team. That’s why you need to do team-building sessions as much as you can.

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

50 Case Studies for Management and Supervisory Training

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2023

Management Training Institute

A division of bold new directions.

Case Studies

See how we have worked with past clients to address their workplace challenges through our management training solutions. Take a look at recent case studies to learn about Client Challenges, Our Solutions, and End Results.

• Global Company Needs Managers in UK & US Leading From Same Play Book More Info
• New York Based Content Marketing Firm Needs People Management Training More Info
• Global Shipping Firm Requires Executive Management Coaching For Top Players More Info
• Medical Services Firm Needs Interactive Leadership Training At Company Wide Retreat More Info
• North American Firm Gets Customized Management Training At Four Locations More Info

Please contact the Management Training Institute, a division of Bold New Directions, at 1-800-501-1245 to discuss how we can best meet your organization’s needs for management training programs and management training courses. We deliver onsite management training seminars at a variety of locations around the globe. Whether you want to book a virtual management training course, plan an onsite session, schedule a keynote event, plan a virtual leadership coaching program, or sign up for private executive management training, our team of experts is here to work with you. Together we can determine the management training course to meet your organizations’ needs for management skills training & development.

Contact us today at 1-800-501-1245 to request information about virtual management training courses and onsite courses from the Management Training Institute as well as other corporate training programs offered through our parent company Bold New Directions. Get a free quote and learn more about the best management skills training solutions for you.

Management Training Case Studies

Having attended this initial programme delegates returned for a series of follow-up training sessions looking in more depth at a host of topics including Change Management, Conflict Handling, Influencing Skills, Presentation Skills and Organisation & Delegation. This series of programmes has seen a transformation in staff from all parts of the businesses over the past 9 years and continues to be a great success.

Towards the end of 2012 we developed a second level management programme ‘Developing Leader’, specifically for middle managers continuing on their leadership pathway. The programme further equips managers with the skills needed to support staff and their business at a more strategic level.

Wessex Water Feedback :

Four Steps Training designed the course for our experienced managers and due to its success it has been added as a flagship programme for our 2013 training schedule.  By tailoring the programme to our workforce Graham was able to ‘hone in’ on the core skills needing to be improved.

When we piloted the management skills programme, Graham was key to facilitating the sessions and gave the group time and space to discuss and share their thoughts. The delegates embraced the exercises included in the programme which provided both meaning and purpose.  Graham has a genuine affinity with his training materials and demonstrates confidence in the difference that bespoke training can make.  Delegates from the first programme have gained so much from the course, as was evidenced in their presentations and in the journals they had kept in between the input days.

As for results, I have seen managers’ awareness of themselves and of how they get the best out of people increase. They are now adapting their management styles to match the needs of individuals in their teams and have a revitalised approach to training.

The Four Steps team worked closely with us to ensure the programme could be owned by the delegates, not by the trainers. Given this approach we are not surprised with how well it was received and the results we are already seeing.

Helen Robson Leadership & Talent Consultant, Wessex Water

How it works

For Business

Join Mind Tools

Article • 10 min read

Case Study-Based Learning

Enhancing learning through immediate application.

By the Mind Tools Content Team

If you've ever tried to learn a new concept, you probably appreciate that "knowing" is different from "doing." When you have an opportunity to apply your knowledge, the lesson typically becomes much more real.

Adults often learn differently from children, and we have different motivations for learning. Typically, we learn new skills because we want to. We recognize the need to learn and grow, and we usually need – or want – to apply our newfound knowledge soon after we've learned it.

A popular theory of adult learning is andragogy (the art and science of leading man, or adults), as opposed to the better-known pedagogy (the art and science of leading children). Malcolm Knowles , a professor of adult education, was considered the father of andragogy, which is based on four key observations of adult learners:

• Adults learn best if they know why they're learning something.
• Adults often learn best through experience.
• Adults tend to view learning as an opportunity to solve problems.
• Adults learn best when the topic is relevant to them and immediately applicable.

This means that you'll get the best results with adults when they're fully involved in the learning experience. Give an adult an opportunity to practice and work with a new skill, and you have a solid foundation for high-quality learning that the person will likely retain over time.

So, how can you best use these adult learning principles in your training and development efforts? Case studies provide an excellent way of practicing and applying new concepts. As such, they're very useful tools in adult learning, and it's important to understand how to get the maximum value from them.

What Is a Case Study?

Case studies are a form of problem-based learning, where you present a situation that needs a resolution. A typical business case study is a detailed account, or story, of what happened in a particular company, industry, or project over a set period of time.

The learner is given details about the situation, often in a historical context. The key players are introduced. Objectives and challenges are outlined. This is followed by specific examples and data, which the learner then uses to analyze the situation, determine what happened, and make recommendations.

The depth of a case depends on the lesson being taught. A case study can be two pages, 20 pages, or more. A good case study makes the reader think critically about the information presented, and then develop a thorough assessment of the situation, leading to a well-thought-out solution or recommendation.

Why Use a Case Study?

Case studies are a great way to improve a learning experience, because they get the learner involved, and encourage immediate use of newly acquired skills.

They differ from lectures or assigned readings because they require participation and deliberate application of a broad range of skills. For example, if you study financial analysis through straightforward learning methods, you may have to calculate and understand a long list of financial ratios (don't worry if you don't know what these are). Likewise, you may be given a set of financial statements to complete a ratio analysis. But until you put the exercise into context, you may not really know why you're doing the analysis.

With a case study, however, you might explore whether a bank should provide financing to a borrower, or whether a company is about to make a good acquisition. Suddenly, the act of calculating ratios becomes secondary – it's more important to understand what the ratios tell you. This is how case studies can make the difference between knowing what to do, and knowing how, when, and why to do it.

Then, what really separates case studies from other practical forms of learning – like scenarios and simulations – is the ability to compare the learner's recommendations with what actually happened. When you know what really happened, it's much easier to evaluate the "correctness" of the answers given.

When to Use a Case Study

As you can see, case studies are powerful and effective training tools. They also work best with practical, applied training, so make sure you use them appropriately.

Remember these tips:

• Case studies tend to focus on why and how to apply a skill or concept, not on remembering facts and details. Use case studies when understanding the concept is more important than memorizing correct responses.
• Case studies are great team-building opportunities. When a team gets together to solve a case, they'll have to work through different opinions, methods, and perspectives.
• Use case studies to build problem-solving skills, particularly those that are valuable when applied, but are likely to be used infrequently. This helps people get practice with these skills that they might not otherwise get.
• Case studies can be used to evaluate past problem solving. People can be asked what they'd do in that situation, and think about what could have been done differently.

Ensuring Maximum Value From Case Studies

The first thing to remember is that you already need to have enough theoretical knowledge to handle the questions and challenges in the case study. Otherwise, it can be like trying to solve a puzzle with some of the pieces missing.

Here are some additional tips for how to approach a case study. Depending on the exact nature of the case, some tips will be more relevant than others.

• Read the case at least three times before you start any analysis. Case studies usually have lots of details, and it's easy to miss something in your first, or even second, reading.
• Once you're thoroughly familiar with the case, note the facts. Identify which are relevant to the tasks you've been assigned. In a good case study, there are often many more facts than you need for your analysis.
• If the case contains large amounts of data, analyze this data for relevant trends. For example, have sales dropped steadily, or was there an unexpected high or low point?
• If the case involves a description of a company's history, find the key events, and consider how they may have impacted the current situation.
• Consider using techniques like SWOT analysis and Porter's Five Forces Analysis to understand the organization's strategic position.
• Stay with the facts when you draw conclusions. These include facts given in the case as well as established facts about the environmental context. Don't rely on personal opinions when you put together your answers.

Writing a Case Study

You may have to write a case study yourself. These are complex documents that take a while to research and compile. The quality of the case study influences the quality of the analysis. Here are some tips if you want to write your own:

• Write your case study as a structured story. The goal is to capture an interesting situation or challenge and then bring it to life with words and information. You want the reader to feel a part of what's happening.
• Present information so that a "right" answer isn't obvious. The goal is to develop the learner's ability to analyze and assess, not necessarily to make the same decision as the people in the actual case.
• Do background research to fully understand what happened and why. You may need to talk to key stakeholders to get their perspectives as well.
• Determine the key challenge. What needs to be resolved? The case study should focus on one main question or issue.
• Define the context. Talk about significant events leading up to the situation. What organizational factors are important for understanding the problem and assessing what should be done? Include cultural factors where possible.
• Identify key decision makers and stakeholders. Describe their roles and perspectives, as well as their motivations and interests.
• Make sure that you provide the right data to allow people to reach appropriate conclusions.
• Make sure that you have permission to use any information you include.

A typical case study structure includes these elements:

• Executive summary. Define the objective, and state the key challenge.
• Opening paragraph. Capture the reader's interest.
• Scope. Describe the background, context, approach, and issues involved.
• Presentation of facts. Develop an objective picture of what's happening.
• Description of key issues. Present viewpoints, decisions, and interests of key parties.

Because case studies have proved to be such effective teaching tools, many are already written. Some excellent sources of free cases are The Times 100 , CasePlace.org , and Schroeder & Schroeder Inc . You can often search for cases by topic or industry. These cases are expertly prepared, based mostly on real situations, and used extensively in business schools to teach management concepts.

Case studies are a great way to improve learning and training. They provide learners with an opportunity to solve a problem by applying what they know.

There are no unpleasant consequences for getting it "wrong," and cases give learners a much better understanding of what they really know and what they need to practice.

Case studies can be used in many ways, as team-building tools, and for skill development. You can write your own case study, but a large number are already prepared. Given the enormous benefits of practical learning applications like this, case studies are definitely something to consider adding to your next training session.

Knowles, M. (1973). 'The Adult Learner: A Neglected Species [online].' Available here .

You've accessed 1 of your 2 free resources.

Get unlimited access

Discover more content

Establishing credibility.

Inspiring Trust in Others

7 Ways to Use Office Politics Positively Video

Video Transcript

Add comment

Comments (0)

Be the first to comment!

Get unlimited access to 2500+ leadership & management resources in a range of learning formats when you join Mind Tools.

Sign-up to our newsletter

Subscribing to the Mind Tools newsletter will keep you up-to-date with our latest updates and newest resources.

Subscribe now

Business Skills

Personal Development

Leadership and Management

Most Popular

Newest Releases

Winning Body Language

Ten Things You Need to Know About AI

Mind Tools Store

About Mind Tools Content

Discover something new today

How to encourage diverse perspectives video.

Promoting and Benefitting from Diversity of Thought

How to Encourage Diverse Perspectives

Unlocking Diversity of Thought

How to Guides

How Emotionally Intelligent Are You?

Boosting Your People Skills

Self-Assessment

What's Your Leadership Style?

Learn About the Strengths and Weaknesses of the Way You Like to Lead

Recommended for you

Interrelationship diagrams.

Identifying Cause and Effect Relationships

The Most Beautiful Word in the English Language

Business Ethics and Values

Business Operations and Process Management

Customer Service

Handling Information and Data

Knowledge Management

Project Management

Strategy Tools

Career Skills

Communication Skills

Creativity Tools

Difficult Conversations

Learning Skills

Negotiation, Persuasion and Influence

Presentation Skills

Self-Development and Goal Setting

Self-Management

Stress Management and Well-Being

Time Management

Work-Life Balance

Working With Others

Change Management

Coaching and Mentoring

Decision Making

Delegation and Empowerment

Developing Your Team

Leadership Skills

Managing Conflict

Performance Management

Problem Solving

Talent Management

Team Management

Training Industry

Case study: training effective managers.

Some of your organization’s most difficult challenges likely come from working with others.

An effective manager training program will enable your leaders to resolve conflicts, improve your workplace culture and boost profits.

Download this case study to learn how Gib-San Pools transformed its productivity and business results using a management training course.

• #case study
• #management training
• #manager training

This topic is proudly sponsored by

Related Content

4 challenges managers face when giving feedback — and how ai can help, thrive teams up with clo100 to offer their global learning leaders program a cutting-edge, digital learning experience, 6 best practices for training your new hires from day one.

Stay up to date on the latest articles, webinars and resources for learning and development.

Privacy Overview

The Use of Case Studies in Training

As a trainer, I always use practical exercises and case studies in my training sessions, workshops, or masterclasses. Irrespective if it's an onsite or online training I firstly present a case study to the class showing the methods and steps that lead to its successful finalization. Then I split the trainees in two working groups and assign two different case studies for which the respective groups must prepare a solution. Then the solution for each case study will be presented in front of the whole audience by two group leaders. 

The case study is a method of sharing descriptive situations with the goal to stimulate the trainees to think and make decisions to successfully accomplish their job tasks, apply and develop new ideas, manage or improve processes, and solve problems at work. This method takes on a practical approach.

It is instrumental to include studies in training sessions as they are based on real-life situations, can be related to the trainees’ areas of responsibilities, thus enabling them to implement the respective new concepts and best practices learned.

Based on my experience of using case studies, I conclude that:

• As a training tool, case studies develop effective management and decision-making skills, enhance team spirit, better communication, and interpersonal skills, and strengthen the analytical skills of trainees.
• Training sessions that provide tons of theory but no practical case studies only lead to an incomplete know-how transfer from the trainer to the trainees.
• The only way training sessions can be really beneficial to the trainees and their companies is when the respective trained staff is able to apply and implement at their workplaces what they learned in the classrooms.
• Training beneficiaries should always request that applicable case studies be included in the training sessions.
• No training sessions should be conducted without case studies. Training based on case studies is king.?

And, after all, it will give a trainer great satisfaction to see at the end of each session that the learners acquired both theoretical and practical know-how.

Photo by Annie Spratt on Unsplash

Latest From the Blog

Organization Registration

Registration in the directory of training providers is limited to users with existing user accounts.

If you have a user account, please log in before you proceed to register in the directory.

If you don't have a user account, please create an account and then proceed to register in the directory.

Please note that in order to register in the directory, you must meet at least one of the following eligibility criteria and upload evidence for each criterion selected:

• You participated in one of IFC's capacity-building programs. 
• You participated in or graduated from a non-IFC program or a course of study, such as training of trainers, training of assessors, instructional design, training needs assessment, training impact assessment, coaching skills or similar.
• You provided a performance improvement service that includes training, coaching, instructional design or similar, and have a commendation letter from a client testifying to the excellence of service provided. 

Individual Registration

Notification.

[current-user:field_first_name] ,your profile is missing important information. Please click here to update your profile.

50 Case Studies for Management and Supervisory Training by Alan Clardy

Get full access to 50 Case Studies for Management and Supervisory Training and 60K+ other titles, with a free 10-day trial of O'Reilly.

There are also live events, courses curated by job role, and more.

Get 50 Case Studies for Management and Supervisory Training now with the O’Reilly learning platform.

O’Reilly members experience books, live events, courses curated by job role, and more from O’Reilly and nearly 200 top publishers.

Don’t leave empty-handed

Get Mark Richards’s Software Architecture Patterns ebook to better understand how to design components—and how they should interact.

It’s yours, free.

Check it out now on O’Reilly

Dive in for free with a 10-day trial of the O’Reilly learning platform—then explore all the other resources our members count on to build skills and solve problems every day.

50 Case Studies For Management and Supervisory Training (Print Version)

Free ground shipping on U.S. orders.

50 Case Studies for Management & Supervisory Training - Download

Free ground shipping on U.S. orders over $395.00

Additional information about 50 Case Studies For Management and Supervisory Training (Print Version)

Customer reviews, other items you might want to order:.

Diversity and Inclusion Combo Set (2 Courses)

Quid Pro Quo: When People with Power Make Demands

Cyber Security: Self-Defense in the Digital Age

Managing the Drug-Free Workplace

Inclusion Insights: Stereotypes, Lazy Brains & Unintentional Intolerance

Management & Leadership Skills for Supervisors - Video

Federal Wage and Hour Laws: What You Need to Know

Employment Laws: What Supervisors Need to Know - Video

© Copyright 2023 Business Training Media, Inc. - All rights reserved -- Privacy | Terms of Use | Site Map

To read this content please select one of the options below:

Please note you do not have access to teaching notes, the use of case studies in management training and development. part 1.

Industrial and Commercial Training

ISSN : 0019-7858

Article publication date: 1 February 2002

The authors draw on their considerable experience in writing and using case studies both in the UK and abroad to explain the potential benefits of using the case study method in management teaching. In this, the first of two articles on the subject, they elaborate on the potential benefits of using the case study method but also the ways in which the method can be misused. They go on to explain how case studies can be used effectively in developing management skills. In the second article they will deal with the topics of writing case studies, their use in assessment and cross‐cultural issues in using case studies. Details of the on‐line access to over 40 management case studies and exercises, with supporting teaching notes, are contained in the 5th edition of their book Skills of Management ( http://thomsonlearning. co.uk ).

• Case studies
• Management development
• Management skills

Rees, W.D. and Porter, C. (2002), "The use of case studies in management training and development. Part 1", Industrial and Commercial Training , Vol. 34 No. 1, pp. 5-8. https://doi.org/10.1108/00197850210414026

Copyright © 2002, MCB UP Limited

Related articles

We’re listening — tell us what you think, something didn’t work….

Report bugs here

All feedback is valuable

Please share your general feedback

Join us on our journey

Platform update page.

Visit emeraldpublishing.com/platformupdate to discover the latest news and updates

Questions & More Information

Answers to the most commonly asked questions here

• EXPLORE Coupons Tech Help Pro Random Article About Us Quizzes Contribute Train Your Brain Game Improve Your English Popular Categories Arts and Entertainment Artwork Books Movies Computers and Electronics Computers Phone Skills Technology Hacks Health Men's Health Mental Health Women's Health Relationships Dating Love Relationship Issues Hobbies and Crafts Crafts Drawing Games Education & Communication Communication Skills Personal Development Studying Personal Care and Style Fashion Hair Care Personal Hygiene Youth Personal Care School Stuff Dating All Categories Arts and Entertainment Finance and Business Home and Garden Relationship Quizzes Cars & Other Vehicles Food and Entertaining Personal Care and Style Sports and Fitness Computers and Electronics Health Pets and Animals Travel Education & Communication Hobbies and Crafts Philosophy and Religion Work World Family Life Holidays and Traditions Relationships Youth
• HELP US Support wikiHow Community Dashboard Write an Article Request a New Article More Ideas...
• EDIT Edit this Article
• PRO Courses Guides New Tech Help Pro Expert Videos About wikiHow Pro Coupons Quizzes Upgrade Sign In
• Browse Articles
• Learn Something New
• Train Your Brain
• Improve Your English
• Explore More
• Support wikiHow
• About wikiHow
• H&M Coupons
• Hotwire Promo Codes
• StubHub Discount Codes
• Ashley Furniture Coupons
• Blue Nile Promo Codes
• NordVPN Coupons
• Samsung Promo Codes
• Chewy Promo Codes
• Ulta Coupons
• Vistaprint Promo Codes
• Shutterfly Promo Codes
• DoorDash Promo Codes
• Office Depot Coupons
• adidas Promo Codes
• Home Depot Coupons
• DSW Coupons
• Bed Bath and Beyond Coupons
• Lowe's Coupons
• Surfshark Coupons
• Nordstrom Coupons
• Walmart Promo Codes
• Dick's Sporting Goods Coupons
• Fanatics Coupons
• Edible Arrangements Coupons
• eBay Coupons
• Log in / Sign up
• Education and Communications

How to Write a Management Case Study

Last Updated: May 28, 2023

wikiHow is a “wiki,” similar to Wikipedia, which means that many of our articles are co-written by multiple authors. To create this article, volunteer authors worked to edit and improve it over time. This article has been viewed 134,807 times. Learn more...

A management case study contains a description of real-life management issues and proposed solutions. Students, practitioners and professionals write case studies to thinking critically about issues, and devise and implement remedies for challenging management situations. A case study generally contains facts, theories, assumptions, analysis, and prioritized solutions. The following are the steps for writing a management case study.

Identify the Objective, Method and Facts

• Choose an analytical approach to increase awareness. In the preliminary stages of solving management problems, an analytical case study might best meet the goal of alerting upper management to core facts and issues. An analytical case study primarily focuses on what has occurred and why.
• Select a problem-solving approach to pinpoint and solve major issues. If the goal is to make solution recommendations, write a problem-solving case study that clearly outlines problems and solutions.

Set the Scope for Readers

Focus on Issues and Solutions

• Address the challenges that might accompany suggested solutions. For example, cross-cultural conflicts in an organization might require additional training for managers, which may require funds or an extensive search for topic experts.

Provide a Clear Conclusion

Cite References

Community Q&A

You Might Also Like

• ↑ https://www.wordstream.com/blog/ws/2017/04/03/how-to-write-a-case-study
• ↑ https://libguides.usc.edu/writingguide/casestudy
• http://monash.edu/lls/llonline/quickrefs/27-case-study.pdf
• http://www.schreyerinstitute.psu.edu/pdf/CaseWritingGuide.pdf

About This Article

To write a management case study, first give a clear industry overview of the problem and explain theories and current knowledge. Next, pinpoint all the important issues and identify any underlying problems. For example, conflicts between team members might stem from unclear workplace policies. Finally, generate effective solutions and explain why they will work. Wrap it up with a conclusion that summarizes the problems and solutions you discussed. Read on for more details on how to conduct research for a management case study and cite your sources. Did this summary help you? Yes No

• Send fan mail to authors

Did this article help you?

Featured Articles

Trending Articles

Watch Articles

• Terms of Use
• Privacy Policy
• Do Not Sell or Share My Info
• Not Selling Info

wikiHow Tech Help Pro:

Level up your tech skills and stay ahead of the curve

• Study protocol
• Open Access
• Published: 07 June 2023

The POP (Permanent Supportive Housing Overdose Prevention) Study: protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial

• Kelly M. Doran   ORCID: orcid.org/0000-0001-8961-3724 1 , 2 ,
• Allison Torsiglieri 1 ,
• Stephanie Blaufarb 1 ,
• Patricia Hernandez 3 ,
• Emily Melnick 3 ,
• Lauren Velez 3 ,
• Charles M. Cleland 2 ,
• Charles Neighbors 2 ,
• Megan A. O’Grady 4 &
• Donna Shelley 5 , 6  

Implementation Science volume  18 , Article number:  21 ( 2023 ) Cite this article

27 Accesses

7 Altmetric

Metrics details

Permanent supportive housing (PSH)—subsidized housing paired with support services such as case management—is a key part of national strategic plans to end homelessness. PSH tenants face high overdose risk due to a confluence of individual and environmental risk factors, yet little research has examined overdose prevention in PSH.

We describe the protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial (RCT) of overdose prevention practice implementation in PSH. We adapted evidence-based overdose prevention practices and implementation strategies for PSH using input from stakeholder focus groups. The trial will include 20 PSH buildings (with building size ranging from 20 to over 150 tenants) across New York City and New York’s Capital Region. Buildings will be randomized to one of four 6-month intervention waves during which they will receive a package of implementation support including training in using a PSH Overdose Prevention (POP) Toolkit, time-limited practice facilitation, and learning collaboratives delivered to staff and tenant implementation champions appointed by each building. The primary outcome is building-level fidelity to a defined list of overdose prevention practices. Secondary and exploratory implementation and effectiveness outcomes will be examined using PSH staff and tenant survey questionnaires, and analysis of tenant Medicaid data. We will explore factors related to implementation success, including barriers and facilitators, using qualitative interviews with key stakeholders. The project is being conducted through an academic-community partnership, and an Advisory Board including PSH tenants and other key stakeholders will be engaged in all stages of the project.

We describe the protocol for a hybrid type 3 stepped-wedge cluster RCT of overdose prevention practice implementation in PSH. This study will be the first controlled trial of overdose prevention implementation in PSH settings. The research will make a significant impact by testing and informing future implementation strategies to prevent overdose for a population at particularly high risk for overdose mortality. Findings from this PSH-focused research are expected to be broadly applicable to other housing settings and settings serving people experiencing homelessness.

Trial registration

ClinicalTrials.gov, NCT05786222 , registered 27 March 2023.

Contributions to the literature

• Permanent supportive housing (PSH) is an evidence-based intervention for homelessness and is expanding across the USA. Overdose is a critical issue in PSH, yet overdose prevention in this setting has been sparsely researched.

• This manuscript describes the protocol for a stepped-wedge cluster randomized controlled trial of overdose prevention practice implementation in PSH. This trial will be the largest study of overdose prevention implementation in PSH to date.

• The study will test an implementation framework and novel implementation strategies in PSH, with potential broad relevance to other housing settings.

The overdose crisis continues to worsen in the USA, and health disparities related to overdose have widened in recent years [ 1 , 2 , 3 , 4 ]. Amidst these widening disparities, the connections between social determinants of health and overdose have become increasingly clear. For example, research has shown that homelessness is strongly associated with heightened risk for overdose [ 5 , 6 , 7 , 8 ].

Permanent supportive housing (PSH)—subsidized housing paired with support services such as case management—is a key part of national strategic plans to end homelessness [ 9 ]. PSH is generally targeted to people who have been chronically homeless and have significant health conditions, including substance use disorders and mental illness. Decades of evidence, including multiple RCTs, have proven that PSH is highly effective in durably resolving an individual’s homelessness, including for people with serious mental illness and people who use drugs [ 10 , 11 , 12 , 13 , 14 ]. There are currently 387,305 units of PSH across the USA, a number that has grown consistently in the past 15 years and that continues to grow [ 9 , 15 ]. PSH is sometimes referred to as “Housing First,” which originated as a specific model, but now is a term often used more generally to describe the approach of placing people into housing without stepwise requirements or prerequisites of sobriety or “stability” of mental illness [ 16 , 17 ]. The original Housing First model has harm reduction as a core tenet, but currently there is variability regarding the extent to which different PSH agencies embrace harm reduction [ 18 ].

While housing is critical to ending homelessness, placement into housing alone may not reduce overdose risk [ 10 ]. In fact, emerging evidence suggests relatively high overdose rates in PSH and similar housing settings such as single room occupancies (SROs), likely due to a confluence of individual and environmental risk factors [ 19 , 20 , 21 ]. For example, in a 2019 survey of leaders from 49 New York PSH agencies, 63% of agencies reported at least one opioid-involved overdose among their PSH tenants in the past year, and at least 118 tenants were known to have died from an overdose in the past 5 years [ 20 ]. PSH leaders completing the survey also identified multiple modifiable gaps related to overdose prevention in PSH [ 20 ].

Evidence-based practices for overdose prevention exist but their implementation in PSH has been sparsely studied. In general, integration of harm reduction principles and substance use-related initiatives in PSH settings is variable [ 22 , 23 , 24 , 25 ]. Limited non-experimental research has examined implementation of “Housing First” principles including harm reduction into PSH [ 26 ]. One study suggested that training and practice facilitation positively impacted PSH staff knowledge and attitudes toward harm reduction, and was met with high satisfaction [ 26 ]. Researchers in Vancouver, Canada, conducted qualitative research examining overdose risk and selected overdose prevention interventions (overdose response buttons and peer-led naloxone training and distribution) in PSH and SROs [ 21 , 27 , 28 ]. However, overall there is a paucity of high-quality evidence related to harm reduction in PSH [ 29 ] and there remains a significant gap in the evidence related to the effective implementation of overdose prevention practices in these settings. Indeed, to our knowledge, there has not yet been any experimental research examining implementation of overdose prevention practices in PSH. We seek to fill this gap by conducting a stepped-wedge cluster RCT to study the implementation of overdose prevention practices across 20 PSH buildings in New York.

Study design

This study is a hybrid type 3 trial using a stepped-wedge cluster RCT design [ 30 ], with the primary goal of studying building-level implementation of overdose prevention practices in PSH and a secondary goal of examining effectiveness on clinically relevant tenant outcomes. A stepped-wedge cluster RCT design was chosen because it can provide rigorous evidence for intervention effects while allowing all participating buildings to eventually receive the intervention, in contrast to traditional two-arm RCTs. The stepped-wedge design also presents advantages including feasibility related to staggered intervention start times, and improved power versus parallel cluster RCTs.

The study is funded by the National Institute on Drug Abuse of the National Institutes of Health and was approved by the Institutional Review Board at NYU Grossman School of Medicine. The study’s external Data Safety and Monitoring Board meets twice yearly. This manuscript adheres to CONSORT reporting guidelines for cluster randomized trials (checklist provided as an Additional file 1 : Table S1).

Conceptual frameworks

We drew on the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to guide the study’s design [ 31 , 32 ]. This multilevel framework includes both process (“phases”) and determinant (“constructs”) components. We previously completed the Exploration phase through surveys conducted with PSH building leaders in New York to identify the scope of overdose and related gaps in PSH [ 20 ]. The Preparation phase of our work uses key stakeholder focus groups to refine a package of overdose prevention practices and implementation strategies for PSH. The stepped-wedge cluster RCT encompasses both the implementation and sustainment phases of EPIS, as further described in the sections that follow.

We consider key drivers of overdose risk and overdose prevention practice implementation in PSH within the EPIS constructs of outer context, inner context, bridging factors, and innovation factors. We organize these further within Rhodes’ Risk Environment Framework, which categorizes physical, social, economic, and policy-level risks at the level of the micro- and macro-environment [ 33 ]. Researchers have previously used Rhodes’ Risk Environment Framework to categorize environmental factors that confer risk for overdose in SROs, such as lack of shared spaces and rules or norms which may lead to using drugs alone [ 21 , 34 , 35 ]; many of these risks are common to PSH settings. We hypothesize that building receipt of an intervention package that considers the inner and outer context in PSH—as we are developing in the study’s Preparation phase—will improve fit and, subsequently, the likelihood that buildings will successfully implement the overdose prevention practices.

The overall project is grounded in the philosophies of community based participatory research (CBPR) [ 36 ]. From the beginning of the project, academic investigators have worked in partnership with the Metro Team (covering New York, New Jersey, and Pennsylvania) of the Corporation for Supportive Housing (CSH). CSH is intimately familiar with strengths, assets, and barriers specific to PSH. In the study’s Preparation phase, the planned overdose prevention practices and implementation strategy package are being refined based on input from PSH leaders, frontline staff, and tenants. Additionally, the project is guided by a Study Advisory Board (SAB) at all stages of the research. The SAB includes PSH tenants and staff, people with lived experience of drug use, and representatives from relevant community (e.g., harm reduction, housing advocacy) and governmental (e.g., city and state departments of health) organizations.

The stepped-wedge cluster RCT will include 20 PSH buildings in New York City (NYC) and New York’s Capital Region. These areas were chosen to provide a diversity of settings, enhancing generalizability. New York’s Capital Region encompasses the mid-sized metropolitan areas of Albany, Troy, and Schenectady. This trial includes congregate PSH buildings, where PSH tenants live together and have access to onsite social services such as case management. In general, onsite services are provided by a nonprofit agency whose portfolio might include multiple PSH buildings as well as other homeless services. Separate property/building management companies may operate the physical housing/apartment complex. Some congregate PSH buildings are mixed-use buildings, also having affordable or market-rate units for non-PSH tenants. Congregate PSH stands in contrast to “scattered site” PSH, where PSH tenants live “scattered” in subsidized market units across the community. Our trial focuses on congregate PSH because this form of PSH is most amenable to building-level interventions and most generalizable to other types of buildings serving populations at high risk for overdose.

Study population and eligibility

Twenty PSH buildings in NYC and New York’s Capital Region were selected for participation in the trial. CSH’s Metro Team conducted initial outreach to 57 nonprofit agencies in NYC and the Capital Region that provide PSH services, representing the large majority of such agencies in these areas. Agency leaders were provided with written information about the project. They were also invited to an information session held by Zoom and engaged in individual meetings to discuss the project. Agencies were asked to complete online building assessment questionnaires including questions about the size of the building, population served, number of fatal and nonfatal overdoses in the past year, and existing building practices related to overdose prevention. Questionnaires were completed by 25 agencies, encompassing 44 unique buildings. Of the 32 agencies to whom outreach was conducted who did not ultimately complete a questionnaire, 15 did not reply to outreach e-mails, 8 expressed that they were not interested in the project, and 9 were determined not to be eligible (e.g., due to not providing congregate PSH).

The CSH Metro Team and academic study team used the information gathered from their meetings with buildings and from the building assessment questionnaires to select buildings for participation. The primary selection criteria were that buildings had to have at least 20 PSH tenants and overdose had to be a significant concern, as demonstrated either by report of past overdoses on building assessment questionnaires or report from building leaders during meetings. Of the 44 buildings completing building assessment questionnaires, 2 were not eligible based on size and 2 expressed that they did not want to participate. From the remaining 40 buildings, we selected and invited 20 to participate; 3 buildings (from 2 agencies) declined and were replaced to reach 20 participating buildings. Selection prioritized buildings with high levels of overdose concern. Buildings also had to have some degree of “room to improve” in overdose prevention, as demonstrated by their building assessment questionnaire responses related to existing overdose prevention efforts or based on gaps in overdose prevention identified in meetings. To maximize generalizability, buildings were not required to demonstrate a certain level of readiness for implementing new overdose prevention practices; however, buildings did have to express willingness to engage in activities to support them in implementing new overdose prevention practices (e.g., practice facilitation meetings), and to participate in the research study procedures. We also aimed to ensure diversity in participating buildings (e.g., in population served or agency size). No more than two buildings were selected from any given nonprofit agency and, in the case of multiple buildings from the same agency, buildings were required to be geographically dispersed, have different directors, and operate independently, to avoid concerns related to “clustering.” Larger buildings were prioritized for selection in NYC given that Capital Region buildings tend to be smaller (see “Sample size” and “Power” sections).

Leaders from the 20 buildings participating in the trial completed a project participation agreement with CSH and a data sharing agreement with the academic study team.

Intervention overview

The intervention is provision of multi-faceted implementation support to PSH buildings, with the goal of helping them implement a set of evidence-based practices to reduce tenant overdose. As detailed below, the intervention will be delivered by CSH. The implementation strategies to be tested and overdose prevention practices to be implemented and are being refined in a 1-year preparation phase. In this phase, insight to and feedback on the implementation strategies and overdose prevention practices are being gathered from multiple sources including: focus groups with PSH tenants, staff, and leaders in NYC and New York’s Capital Region; additional discussions with PSH staff and leaders from buildings participating in the study; Study Advisory Board meetings; and meetings with and review by content experts and other relevant stakeholders. In future publications we will present focus group results and the final implementation strategy and overdose prevention practice packages. In the sections that follow, we provide an overview of the anticipated implementation strategies to be tested and overdose prevention practices to be implemented.

Implementation strategies to be tested

Each building participating in the trial will receive 6 months of support in implementing the overdose prevention practices. CSH will provide implementation support consisting of four primary strategies (see Table  1 ): (1) a POP (PSH Overdose Prevention) Toolkit and associated trainings, (2) tenant and staff implementation champions, (3) limited practice facilitation, and (4) learning collaboratives. These strategies—which are included in the compilation of implementation strategies from the Expert Recommendations for Implementing Change (ERIC) project [ 37 ]—were selected based on conversations between the academic study team and CSH about which implementation strategies were most likely to be accepted by and useful to PSH buildings. Together, we are calling this package of implementation support “technical assistance,” to align with language more commonly used by PSH buildings.

Trainings, initial practice facilitation meetings and coaching sessions, and learning collaboratives are expected to amount to approximately 20 h over the first 3 months of each 6-month technical assistance period. More limited practice facilitation will continue in the next 3 months, in addition to ongoing learning collaborative meetings. Outside of scheduled meetings, building leaders and staff and tenant implementation champions are expected to spend additional time working to implement the overdose prevention practices in their building. Overall, the amount of time for active implementation activities is moderate, and deliberately designed to maximize generalizability in PSH settings given real-world resource constraints.

Overdose prevention practices to be implemented

Buildings will receive support for implementing overdose prevention practices in three core categories: (1) overdose response; (2) harm reduction; and (3) support for substance use disorder (SUD) treatment. While the exact list of specific overdose prevention practices within each category is being refined in the study’s preparation phase, examples of anticipated practices are shown in Table  2 .

There has been no past research that would suggest a set of “gold standard” overdose prevention practices for PSH specifically. However, the planned overdose prevention strategies outlined above have either been studied in other settings or are generally accepted as best practices, including for structurally marginalized populations such as people experiencing homelessness [ 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]. We modeled an initial list of overdose prevention practices on an overdose prevention practice package developed by an interagency workgroup for use in isolation and quarantine hotels for people experiencing homelessness during the COVID-19 pandemic. We felt this package would be promising for adaptation to PSH settings because it was comprehensive, based on expert consensus on evidence-based practices, and developed for settings bearing similarities to PSH (e.g., serving a high-risk and stigmatized population, having private rooms where overdose is possible behind closed doors). We made initial adaptations based on results from New York PSH leader surveys in the project’s exploratory phase [ 20 ], which provided insight to inform overdose prevention in PSH. For example, the surveys revealed stigma and misunderstanding related to medication for opioid use disorder, a lack of defined referral pathways for SUD treatment, and gaps in PSH staff training on naloxone use.

We are further adapting the package of overdose prevention practices for PSH settings in a 1-year preparation phase, including gathering feedback from focus groups with PSH tenants, staff, and leaders in NYC and New York’s Capital Region, as well as from the Study Advisory Board, content experts, and other relevant stakeholders. We will adapt, refine, and finalize the list of overdose prevention practices based on this feedback. We hypothesize that adapting the overdose prevention practices for the specific PSH setting will increase the likelihood that they are viewed as acceptable and appropriate by PSH staff and tenants, and that they are implemented with fidelity and sustained.

Buildings participating in the study will receive education, training, and support for implementing the overdose prevention practices during their randomly assigned 6-month intervention (technical assistance) period. While buildings will be trained on and receive support in implementing each of the overdose prevention practices, we will not require and do not anticipate that all buildings will implement every practice. The primary goal of the study is to examine how successful buildings are in implementing the practices and we expect there to be heterogeneity across buildings.

Randomization

Buildings will be randomly assigned to one of four sequential 6-month intervention waves (five buildings per wave). With the stepped-wedge design, all study buildings will begin in the control condition. Buildings are randomly assigned to cross over at different times, with all eventually receiving the intervention. See Fig.  1 for a schematic of the stepped-wedge cluster RCT design.

Randomization will be conducted by the study statistician, who will not have contact with the PSH buildings. There is no stratification of randomization. Buildings will be notified of their assigned intervention wave before the first wave starts.

POP study stepped-wedge RCT design

Legend: Schematic of the stepped-wedge RCT design. Each building will be randomized to one of 4 waves during which they will receive the 6-month technical assistance intervention. There is a 1-month break/buffer period between each wave to facilitate measurement (e.g., staff surveys and fidelity checklist completion) and preparation for the subsequent wave. Not shown in the figure is that formal measurement of sustainment will occur for each building in the 8th month following wave completion

As a hybrid type 3 effectiveness-implementation trial, this study aims primarily to examine implementation outcomes and secondarily to explore clinical effectiveness.

Primary outcome

The primary outcome is building-level fidelity to the overdose prevention practices. This outcome will be measured with a scored building-level fidelity checklist completed by two raters blinded to building wave assignment. Checklists will be completed for each participating building at five time points: once before the first intervention wave begins, and once as each of the four waves ends. Raters will complete the fidelity checklists using a combination of program material review (e.g., lease language, building overdose prevention plan, training calendar and attendance logs), self-assessment surveys completed by building leaders and key staff, and environmental observation when possible/applicable (e.g., presence of naloxone in the building). For each overdose prevention practice, buildings will receive a fidelity checklist score of 0 (not implemented), 1 (partial implementation), or 2 (full implementation). Scores will be benchmarked to defined, objective, measurable criteria. The two raters will independently complete checklists, and their scores averaged. The primary outcome is the average sum score on the fidelity checklist, treated as a continuous variable. The range of possible scores will depend on the final number of overdose prevention practices (for example, if there are 15 final overdose prevention practices, fidelity checklist scores would range from 0 to 30). Secondary analyses will examine fidelity checklist sub-scores (e.g., for specific overdose prevention practice categories).

Secondary and exploratory outcomes

Secondary implementation and effectiveness outcomes, and exploratory effectiveness outcomes, are summarized in Tables  3 and 4 . Secondary and exploratory outcomes will be examined using (1) PSH staff surveys, (2) Medicaid data analysis, and (3) PSH tenant surveys.

PSH staff surveys will be conducted at five timepoints for staff from all participating buildings: once before the first intervention wave begins, and once as each of the four waves ends. All PSH staff with tenant-facing, supervisory, or leadership roles will be invited via e-mail to complete surveys. Invitation emails will include a hyperlink to a secure online REDCap survey. Invitations to participate in surveys will be non-coercive; it will be made clear that there will be no negative ramifications for their employment if staff decline to participate. A consent document will be included for staff to review prior to deciding whether to participate. Survey content is described in Table  3 . Surveys are anticipated to take less than 20 min to complete.

Medicaid data analysis will use statewide Medicaid data to examine tenant-level effectiveness outcomes, as outlined in Table  3 . Participating PSH buildings will provide investigators with PSH tenant identifying information. Investigators will use deterministic matching procedures to link this data with New York Medicaid data. After linkage, individual identifying information will be removed to create a de-identified Medicaid dataset for analysis; a building code will be retained and each tenant will be given a unique non-identifying study code to facilitate longitudinal analyses.

PSH tenant surveys will be used to examine exploratory effectiveness outcomes. These surveys will be administered twice for tenants of each participating building: immediately before that building’s intervention wave starts and approximately 12 months later. Paper surveys will be mailed to each tenant with a consent document, instructions for completion, and a self-addressed stamped return envelope. Tenants will also be offered the option to complete the survey by phone or online. Tenant surveys are anticipated to take approximately 30 min to complete. The study team will take multiple steps to increase survey participation rates, including explaining to tenants that the surveys are confidential and doing direct outreach in the PSH buildings. Survey content is described in Table  4 .

Buildings participating in the study will complete agreements outlining provisions for data sharing (i.e., of staff and tenant contact information for survey distribution and tenant identifying information for linkage with Medicaid data) with the study team.

Statistical analysis

To estimate effects of the intervention on the primary outcome, we will use a linear mixed model that incorporates both within- and between-cluster information and accounts for secular temporal trends. In particular, to assess the intervention effect, we will use a model with random site effects of the form: Y it  = μ + β 1 t + β 2 I it  + β 3 I it ( t  – s i ) + b i where Y it is the fidelity checklist score in building i during period t, for t  ∈  (0, 1, …, 4). Each period is 6 months; t  = 0 is the first 6-month period. I it is an indicator variable; I it  = 1 if building i has been assigned to implementation at period t and I it  = 0 otherwise. s is the period when implementation begins for building i . b i is a random effect associated with each building i (the deviation of the intercept for the building from the overall intercept μ). Models will take into account a general time trend and allow for the intervention effects to grow over time following implementation. Models will be fit using the lme4 package using R software. Each hypothesis will be tested using a two-sided level of significance α = 0.05. Similar models will be used for analysis of the secondary implementation outcomes.

Implementation sustainment will be measured in the 8th month after the conclusion of each 6-month intervention wave. Paired-samples t tests will be used to compare each building’s fidelity scores at the end of its control period with scores during the sustainment period. For buildings assigned to early waves, there is also an opportunity to measure longer term (> 12 months) sustainment within the study measurement period.

Secondary effectiveness outcomes using Medicaid data and staff surveys will use generalized linear mixed models appropriate to each type of outcome (e.g., a Poisson model to compare visit rates). Health service use variables (e.g., ED visits) will be calculated as rates when appropriate (e.g., visits per study population per time period). For all secondary and exploratory analyses, we will examine the amount and type of missing data (e.g., missing at random or not at random) and implement appropriate statistical procedures for missing data as necessary. We will examine exploratory outcomes from tenant surveys using mixed-effects regression analysis. For the post-intervention survey time point we will conduct sub-analyses limited to tenants who have lived for at least 6 months in the building.

Power and sample size

With 20 buildings participating in the study and 4 “steps” or waves in the stepped-wedge RCT (i.e., n  = 100 observations over time across all buildings given 5 total time points per building), we will have at least 80% power to detect an increase of approximately two-thirds of a standard deviation ( d  = 0.69) or larger in the primary implementation outcome, a meaningful and feasible difference. This assumes a moderate correlation between scores for the same building at different time points (ICC = 0.5), reflecting stable differences among buildings. Even in the unlikely event that we do not retain 20 buildings in the study, with 16 buildings we would still have at least 80% power to detect an increase of about three-quarters of a standard deviation ( d  = 0.77) in the primary implementation outcome. To make these effect sizes more concrete, if the checklist score had a standard deviation of 8 and an average score of 15 under the control condition, the stepped-wedge design has 80% power to detect an increase of about 5 to 6 points on the checklist score (e.g., an increase from 15 to 20).

Qualitative interviews

After the intervention is delivered, we will conduct qualitative interviews with PSH building staff, as well as tenant implementation champions, to explore multilevel factors influencing implementation, including barriers and facilitators. We will use purposeful sampling to maximize breadth and utility of information gained, interviewing individuals holding different staff roles from diverse PSH buildings participating in the study. We will also interview staff and tenant implementation champions. Interviews will use a semi-structured interview guide that will capture key EPIS framework construct domains related to success of implementation (e.g., inner context, outer context, bridging factors, innovation factors). Qualitative interviews with building leaders will additionally explore penetration of the overdose prevention practices across other buildings (i.e., those not participating in the study) operated by their agency. Interview guides will be tailored to each type of key stakeholder.

Interviews will be digitally recorded and professionally transcribed. We will perform line-by-line coding of transcripts using a list of key domains identified a priori based on EPIS and our study goals (deductive), but allowing new themes to emerge organically from the text (inductive) in the grounded theory tradition. We will also create templated summaries of each interview and conduct matrix analysis focused on key EPIS domains [ 59 ]. We will use Dedoose qualitative research web application to assist with thematic analysis and data organization [ 60 ].

Payments and incentives

The Corporation for Supportive Housing is providing an honorarium of $2000 per participating PSH agency plus an additional $1000 per building participating in the study. Tenant champions will receive an honorarium totaling approximately $500. Additionally, tenants and staff will be compensated by the study team for the time they spend completing surveys and qualitative interviews.

We describe the protocol for a hybrid type 3 stepped-wedge RCT of overdose prevention practice implementation in PSH. Changes in the epidemiology of the overdose crisis—including widening racial and ethnic disparities—highlight the necessity of concerted efforts to reduce the disparate burden of overdose faced by structurally marginalized populations. Homelessness and housing instability are strongly associated with increased risk of overdose [ 5 , 7 , 8 , 61 , 62 , 63 , 64 , 65 ]. And, while PSH is an evidence-based intervention to resolve homelessness [ 13 , 66 ], additional interventions are needed to reduce tenant overdose risk.

The 20 PSH buildings participating in the trial have distinct leadership teams, are geographically disbursed across NYC and in New York’s Capital Region, and are not generally accustomed to participating in research studies. Buildings are heterogenous in size, harm reduction orientation, and existing tenant services. Though these factors increase the complexity of study administration, ultimately, we hope that they enhance the real-world applicability and generalizability of the study. The partnership of academic researchers with the Metro Team of CSH, a national nonprofit organization focused on advancing best practices in PSH, is critical for enhancing the feasibility of the study. As a trusted entity in the field, CSH is well-positioned to deliver the implementation intervention to PSH buildings participating in the study and, eventually, to disseminate the study results nationally. Project planning has also included significant involvement of people with lived experience of drug use and as PSH tenants, which we believe has further enhanced the feasibility and real-world applicability of the study. Other strengths of the trial include the multiple, robust sources of data being used to evaluate implementation and effectiveness outcomes.

To our knowledge, our study will be the first controlled trial of overdose prevention in PSH. In general, little prior overdose prevention research has focused on PSH or similar housing settings, despite their being high-risk environments for overdose and potentially promising sites for interventions [ 34 ]. The majority of related studies have been conducted in PSH and SROs in Vancouver, Canada. There, researchers have conducted qualitative interviews with PSH residents identifying overdose risks related to using drugs alone in their rooms and potential benefits of safer supply medications [ 28 ]; qualitative interviews examining a tenant-led naloxone training and distribution intervention in SROs [ 21 ]; and qualitative interviews assessing use of overdose response buttons in a women-only PSH building [ 27 ]. These studies suggested risk factors and a few potentially promising interventions to prevent overdose in PSH and SROs, yet overall there remains a large gap in the literature related to effective interventions to prevent overdose deaths in these settings.

In general, very little implementation science research has been conducted in PSH or similar housing settings [ 26 , 67 , 68 , 69 ]. Notably, interventions for substance use disorders are still primarily delivered in healthcare or other specialized settings, despite the fact that individuals generally spend only several hours per year in healthcare settings and orders of magnitude more time in housing settings. Our study sets the stage for a new paradigm of research and strategies bringing overdose prevention to where people live and spend most of their time. Additionally, through the study we will test the application of the EPIS implementation science framework in PSH settings, shedding light on its utility in such settings and examining whether modifications should be made to maximize its applicability in future housing-based implementation efforts.

Our trial does have some limitations. First, the building-level fidelity checklist we will use to assess the primary outcome has not been previously validated. However, a similar measure has been used successfully by the study team and we have described the multiple steps we plan to take to ensure rigor of this measure, including having two blinded raters independently complete each fidelity checklist [ 70 ]. A second small limitation is that outcomes based on Medicaid data will exclude a small number of tenants (anticipated to be < 10%) who do not have Medicaid. However, using Medicaid data will allow us to feasibly assess objective outcome measures for most tenants from PSH buildings in the study. As described, we are supplementing Medicaid data analysis with tenant-collected survey questionnaires. We will attempt to maximize tenant survey participation as described earlier, but there is still the possibility of selection bias in who completes surveys and social desirability bias in responses. Finally, we are testing a package of implementation strategies; our study design will not provide experimental evidence of which of the strategies were most impactful. We will, however, explore staff and tenant champion perceptions of the specific strategies in qualitative interviews. Our priority is to test a package of implementation strategies that we believe will be effective yet which is potentially feasible for broad replication in PSH. If this research finds the package was effective, we will pursue future studies to refine the most effective combination of strategies and minimum effective dose.

In conclusion, this stepped-wedge cluster RCT will test strategies to support implementation of overdose prevention practices in PSH settings. We anticipate that the knowledge gained about implementation of overdose prevention practices in PSH will be generalizable to other types of housing settings including transitional housing provided in hotels and motels (which became more common during the COVID-19 pandemic), other types of transitional housing, SROs, and public housing or other subsidized housing buildings. Ultimately, we hope that this work will inform efforts to prevent death and suffering among the many people affected by the junction of the overdose and housing crises.

Availability of data and materials

Not applicable.

Abbreviations

Corporation for Supportive Housing

Exploration, Preparation, Implementation, Sustainment framework

Medication for opioid use disorder (e.g., methadone, buprenorphine)

New York City

Permanent supportive housing

Randomized controlled trial

Study advisory board

Single-room occupancy

Substance use disorder

Townsend T, Kline D, Rivera-Aguirre A, Bunting AM, Mauro PM, Marshall BDL, et al. Racial/ethnic and geographic trends in combined stimulant/opioid overdoses, 2007–2019. Am J Epidemiol. 2022;191(4):599–612.

Article   PubMed   PubMed Central   Google Scholar  

Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL. Trends and geographic patterns in drug and synthetic opioid overdose deaths - United States, 2013–2019. MMWR Morb Mortal Wkly Rep. 2021;70(6):202–7.

Friedman JR, Hansen H. Evaluation of increases in drug overdose mortality rates in the US by race and ethnicity before and during the COVID-19 pandemic. JAMA Psychiat. 2022;79(4):379–81.

Article   Google Scholar  

Furr-Holden D, Milam AJ, Wang L, Sadler R. African Americans now outpace whites in opioid-involved overdose deaths: a comparison of temporal trends from 1999 to 2018. Addiction. 2021;116(3):677–83.

Article   PubMed   Google Scholar  

Barocas JA, Wang J, Marshall BDL, LaRochelle MR, Bettano A, Bernson D, et al. Sociodemographic factors and social determinants associated with toxicology confirmed polysubstance opioid-related deaths. Drug Alcohol Depend. 2019;200:59–63.

Kerr T, Fairbairn N, Tyndall M, Marsh D, Li K, Montaner J, et al. Predictors of non-fatal overdose among a cohort of polysubstance-using injection drug users. Drug Alcohol Depend. 2007;87(1):39–45.

Marshall JR, Gassner SF, Anderson CL, Cooper RJ, Lotfipour S, Chakravarthy B. Socioeconomic and geographical disparities in prescription and illicit opioid-related overdose deaths in Orange County, California, from 2010–2014. Subst Abus. 2019;40(1):80–6.

Doran KM, Rahai N, McCormack RP, Milian J, Shelley D, Rotrosen J, et al. Substance use and homelessness among emergency department patients. Drug Alcohol Depend. 2018;188:328–33.

The U.S. Interagency Council on Homelessness. All In: The Federal Strategic Plan to Prevent and End Homelessness. December 2022. Available at: https://www.usich.gov/All_In_The_Federal_Strategic_Plan_to_Prevent_and_End_Homelessness.pdf . Accessed 2 Jan 2023.

National Academies of Sciences, Engineering, and Medicine. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press; 2018.

Google Scholar  

Raven MC, Niedzwiecki MJ, Kushel M. A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services. Health Serv Res. 2020;55(S2):797–806.

Kertesz SG, Baggett TP, O’Connell JJ, Buck DS, Kushel MB. Permanent supportive housing for homeless people - reframing the debate. N Engl J Med. 2016;375(22):2115–7.

Rog DJ, Marshall T, Dougherty RH, George P, Daniels AS, Ghose SS, et al. Permanent supportive housing: assessing the evidence. Psychiatr Serv. 2014;65(3):287–94.

Urbanoski K, Veldhuizen S, Krausz M, Schutz C, Somers JM, Kirst M, et al. Effects of comorbid substance use disorders on outcomes in a housing first intervention for homeless people with mental illness. Addiction. 2018;113(1):137–45.

The U.S. Department of Housing and Urban Development. The 2022 Annual Homelessness Assessment Report (AHAR) to Congress. Part I: Point-in-Time Estimates of Homelessness. December 2022. Available at: https://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf . Accessed 2 Jan 2023.

Tsemberis S. Providing housing first and recovery services for homeless adults with severe mental illness. Psychiatr Serv. 2005;56(10):1303–5.

Tsemberis S. From streets to homes: An innovative approach to supported housing for homeless adults with psychiatric disabilities. J Community Psychol. 1999;27(2):225–41.

Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651–6.

Rowe CL, Riley ED, Eagen K, Zevin B, Coffin PO. Drug overdose mortality among residents of single room occupancy buildings in San Francisco, California, 2010–2017. Drug Alcohol Depend. 2019;204:107571.

Corporation for Supportive Housing. Supportive Housing and the Opioid Crisis. Dec 2020. Available from: https://www.csh.org/resources/supportive-housing-and-the-opioid-crisis/ . Accessed 25 Apr 2023.

Bardwell G, Fleming T, Collins AB, Boyd J, McNeil R. Addressing intersecting housing and overdose crises in Vancouver, Canada: opportunities and challenges from a tenant-led overdose response intervention in single room occupancy hotels. J Urban Health. 2019;96(1):12–20.

Dickson-Gomez J, Quinn K, Bendixen A, Johnson A, Nowicki K, Ko Ko T, et al. Identifying variability in permanent supportive housing: a comparative effectiveness approach to measuring health outcomes. Am J Orthopsychiatry. 2017;87(4):414–24.

The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) and Corporation for Supportive Housing. Unlocking the door: an implementation evaluation of supportive housing for active substance users in NYC. 2012. Available from: https://www.csh.org/wp-content/uploads/2012/07/report_casafullreport_712.pdf.pdf . Accessed 12 Dec 2020.

Henwood BF, Harris T, Woo D, Winetrobe H, Rhoades H, Wenzel SL. Availability of comprehensive services in permanent supportive housing in Los Angeles. Health Soc Care Community. 2018;26(2):207–13.

Robbins PC, Callahan L, Monahan J. Perceived coercion to treatment and housing satisfaction in housing-first and supportive housing programs. Psychiatr Serv. 2009;60(9):1251–3.

Watson DP, Ahonen EQ, Shuman V, Brown M, Tsemberis S, Huynh P, et al. The Housing First Technical Assistance and Training (HFTAT) implementation strategy: outcomes from a mixed methods study of three programs. Subst Abuse Treat Prev Policy. 2018;13(1):32.

Bardwell G, Fleming T, McNeil R, Boyd J. Women’s multiple uses of an overdose prevention technology to mitigate risks and harms within a supportive housing environment: a qualitative study. BMC Womens Health. 2021;21(1):51.

Ivsins A, MacKinnon L, Bowles JM, Slaunwhite A, Bardwell G. Overdose prevention and housing: a qualitative study examining drug use, overdose risk, and access to safer supply in permanent supportive housing in Vancouver. Canada J Urban Health. 2022;99(5):855–64.

Kerman N, Polillo A, Bardwell G, Gran-Ruaz S, Savage C, Felteau C, et al. Harm reduction outcomes and practices in Housing First: a mixed-methods systematic review. Drug Alcohol Depend. 2021;228:109052.

Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–26.

Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38(1):4–23.

Moullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GA. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci. 2019;14(1):1.

Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. Int J Drug Policy. 2009;20(3):193–201.

Bardwell G, Collins AB, McNeil R, Boyd J. Housing and overdose: an opportunity for the scale-up of overdose prevention interventions? Harm Reduct J. 2017;14(1):77.

Knight KR, Lopez AM, Comfort M, Shumway M, Cohen J, Riley ED. Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: the intersection of policy, drug use, trauma, and urban space. Int J Drug Policy. 2014;25(3):556–61.

Israel BA, Schulz AJ, Parker EA, Becker AB. Community-based participatory research: policy recommendations for promoting a partnership approach in health research. Educ Health (Abingdon). 2001;14(2):182–97.

Article   CAS   PubMed   Google Scholar  

Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):21.

Chimbar L, Moleta Y. Naloxone effectiveness: a systematic review. J Addict Nurs. 2018;29(3):167–71.

Chou R, Korthuis PT, McCarty D, Coffin PO, Griffin JC, Davis-O’Reilly C, et al. Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review. Ann Intern Med. 2017;167(12):867–75.

Malta M, Varatharajan T, Russell C, Pang M, Bonato S, Fischer B. Opioid-related treatment, interventions, and outcomes among incarcerated persons: a systematic review. PLoS Med. 2019;16(12):e1003002.

Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.

Bahji A, Cheng B, Gray S, Stuart H. Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis. Acta Psychiatr Scand. 2019;140(4):313–39.

Chou R, Dana T, Blazina I, Grusing S, Fu R, Bougatsos C. U.S. Preventive Services Task Force Evidence Syntheses. Interventions for unhealthy drug use—supplemental report: a systematic review for the U.S. preventive services task force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020.

Magwood O, Salvalaggio G, Beder M, Kendall C, Kpade V, Daghmach W, et al. The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS ONE. 2020;15(1):e0227298.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Winhusen T, Walley A, Fanucchi LC, Hunt T, Lyons M, Lofwall M, et al. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): evidence-based practices in the HEALing Communities Study. Drug Alcohol Depend. 2020;217:108325.

Irvine MA, Kuo M, Buxton JA, Balshaw R, Otterstatter M, Macdougall L, et al. Modelling the combined impact of interventions in averting deaths during a synthetic-opioid overdose epidemic. Addiction. 2019;114(9):1602–13.

Barglow P. Commentary: The opioid overdose epidemic: evidence-based interventions. Am J Addict. 2018;27(8):605–7.

U.S. Interagency Council on Homelessness. Strategies to address the intersection of the opioid crisis and homelessness. 2017. Available from: https://www.usich.gov/resources/uploads/asset_library/Strategies_to_Address_Opioid_Crisis.pdf . Accessed 25 Apr 2023.

Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108.

Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: an organizational analysis. J Appl Psychol. 2001;86(5):811–24.

Dunn KE, Barrett FS, Yepez-Laubach C, Meyer AC, Hruska BJ, Sigmon SC, et al. Brief Opioid Overdose Knowledge (BOOK): a questionnaire to assess overdose knowledge in individuals who use illicit or prescribed opioids. J Addict Med. 2016;10(5):314.

Luoma JB, O’Hair AK, Kohlenberg BS, Hayes SC, Fletcher L. The development and psychometric properties of a new measure of perceived stigma toward substance users. Subst Use Misuse. 2010;45(1–2):47–57.

Owens PL, Fingar KR, McDermott KW, Muhuri PK, Heslin KC. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Statistical Brief #249: inpatient stays involving mental and substance use disorders, 2016. Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb249-appendix.pdf . Accessed 10 Sept 2021.

Peterson AM, Nau DP, Cramer JA, Benner J, Gwadry-Sridhar F, Nichol M. A checklist for medication compliance and persistence studies using retrospective databases. Value Health. 2007;10(1):3–12.

Continuity of pharmacotherapy for opioid use disorder. National Quality Forum, 2018. Available at: https://www.qualityforum.org/Qps/MeasureDetails.aspx?standardID=3175&print=0&entityTypeID=1 . Accessed 8 Sept 2020.

Bohnert AS, Bonar EE, Cunningham R. A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose. Drug Alcohol Depend. 2016;163:40–7.

Coffin PO, Santos GM, Matheson T, Behar E, Rowe C, Rubin T, et al. Behavioral intervention to reduce opioid overdose among high-risk persons with opioid use disorder: a pilot randomized controlled trial. PLoS ONE. 2017;12(10):e0183354.

Gelberg L, Robertson MJ, Arangua L, Leake BD, Sumner G, Moe A, et al. Prevalence, distribution, and correlates of hepatitis C virus infection among homeless adults in Los Angeles. Public Health Rep. 2012;127(4):407–21.

Hamilton AB. Qualitative methods in rapid turn-around health services research. VA HSR&D Cyberseminar Spotlight on Women's Health. Dec 11, 2013. Available at: https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/780-notes.pdf . Accessed 10 Sept 2020.

Dedoose Version 8.0.42, web application for managing, analyzing, and presenting qualitative and mixed method research data (2018). Los Angeles, CA: SocioCultural Research Consultants, LLC www.dedoose.com .

Baggett TP, Hwang SW, O’Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189–95.

Bradford AC, Bradford WD. The effect of evictions on accidental drug and alcohol mortality. Health Serv Res. 2020;55(1):9–17.

Colledge S, Peacock A, Leung J, Larney S, Grebely J, Hickman M, et al. The prevalence of non-fatal overdose among people who inject drugs: a multi-stage systematic review and meta-analysis. Int J Drug Policy. 2019;73:172–84.

Los Angeles County Department of Public Health, Center for Health Impact Evaluation. Recent trends in mortality rates and causes of death among people experiencing homelessness in Los Angeles County. Oct 2019. Available from: http://publichealth.lacounty.gov/chie/reports/HomelessMortality_CHIEBrief_Final.pdf . Accessed 12 Mar 2021.

San Francisco Office of the Chief Medical Examiner. Report on Accidental Overdose Deaths - January to October, 2020. Nov 2020. Available from: https://sf.gov/sites/default/files/2020-12/2020%2011_OCME%20Overdose%20Report.pdf . Accessed 2 Feb 2021.

Shinn M, Khadduri J. In the Midst of Plenty: Homelessness and What to Do About It. Hoboken: Wiley Blackwell; 2020.

Book   Google Scholar  

Tiderington E, Ikeda J, Lovell A. Stakeholder perspectives on implementation challenges and strategies for Moving On initiatives in permanent supportive housing. J Behav Health Serv Res. 2020;47(3):346–64.

Watson DP, Young J, Ahonen E, Xu H, Henderson M, Shuman V, et al. Development and testing of an implementation strategy for a complex housing intervention: protocol for a mixed methods study. Implement Sci. 2014;9:138.

Goering P, Veldhuizen S, Watson A, Adair C, Kopp B, Latimer E, et al. National At Home/Chez Soi Final Report. Calgary, AB: Mental Health Commission of Canada. 2014. Available from: https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/mhcc_at_home_report_national_cross-site_eng_2_0.pdf . Accessed 25 Apr 2023.

Hung DY, Shelley DR. Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics. Health Serv Res. 2009;44(1):103–27.

Download references

Acknowledgements

The authors would like to thank the Study Advisory Board members and Kristin Miller, who was instrumental in preliminary research and planning related to this project.

This study is funded by the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (1R01DA054976). The funder had no role in the study design or writing or reviewing the manuscript. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author information

Authors and affiliations.

Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA

Kelly M. Doran, Allison Torsiglieri & Stephanie Blaufarb

Department of Population Health, NYU School of Medicine, New York, NY, USA

Kelly M. Doran, Charles M. Cleland & Charles Neighbors

Metro Team, Corporation for Supportive Housing, New York, NY, USA

Patricia Hernandez, Emily Melnick & Lauren Velez

Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA

Megan A. O’Grady

Department of Public Health Policy and Management, NYU School of Global Public Health, New York, NY, USA

Donna Shelley

Global Center for Implementation Science and Practice, NYU School of Global Public Health, New York, NY, USA

You can also search for this author in PubMed   Google Scholar

Contributions

KMD, AT, SB, PH, EM, LV, CMC, CN, MAG, and DS participated in conceptualizing and designing the study. KMD obtained study funding. KMD drafted the manuscript. AT, SB, PH, EM, LV, CMC, CN, MAG, and DS contributed revisions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kelly M. Doran .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Institutional Review Board at NYU Grossman School of Medicine (i23-00098).

Consent for publication

Competing interests.

EM, LV, and PH are employed by the Corporation for Supportive Housing. The authors declare that they have no other competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1:.

Table S1. CONSORT 2010 checklist of information to include when reporting a cluster randomised trial.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article.

Doran, K.M., Torsiglieri, A., Blaufarb, S. et al. The POP (Permanent Supportive Housing Overdose Prevention) Study: protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial. Implementation Sci 18 , 21 (2023). https://doi.org/10.1186/s13012-023-01278-z

Download citation

Received : 27 April 2023

Accepted : 28 May 2023

Published : 07 June 2023

DOI : https://doi.org/10.1186/s13012-023-01278-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Stepped-wedge cluster randomized controlled trial
• Implementation study

Implementation Science

ISSN: 1748-5908

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]