Qualitative study design: Narrative inquiry

  • Qualitative study design
  • Phenomenology
  • Grounded theory
  • Ethnography

Narrative inquiry

  • Action research
  • Case Studies
  • Field research
  • Focus groups
  • Observation
  • Surveys & questionnaires
  • Study Designs Home

Narrative inquiry can reveal unique perspectives and deeper understanding of a situation. Often giving voice to marginalised populations whose perspective is not often sought. 

Narrative inquiry records the experiences of an individual or small group, revealing the lived experience or particular perspective of that individual, usually primarily through interview which is then recorded and ordered into a chronological narrative. Often recorded as biography, life history or in the case of older/ancient traditional story recording - oral history.  

  • Qualitative survey 
  • Recordings of oral history (documents can be used as support for correlation and triangulation of information mentioned in interview.) 
  • Focus groups can be used where the focus is a small group or community. 

Reveals in-depth detail of a situation or life experience.  

Can reveal historically significant issues not elsewhere recorded. 

Narrative research was considered a way to democratise the documentation and lived experience of a wider gamut of society. In the past only the rich could afford a biographer to have their life experience recorded, narrative research gave voice to marginalised people and their lived experience. 

Limitations

“The Hawthorne Effect is the tendency, particularly in social experiments, for people to modify their behaviour because they know they are being studied, and so to distort (usually unwittingly) the research findings.” SRMO  

The researcher must be heavily embedded in the topic with a broad understanding of the subject’s life experience in order to effectively and realistically represent the subject’s life experience. 

There is a lot of data to be worked through making this a time-consuming method beyond even the interview process itself. 

Subject’s will focus on their lived experience and not comment on the greater social movements at work at the time. For example, how the Global Financial Crisis affected their lives, not what caused the Global Financial Crisis. 

This research method relies heavily on the memory of the subject. Therefore, triangulation of the information is recommended such as asking the question in a different way, at a later date, looking for correlating documentation or interviewing similarly related participants. 

Example questions

  • What is the lived experience of a home carer for a terminal cancer patient? 
  • What is it like for parents to have their children die young? 
  • What was the role of the nurse in Australian hospitals in the 1960s? 
  • What is it like to live with cerebral palsy? 
  • What are the difficulties of living in a wheelchair? 

Example studies

  • Francis, M. (2018). A Narrative Inquiry Into the Experience of Being a Victim of Gun Violence. Journal of Trauma Nursing, 25(6), 381–388. https://doi-org.ezproxy-f.deakin.edu.au/10.1097/JTN.0000000000000406 
  •  Kean, B., Oprescu, F., Gray, M., & Burkett, B. (2018). Commitment to physical activity and health: A case study of a paralympic gold medallist. Disability and Rehabilitation, 40(17), 2093-2097. doi:10.1080/09638288.2017.1323234  https://doi-org.ezproxy-f.deakin.edu.au/10.1080/09638288.2017.1323234
  • Liamputtong, P. (2009). Qualitative research methods. Oxford University Press. Retrieved from http://ezproxy.deakin.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cat00097a&AN=deakin.b2351301&site=eds-live   
  • Padgett, D. (2012). Qualitative and mixed methods in public health. SAGE. Retrieved from http://ezproxy.deakin.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cat00097a&AN=deakin.b3657335&authtype=sso&custid=deakin&site=eds-live&scope=site  
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  • Last Updated: Feb 27, 2024 3:18 PM
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Narrative Inquiry

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Narrative Inquiry

2 One Design for Narrative Study

  • Published: January 2011
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This chapter considers narrative inquiry in relation to the case study design, identifying its purposes, defining features, and significance. It considers ways in which to define a case and to select a sample. It provides an illustration of a narrative study cast within a case study design, and concludes with a consideration of how to evaluate the trustworthiness of case studies.

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  • Knowledge Base

Methodology

  • What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

  • Provide new or unexpected insights into the subject
  • Challenge or complicate existing assumptions and theories
  • Propose practical courses of action to resolve a problem
  • Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

  • Exemplify a theory by showing how it explains the case under investigation
  • Expand on a theory by uncovering new concepts and ideas that need to be incorporated
  • Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

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case study narrative design

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Normal distribution
  • Degrees of freedom
  • Null hypothesis
  • Discourse analysis
  • Control groups
  • Mixed methods research
  • Non-probability sampling
  • Quantitative research
  • Ecological validity

Research bias

  • Rosenthal effect
  • Implicit bias
  • Cognitive bias
  • Selection bias
  • Negativity bias
  • Status quo bias

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Using narrative analysis in qualitative research

Last updated

7 March 2023

Reviewed by

Jean Kaluza

After spending considerable time and effort interviewing persons for research, you want to ensure you get the most out of the data you gathered. One method that gives you an excellent opportunity to connect with your data on a very human and personal level is a narrative analysis in qualitative research. 

Master narrative analysis

Analyze your qualitative data faster and surface more actionable insights

  • What is narrative analysis?

Narrative analysis is a type of qualitative data analysis that focuses on interpreting the core narratives from a study group's personal stories. Using first-person narrative, data is acquired and organized to allow the researcher to understand how the individuals experienced something. 

Instead of focusing on just the actual words used during an interview, the narrative analysis also allows for a compilation of data on how the person expressed themselves, what language they used when describing a particular event or feeling, and the thoughts and motivations they experienced. A narrative analysis will also consider how the research participants constructed their narratives.

From the interview to coding , you should strive to keep the entire individual narrative together, so that the information shared during the interview remains intact.

Is narrative analysis qualitative or quantitative?

Narrative analysis is a qualitative research method.

Is narrative analysis a method or methodology?

A method describes the tools or processes used to understand your data; methodology describes the overall framework used to support the methods chosen. By this definition, narrative analysis can be both a method used to understand data and a methodology appropriate for approaching data that comes primarily from first-person stories.

  • Do you need to perform narrative research to conduct a narrative analysis?

A narrative analysis will give the best answers about the data if you begin with conducting narrative research. Narrative research explores an entire story with a research participant to understand their personal story.

What are the characteristics of narrative research?

Narrative research always includes data from individuals that tell the story of their experiences. This is captured using loosely structured interviews . These can be a single interview or a series of long interviews over a period of time. Narrative research focuses on the construct and expressions of the story as experienced by the research participant.

  • Examples of types of narratives

Narrative data is based on narratives. Your data may include the entire life story or a complete personal narrative, giving a comprehensive account of someone's life, depending on the researched subject. Alternatively, a topical story can provide context around one specific moment in the research participant's life. 

Personal narratives can be single or multiple sessions, encompassing more than topical stories but not entire life stories of the individuals.

  • What is the objective of narrative analysis?

The narrative analysis seeks to organize the overall experience of a group of research participants' stories. The goal is to turn people's individual narratives into data that can be coded and organized so that researchers can easily understand the impact of a certain event, feeling, or decision on the involved persons. At the end of a narrative analysis, researchers can identify certain core narratives that capture the human experience.

What is the difference between content analysis and narrative analysis?

Content analysis is a research method that determines how often certain words, concepts, or themes appear inside a sampling of qualitative data . The narrative analysis focuses on the overall story and organizing the constructs and features of a narrative.

What is the difference between narrative analysis and case study in qualitative research?

A case study focuses on one particular event. A narrative analysis draws from a larger amount of data surrounding the entire narrative, including the thoughts that led up to a decision and the personal conclusion of the research participant. 

A case study, therefore, is any specific topic studied in depth, whereas narrative analysis explores single or multi-faceted experiences across time. ​​

What is the difference between narrative analysis and thematic analysis?

A thematic analysis will appear as researchers review the available qualitative data and note any recurring themes. Unlike narrative analysis, which describes an entire method of evaluating data to find a conclusion, a thematic analysis only describes reviewing and categorizing the data.

  • Capturing narrative data

Because narrative data relies heavily on allowing a research participant to describe their experience, it is best to allow for a less structured interview. Allowing the participant to explore tangents or analyze their personal narrative will result in more complete data. 

When collecting narrative data, always allow the participant the time and space needed to complete their narrative.

  • Methods of transcribing narrative data

A narrative analysis requires that the researchers have access to the entire verbatim narrative of the participant, including not just the word they use but the pauses, the verbal tics, and verbal crutches, such as "um" and "hmm." 

As the entire way the story is expressed is part of the data, a verbatim transcription should be created before attempting to code the narrative analysis.

case study narrative design

Video and audio transcription templates

  • How to code narrative analysis

Coding narrative analysis has two natural start points, either using a deductive coding system or an inductive coding system. Regardless of your chosen method, it's crucial not to lose valuable data during the organization process.

When coding, expect to see more information in the code snippets.

  • Types of narrative analysis

After coding is complete, you should expect your data to look like large blocks of text organized by the parts of the story. You will also see where individual narratives compare and diverge.

Inductive method

Using an inductive narrative method treats the entire narrative as one datum or one set of information. An inductive narrative method will encourage the research participant to organize their own story. 

To make sense of how a story begins and ends, you must rely on cues from the participant. These may take the form of entrance and exit talks. 

Participants may not always provide clear indicators of where their narratives start and end. However, you can anticipate that their stories will contain elements of a beginning, middle, and end. By analyzing these components through coding, you can identify emerging patterns in the data.

Taking cues from entrance and exit talk

Entrance talk is when the participant begins a particular set of narratives. You may hear expressions such as, "I remember when…," "It first occurred to me when…," or "Here's an example…."

Exit talk allows you to see when the story is wrapping up, and you might expect to hear a phrase like, "…and that's how we decided", "after that, we moved on," or "that's pretty much it."

Deductive method

Regardless of your chosen method, using a deductive method can help preserve the overall storyline while coding. Starting with a deductive method allows for the separation of narrative pieces without compromising the story's integrity.

Hybrid inductive and deductive narrative analysis

Using both methods together gives you a comprehensive understanding of the data. You can start by coding the entire story using the inductive method. Then, you can better analyze and interpret the data by applying deductive codes to individual parts of the story.

  • How to analyze data after coding using narrative analysis

A narrative analysis aims to take all relevant interviews and organize them down to a few core narratives. After reviewing the coding, these core narratives may appear through a repeated moment of decision occurring before the climax or a key feeling that affected the participant's outcome.

You may see these core narratives diverge early on, or you may learn that a particular moment after introspection reveals the core narrative for each participant. Either way, researchers can now quickly express and understand the data you acquired.

  • A step-by-step approach to narrative analysis and finding core narratives

Narrative analysis may look slightly different to each research group, but we will walk through the process using the Delve method for this article.

Step 1 – Code narrative blocks

Organize your narrative blocks using inductive coding to organize stories by a life event.

Example: Narrative interviews are conducted with homeowners asking them to describe how they bought their first home.

Step 2 – Group and read by live-event

You begin your data analysis by reading through each of the narratives coded with the same life event.

Example: You read through each homeowner's experience of buying their first home and notice that some common themes begin to appear, such as "we were tired of renting," "our family expanded to the point that we needed a larger space," and "we had finally saved enough for a downpayment."

Step 3 – Create a nested story structure

As these common narratives develop throughout the participant's interviews, create and nest code according to your narrative analysis framework. Use your coding to break down the narrative into pieces that can be analyzed together.

Example: During your interviews, you find that the beginning of the narrative usually includes the pressures faced before buying a home that pushes the research participants to consider homeownership. The middle of the narrative often includes challenges that come up during the decision-making process. The end of the narrative usually includes perspectives about the excitement, stress, or consequences of home ownership that has finally taken place. 

Step 4 – Delve into the story structure

Once the narratives are organized into their pieces, you begin to notice how participants structure their own stories and where similarities and differences emerge.

Example: You find in your research that many people who choose to buy homes had the desire to buy a home before their circumstances allowed them to. You notice that almost all the stories begin with the feeling of some sort of outside pressure.

Step 5 – Compare across story structure

While breaking down narratives into smaller pieces is necessary for analysis, it's important not to lose sight of the overall story. To keep the big picture in mind, take breaks to step back and reread the entire narrative of a code block. This will help you remember how participants expressed themselves and ensure that the core narrative remains the focus of the analysis.

Example: By carefully examining the similarities across the beginnings of participants' narratives, you find the similarities in pressures. Considering the overall narrative, you notice how these pressures lead to similar decisions despite the challenges faced. 

Divergence in feelings towards homeownership can be linked to positive or negative pressures. Individuals who received positive pressure, such as family support or excitement, may view homeownership more favorably. Meanwhile, negative pressures like high rent or peer pressure may cause individuals to have a more negative attitude toward homeownership.

These factors can contribute to the initial divergence in feelings towards homeownership.

Step 6 – Tell the core narrative

After carefully analyzing the data, you have found how the narratives relate and diverge. You may be able to create a theory about why the narratives diverge and can create one or two core narratives that explain the way the story was experienced.

Example: You can now construct a core narrative on how a person's initial feelings toward buying a house affect their feelings after purchasing and living in their first home.

Narrative analysis in qualitative research is an invaluable tool to understand how people's stories and ability to self-narrate reflect the human experience. Qualitative data analysis can be improved through coding and organizing complete narratives. By doing so, researchers can conclude how humans process and move through decisions and life events.

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  • Chapter 3: Home
  • Developing the Quantitative Research Design
  • Qualitative Descriptive Design
  • Qualitative Narrative Inquiry Research

What is a Qualitative Narrative Inquiry Design?

Tips for using narrative inquiry in a dissertation, summary of the elements of a qualitative narrative inquiry design, sampling and data collection, resource videos.

  • SAGE Research Methods
  • Alignment of Dissertation Components for DIS-9902ABC
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Narrative inquiry is relatively new among the qualitative research designs compared to qualitative case study, phenomenology, ethnography, and grounded theory. What distinguishes narrative inquiry is it beings with the biographical aspect of C. Wright Mills’ trilogy of ‘biography, history, and society’(O’Tolle, 2018). The primary purpose for a narrative inquiry study is participants provide the researcher with their life experiences through thick rich stories. Narrative inquiry was first used by Connelly and Calandinin as a research design to explore the perceptions and personal stories of teachers (Connelly & Clandinin, 1990). As the seminal authors, Connelly & Clandinin (1990), posited:

Although narrative inquiry has a long intellectual history both in and out of education, it is increasingly used in studies of educational experience. One theory in educational research holds that humans are storytelling organisms who, individually and socially, lead storied lives. Thus, the study of narrative is the study of the ways humans experience the world. This general concept is refined into the view that education and educational research is the construction and reconstruction of personal and social stories; learners, teachers, and researchers are storytellers and characters in their own and other's stories. In this paper we briefly survey forms of narrative inquiry in educational studies and outline certain criteria, methods, and writing forms, which we describe in terms of beginning the story, living the story, and selecting stories to construct and reconstruct narrative plots. 

Attribution: Reprint Policy for Educational Researcher: No written or oral permission is necessary to reproduce a tale, a figure, or an excerpt fewer that 500 words from this journal, or to make photocopies for classroom use. Copyright (1990) by the American Educational Research Association; reproduced with permission from the publisher. 

The popularity of narrative inquiry in education is increasing as a circular and pedagogical strategy that lends itself to the practical application of research (Kim, 2016). Keep in mind that by and large practical and professional benefits that arise from a narrative inquiry study revolve around exploring the lived experiences of educators, education administrators, students, and parents or guardians. According to Dunne (2003), 

Research into teaching is best served by narrative modes of inquiry since to understand the teacher’s practice (on his or her own part or on the part of an observer) is to find an illuminating story (or stories) to tell of what they have been involved with their student” (p. 367).

  • Temporality – the time of the experiences and how the experiences could influence the future;
  • Sociality – cultural and personal influences of the experiences; and;
  • Spatiality – the environmental surroundings during the experiences and their influence on the experiences. 

From Haydon and van der Riet (2017)

  • Narrative researchers collect stories from individuals retelling of their life experiences to a particular phenomenon. 
  • Narrative stories may explore personal characteristics or identities of individuals and how they view themselves in a personal or larger context.
  • Chronology is often important in narrative studies, as it allows participants to recall specific places, situations, or changes within their life history.

Sampling and Sample Size

  • Purposive sampling is the most often used in narrative inquiry studies. Participants must meet a form of requirement that fits the purpose, problem, and objective of the study
  • There is no rule for the sample size for narrative inquiry study. For a dissertation the normal sample size is between 6-10 participants. The reason for this is sampling should be terminated when no new information is forthcoming, which is a common strategy in qualitative studies known as sampling to the point of redundancy.

Data Collection (Methodology)

  • Participant and researcher collaborate through the research process to ensure the story told and the story align.
  • Extensive “time in the field” (can use Zoom) is spent with participant(s) to gather stories through multiple types of information including, field notes, observations, photos, artifacts, etc.
  • Field Test is strongly recommended. The purpose of a field study is to have a panel of experts in the profession of the study review the research protocol and interview questions to ensure they align to the purpose statement and research questions.
  • Member Checking is recommended. The trustworthiness of results is the bedrock of high-quality qualitative research. Member checking, also known as participant or respondent validation, is a technique for exploring the credibility of results. Data or results are returned to participants to check for accuracy and resonance with their experiences. Member checking is often mentioned as one in a list of validation techniques (Birt, et al., 2016).

Narrative Data Collection Essentials

  • Restorying is the process of gathering stories, analyzing themes for key elements (e.g., time, place, plot, and environment) and then rewriting the stories to place them within a chronological sequence (Ollerenshaw & Creswell, 2002).
  • Narrative thinking is critical in a narrative inquiry study. According to Kim (2016), the premise of narrative thinking comprises of three components, the storyteller’s narrative schema, his or her prior knowledge and experience, and cognitive strategies-yields a story that facilitates an understanding of the others and oneself in relation to others.

Instrumentation

  • In qualitative research the researcher is the primary instrument.
  • In-depth, semi-structured interviews are the norm. Because of the rigor that is required for a narrative inquiry study, it is recommended that two interviews with the same participant be conducted. The primary interview and a follow-up interview to address any additional questions that may arise from the interview transcriptions and/or member checking.

Birt, L., Scott, S., Cavers, D., Campbell, C., & Walter, F. (2016). Member checking: A tool to enhance trustworthiness or merely a nod to validation? Qualitative Health Research, 26 (13), 1802-1811. http://dx.doi.org./10.1177/1049732316654870

Cline, J. M. (2020). Collaborative learning for students with learning disabilities in inclusive classrooms: A qualitative narrative inquiry study (Order No. 28263106). Available from ProQuest Dissertations & Theses Global. (2503473076). 

Connelly, F. M., & Clandinin, D. J. (1990). Stories of Experience and Narrative Inquiry. Educational Researcher, 19 (5), 2–14. https://doi.org/10.1080/03323315.2018.1465839

Dunne, J. (2003). Arguing for teaching as a practice: A reply to Alasdair Macintyre. Journal of Philosophy of Education . https://doi.org/10.1111/1467-9752.00331 

Haydon, G., & der Riet, P. van. (2017). Narrative inquiry: A relational research methodology suitable to explore narratives of health and illness. Nordic Journal of Nursing Research , 37(2), 85–89. https://doi.org/10.1177/2057158516675217

Kim, J. H. (2016). Understanding Narrative Inquiry: The crafting and analysis of stories as research. Sage Publications. 

Kim J. H. (2017). Jeong-Hee Kim discusses narrative methods [Video]. SAGE Research Methods Video https://www-doi-org.proxy1.ncu.edu/10.4135/9781473985179

O’ Toole, J. (2018). Institutional storytelling and personal narratives: reflecting on the value of narrative inquiry. Institutional Educational Studies, 37 (2), 175-189. https://doi.org/10.1080/03323315.2018.1465839

Ollerenshaw, J. A., & Creswell, J. W. (2002). Narrative research: A comparison of two restorying data analysis approaches. Qualitative Inquiry, 8 (3), 329–347. 

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Transforming the Case Study: The Impact of Narrative and Graphic Design

by ocambern1 | Oct 10, 2023 | Design Notes

Case studies can be dense with information, and there is often little attention given to the narrative or graphic design. Is it possible for a case study to be something more? Is it possible to make a case study that’s not only visually appealing but impactful and relevant to students’ learning?

This is the question that Ramakrishnan , Angie Hartley , and Christian Thoroughgood asked when they first approached the Multimedia team at CETLOE for their courses , Marketing Research, HR Management, and Human Resource Analytics .

Image of student at a computer viewing case study example.

L ike many of the instructors who work with us, they recognized the benefit of design and immersion in their previous projects with CETLOE and wanted t o make similar improvements t o their next course .

P er Christian Thoroughgood :   

“ I had a pre-existing case study for the course, which included fictional characters, weekly case study exercises, etc., but [it] was not terribly engaging. I wanted it to be more immersive …I felt that the graphic case study approach would make the projec t “come alive” and, in turn, engage students more.”    

Our instructors and their Learning Experience Design partner provided us with their goal: to have students roleplay as a professional in a fictional company. Throughout the case study, they would not only complete projects for clients but resolve team-member disputes and navigate ethical or legal dilemmas based on real-world scenarios. 

To achieve this goal, we combined two things: narrative and graphic design. On the narrative side, we developed characters who would make up the students’ colleagues and managers. These characters each had their own position in an org chart, voice, and opinion on how best to handle challenges. On the design side, we created consistent brand identities for the companies involved and built detailed and appealing chat windows, emails, advertisements, websites, and more to immerse students in a realistic professional environment. 

For Ramakrishnan’s Marketing Research course, I worked with Ramakrishnan to deliver course assignments through the case study itself via emails, chats, or other missives from the students’ team. Rather than directing students towards “Assignment Sheet C on iCollege,” we had their colleagues assign them projects. Of course, these projects still correlated to an iCollege assignment sheet, but the goal was to provide realistic delivery. To complete this immersion, our designers emulated the style conventions of real-world companies and programs that students might interact with post-graduation, like Microsoft Teams.

Per Ramakrishnan:   

“The design makes it seem so similar to the real-world interactions that would occur in such [companies]. This takes the simulation elements to the next level. It helps students feel more involved in the company and get a better sense of the position of the key person[s] involved in the case.”  

Org chart displaying the employees of fictional company, Luster Research Group

For Angie Hartley’s HR Management course, I focused on the characterization of the two co-owners of the bakery students would be consulting for. In each of their interactions with the student, these co-owners not only typed differently , but had conflicting opinions on how best to handle HR processes, unions, and the expansion of their business . This extra level of deta il challenged students to think critically about how best to appease both owners, while still making sound decisions. On the design side, too, we added an additional media component to this case study: sound. For one of the assignments, students were encouraged to listen to a voicemail from an angry employee and decide how best to remedy her complaints in a professional manner.

“This was a completely new online course, [which] I had only ever taught face-to-face in the past … I believe the students have resp onded very well. They seem to enjoy how [the case study] ties into what they are learning .”  

Pop-up window of welcoming email from Susan and Sandra Hooper, the fictional CEOs of Sea is for Cookie Seaside Bakery and Bistro.

For Christian Throroughgood’s Human Resource Analytics course, we once again stepped up our media involvement. Initially, Christian provided us with a PowerPoint presentation that contained a basic company logo, the company’s story and values, and some statistics students would use in their assignments. Rather than delivering this information through chats or emails, like we did with previous case studies, we decided to go another step further. Using sites.gsu.edu, w e created a company website that would not only introduce students to their client but provide all the information they would need to complete their first assignment . The design elements used to create the website, the colors, fonts, and shape language, were then echoed throug hout the rest of the case stud y to maintain consistency and realism . 

Per Christian, 

“I was just surprised by how well it all turned out! Week-to-week, students are exposed to different ways of interacting with the case study, from reading through text and email conversations between the case’s fictional characters to reading information from the case’s fictional company website etc. The case study has been transformed from its previous version.”  

Graphic org chart of the fictional company, Henshaws, and a shortened org chart of the external consulting firm working with Henshaws.

At the end of the day, traditional case studies are still a valuable tool. They’re not only accessible but they help students practice analysis, problem solving, and practical application. By no means do we want traditional, textual case studies to go away, even if we think they’re a little boring. Rather, we want to encourage instructors to think about the impact narrative and graphic design can have on their assignments. As we discovered while working on these case studies, providing a polished, detailed, and engaging experience for students truly makes a difference in their learning. 

Per Ramakrishnan,   

“ The most positive responses involved the levels of participation and the levels of detail that the students showcased in their reports and during class discussions…I have had many students mention [that] they would miss working on the graphic cases once the semester ended.”   

If you’d like to find out more about CETLOE’s Learning Design Team, try checking out our multimedia portfolio , perusing our sample course or design suggestions , or exploring our UX research and design capabilities . If those get you inspired, share your ideas with us! Every design project starts with a conversation. Let’s see where ours goes.   

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International Conference on Human-Computer Interaction

HCII 2023: Universal Access in Human-Computer Interaction pp 620–631 Cite as

Research on the Design Narrative for Medical Popular Science Serious Games: A Case Study of AIDS Prevention Game “Bluebridge Cafe”

  • Xu Yang 9 ,
  • Xin Sun 10 &
  • Jianhua Yang 11  
  • Conference paper
  • First Online: 09 July 2023

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Part of the Lecture Notes in Computer Science book series (LNCS,volume 14021)

The primary aim in the present study was to investigate the design narrative expression in the medical popular science serious games. Methods of integrating the relevant content of disease prevention and treatment into the challenging, interesting, and interactive game segments in serious games, and how to present it through the narrative and design methods were key areas of investigation. Firstly, the relevant theoretical background was reviewed. After theoretical research, the relationships between content, vision, and interactive experiences in the AIDS prevention game “Bluebridge Cafe” developed by Tencent were investigated and analyzed. The focuses in the present study were the design and expression of content related to AIDS prevention and post infection disease treatment in the game, how to guide users to change their attitudes and behaviors in storytelling, and how to combine the content with the functions of the game segments. The results of the present study can help improve the design of functional games for medical science popularization, so as to enhance the transmission of health information and improve the effects of medical knowledge popularization.

  • Medical Serious Game
  • AIDS education

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Acknowledgement

This research was supported by the Key Project of the National Social Science Fund (22AC003).

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Yang, X., Sun, X., Yang, J. (2023). Research on the Design Narrative for Medical Popular Science Serious Games: A Case Study of AIDS Prevention Game “Bluebridge Cafe”. In: Antona, M., Stephanidis, C. (eds) Universal Access in Human-Computer Interaction. HCII 2023. Lecture Notes in Computer Science, vol 14021. Springer, Cham. https://doi.org/10.1007/978-3-031-35897-5_44

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What Is Narrative Design? How Do You Learn It?

Nathan scott.

I wrote this post to provide a clear overview on the craft of narrative design and how you can get started.

Everything is based on my first hand experience from pivoting from a different discipline to narrative design (from scratch).

I’ll be covering these three main topics:

  • What is narrative design?
  • What is “good” narrative design?
  • How do you train your narrative design skills?

But before we dive in, it’s important to remember: The first step to being a good narrative designer is to be a good game designer .

Narrative design is a sub-discipline of game design , which means you are a game designer first . Refine the basics before you specialize.

By the way, as you’re reading this post, if you have any questions or issues implementing you can get free help in the  #game-design  channel in  Funsmith Club Discord , or you can DM me there.

Alright. Let’s get into it.

Table of Contents

What is Narrative Design Under Video Game Design?

Game development is a young field, and narrative design is even younger. In fact, the term “narrative design” was first used in games in 2006. That was less than 18 years ago. Narrative design can’t even vote yet!

In many ways, this is exciting. We’re still exploring narrative design and discovering new expectations and conventions. Every year designers come up with new ways of engaging the player.

But it also means that any “rules” I tell you about narrative design will have exceptions. At one studio, I worked closely with writers to turn story into gameplay. At another, writers came in after implementation to provide feedback and copy edit.

That being said, let’s go over the fundamentals of narrative design and how it’s different from other game studio roles.

Narrative Design is Not Game Writing

As a narrative designer, you work closely with the story, but you are not a game writer. You may have input on the plot, characters, or lore, but it is rare that you will actually write the storyline.

Often, narrative designers are bringing other people’s visions to life. A writer may bring a script, pitch, or idea to you, and it is then your job as the narrative designer to make that idea happen. You take plot and turn it into gameplay.

Narrative design can be a good fit for people who are interested in storytelling but want to focus on the player experience. Other team members will create cutscenes, dialogue, barks, and item descriptions, but you’ll be using these building blocks to enhance gameplay.

How Does Narrative Design Mix with Mechanics and Systems Design

The narrative designer acts as the cross-discipline bridge between the story and the game mechanics and systems. This involves two main types of work (which might be done by the same designers, depending on the studio):

  • Narrative systems design
  • Narrative content design

What are the narrative systems design responsibilities?

Narrative systems design is the sub-specialization in creating the systems through which the story will be told such as:

  • NPC behavior

👆 All these systems affect the kinds of experiences the player can have.

Those starting in junior narrative design positions have a tendency to focus on dialogue, but the systemic interactions you have with the world can be just as, if not more, impactful.

A game like Dishonored is a perfect example of this. It tells its story primarily through the world’s reactions. Whether the player uses violent or non-violent approaches, narrative system design specialists have carefully determined how those gameplay decisions affect NPC reactions and the environment.

What are the narrative content design responsibilities?

Later in development, those who focus on narrative content design are responsible for coming up with quests, NPCs, towns, vignettes, and so on.

Although this sub-discipline involves writing, thinking in terms of the game itself, and the series of choices the player can make, turning a linear experience into an interactive one.

  • What if the player is attacked here?
  • What if the player wants to attack this NPC?
  • What if the player has been skipping all the dialogue; will they understand their objective?
  • How do I cope with knowing players see the story as a barrier to playing the game? 😭

Narrative content design specialists consider these questions and turn a script on paper into a dynamic game.

What is “Good” Narrative Design?

I’m sure you’re tired of hearing this by now, but it depends. There is no hard and fast rule for “good” narrative design. What works for one game is not going to necessarily work for another.

Games focused on cinematic, linear stories will have very different requirements than games focused on branching, choice-heavy stories. Like all game design, narrative design is beholden to the game’s high level goals.

But because “it depends” isn’t particularly useful advice, here are three guidelines that will help with almost any narrative design project:

Put Gameplay First

  • Match the Story to Your Players’ Motivation

Plot Out Storyline Arcs

When we talk about our favorite games, we often talk about our favorite stories. We talk about moments that we remember, characters that we loved, or worlds that entranced us.

Even when talking about gameplay, players usually describe the game through  narrative wrappers , not the mechanics themselves.

For example:

  • We don’t “cause a damage-over-time effect;” we “inflict poison.”
  • We don’t “exhaust the game’s available text options;” we “talk with Garrus.”

Because we often interpret the wrapper as the game, there can be a tendency to value story too highly.

Storytelling is certainly important, but if the gameplay isn’t good, players will never be excited about the poison or pay attention to the writing. Gameplay must come first.

If changing a mechanic would result in better gameplay but would require changing the story, change the story. No matter how attached to it you are, the story is always more flexible than the gameplay.

If your game idea starts with the story, it probably shouldn’t be a game. It might make for a great book or movie, but games start with gameplay. A narrative designer must make the story work within gameplay’s “box.”

Match The Story to Your Players’ Motivation

A major goal of narrative design is what I call  Emotional/Motivational Parity . The player’s motivations (created through gameplay) should match the emotional beats of the story.

When story and gameplay aren’t aligned, we risk breaking the player’s immersion. The story and gameplay contradicting each other can snap the player out of the experience and sever the suspension of disbelief.

At best, this is humorous; “Press F to Pay Respects.” At worst, this is frustrating or insulting; the ending of Mass Effect being distilled down to “red, green, or blue.” The $10 word for this experience is “ludonarrative dissonance.”

The easiest way to avoid ludonarrative dissonance is to ensure what the player wants to do is also what the story is asking the player to do.

This sounds simple, but story often competes against gameplay for the player’s attention. It’s common for writers to include lots of exposition early in the game, but if it delays or interrupts gameplay, players may get irritated or ignore it because they’re not yet invested.

Dark Souls games, on the other hand, have little explicit storytelling, but are often heralded for their lore and story anyway. The strange, Gothic world and story complement the brutal gameplay; the rare cutscenes are a reward, not an interruption.

Arc diagrams are a tool I use for visualizing pacing and progression. They can help you catch potential problems early on. I most often use arcs to help me plan out quests, but arcs are also useful for plotting out a character’s development or a level’s gameplay beats.

Let’s look at examples of a bad arc and a good arc. We’ll start with this (fake) quest pitch:

The city of Corbach is under siege by a horde of undead. Bjorn, a local cleric, has a plan to bless the nearby river, creating a near-endless supply of holy water. However, blessing the river draws the attention of the necromancer creating the undead.

The pitch provides a baseline. Let’s break up the idea into gameplay beats.

  • Enter Corbach
  • Speak with Bjorn
  • Travel to the River
  • Bjorn blesses the River

At a glance, this looks like a perfectly fine quest, but in this form, we’re lacking context. How these gameplay beats are presented will dramatically change the player’s experience. To better grasp the player’s experience, let’s plot these beats using an intensity arc.

This quest starts with a high intensity combat before the player can enter the town. An arc like this risks the player becoming numb or fatigued before they reach the final boss.

Let’s try a different approach to this pitch, that uses high and low intensity gameplay to make your story beats more impactful.

Now we’ve broken up the quest into more granular chunks and introduced a couple new beats to give us a more interesting arc. The “Swarms of Enemies” now appears later, after we’ve slowly built up to it.

We’ve also made “The Guarded Chamber” its own beat, separate from combat, allowing time for environmental storytelling and mood setting.

Finally, rather than letting the boss fight occur immediately after high intensity combat, we’re using a brief pause to give greater impact to the finale.

While these two versions come from the same pitch, minor changes can make dramatic differences.

Now that we’ve established what’s considered as “good” narrative design, let’s get into how you can practically train and improve your narrative design skills.

If you’re serious about getting hired as a narrative designer make sure you get these two parts down:

  • How to make a game design portfolio
  • How to make a narrative design portfolio
  • #portfolio-feedback and #career-guidance channels in Funsmith Club Discord
  • How to get your first game design job without depending on luck
  • Your narrative design and game design skills to make and implement good design judgements.

See How You Can Learn the Gameplay Design Abilities Game Studios Are After To...

  • Get more interview invites & job offers
  • Replicate decisions that make games fun
  • Learn faster with mentorship guidance

After trying different ways to improve my narrative design skills, these are the three methods that helped me level up the most.

Industry tip: Narrative design positions are around 5% of the entire available game design positions, so it’s much more realistic to first enter the industry starting at a more plentiful position such as playtesting or level design first, then pivot to a narrative design position.

1. Critically Consume Game Stories and Other Media

But seriously. Don’t concern yourself with “new ideas.” As you’re playing games, reading books, watching movies, and so on, pay attention to what you like and what you don’t. Critically consuming media is one of the fastest ways to improve.

Remember, “critically” is the keyword here.And make sure you assess what you intentionally consume through both lens of game design and narrative design.

It’s not enough to be passive; you must ask yourself questions and evaluate why you feel the way you do. Here are some questions to get you started:

  • What moment stood out to you? What made it memorable?
  • Did you ever get lost or confused? How did you figure out what to do?
  • Were there beats you would have changed? Why do you think they made the choices they did? (Think about their process and restrictions, not just their creative choices.)
  • (For non-game media) How would you capture this feeling in a game? What’s the simplest and easiest to develop version? If you had more resources, what would you focus on?

When you discover mechanics, systems, and stories that you are drawn to, put those elements in your game. It may feel like stealing at first, but as you iterate and build (and steal more), you’ll end up with something that is uniquely yours.

2. Create Your Own Games

One of the best ways to hone your narrative design skills is to make text based games using a free open source software called Twine , which is a great way to build branching, story-heavy games.

While practicing your storytelling skills, think critically about all the component parts that contribute to your game’s narrative experience:

  • Which narrative beats should every player experience, and which only work on certain branches? Try plotting arcs for each possible path through a quest.
  • Do you want your item descriptions to communicate function, add atmosphere, or give specific information that could affect players’ decisions?
  • Analyze the big picture. How does each major decision point affect which characters, story elements, and mechanics the player will interact with? Are these effects well signposted, or will the player be unpleasantly surprised?

Once you’ve got some individual practice, look for game jams or other opportunities to work with other designers.

Narrative designers need to be good collaborators and communicators so they can help the story and gameplay teams work together.

3. Play Your Games Critically

Arguably more than any other design discipline, narrative designers need a holistic understanding of the game. As the bridge between story and gameplay, you must understand both.

This understanding is only possible by playing the game you’re working on.

No matter how strong you think your comprehension of the mechanics and systems, it will never compare to actually stepping into the shoes of your player by playing your game.

Take the pitch from earlier. On paper, this looks like a solid quest, but it’s impossible to truly know how these beats feel until we can experience it through the game.

For example: Let’s say we’re building this quest in an isometric game. A beat that relies on environmental storytelling may not be effective. Once in the game, the restricted camera makes environment props difficult to notice, and the moment may feel boring instead of atmospheric.

It’s expected that your story won’t mesh with your gameplay on the first try. Iteration is an important part of game development. So try something else, and test again.

Resource: If you have never made a game before, please checkout this free game design workshop, where you can build your playable prototype using the video instructions, templates, examples, playtesting, and feedback. And you don’t need to code.

Final thoughts…

We covered a lot of information. Here are the main takeaways:

  • Narrative design is not the same as game writing. Rather, narrative designers act as the bridge between gameplay and story, using mechanics and systems for storytelling.
  • Good narrative design puts the game first, using narrative to enhance and elevate gameplay.
  • The best narrative design aligns gameplay and story. When unaligned and fighting for attention, these two elements can result in ludonarrative dissonance.
  • The best way to practice narrative design is by making games and thinking critically about the games and media you’re consuming.

If you’re an aspiring dev specifically interested in narrative design, I also recommend you to checkout Alex’s post on how to become a video game designer .

If you have any additional thoughts or questions, feel free to share them in the comments. I’d love to hear from you!

By the way, whenever you’re ready, here are 3 ways to help you start or level-up your game design career:

1. First Principles of Game Design: Skill Development Program:  Join game devs who got hired or promoted across 51 AAA and Indie game studios including Riot, Blizzard, Ubisoft, Bethesda, and etc.

Improve player retention and word of mouth by learning to accurately diagnose why the players are losing interest in any game and how to adjust accordingly – one of the main skills studios hire for .

2. Game Design Mentorship – Get access to live weekly video calls and chat feedback support directly from veteran game designer with 25 years of industry experience ( see example sessions ).

3.   Game Design Career Goal Strategy Workshop:  A live workshop to help you figure out exact action steps to reach your goal, whether you aim to

  • Break into the video game industry
  • Get promoted (or pivot) from your current position
  • Ship a successful Indie game

Join the Funsmith Tavern to get exclusive game dev tips that I don’t share anywhere else

2 responses.

Looking at interaction design as part of narrative design has certainly helped me understand both of these disciplines better. Prior to reading this, I couldn’t place my finger on what classifies as narrative design.

This is a largely useless post, unfortunately. Here’s the evidence:

“Because we often interpret the wrapper as the game, there can be a tendency to value story too highly. Storytelling is certainly important, but if the gameplay isn’t good, players will never be excited about the poison or pay attention to the writing. Gameplay must come first.”

How, exactly, does a writer claim the story’s not important? Does a coder say that of the code? Does a composer say that of the music? Does an artist say that of the visuals? If we concede that anything is “certainly important”, then it cannot be “too high” a value, for each one of us must represent the value of one’s own department to the ultimate extent in order for a balance to exist between all the departments which contribute to the outcome.

Storytelling is a universal medium and quintessential to both Art and Life, and its traditions reach back for millennia. It’s not a “wrapper”. Rather, if we must say something is a “wrapper” for the game’s “true content”, then mechanics are that wrapper, as they are a symptom of the interface with the machine and, as such, little more but vehicles by which to tell the STORY.

What is the significance of poison? When I think of it, what comes to mind? The Ricin Cigarette from Breaking Bad, the hebenon in Hamlet:

“That’s when he must’ve stolen it off of me, right? That’s the plan? Was that the plan? Jesse, why? Why, in God’s name, would I poison a child? To get back at me.”

“Upon my secure hour thy uncle stole, With juice of cursed hebenon in a vial, And in the porches of my ears did pour The leperous distilment;”

I stopped playing FFVII Remake since I could not sympathise with the protagonists and ecoterrorism. I don’t give a damn about mechanics. If I’m going to kill law enforcement officers, I need a reason that’s convincing. That was why I finished Jak II, many times, despite the difficulty and “frustration”, and I grew to love them both. The writers took the time to illustrate that Baron Praxis was a bad guy, and the Krimzon Guards were bastards. I would not assume that of most law enforcement officers. That’s just the power of great narrative design, and anyone who wants to make a game must start with serious consideration for the moral, social, scientific, and transcendent implications of the Narrative.

I’m sorry that my feedback from two years ago went in one ear and out the other, (thankfully, it was not poison!!) but I hope that it will stick this time. At least this proves my other point that confirmation is not bias, as, unfortunately, people who insist on rules will often tend to follow trends, and while I’d love to see them once surprise me with real evidence against my viewpoint, they but aggravate my cynicism and my grim prediction that it will be long before Games are successful as an Art Form once again.

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[studio] blizzard entertainment: content, mechanics, and systems designer.

[GAME] World of Warcraft: MMORPG with 8.5 million average monthly players, won Gamer’s Choice Award – Fan Favorite MMORPG, VGX Award for Best PC Game, Best RPG, and Most Addictive Video Game.

  • Designed Cosmos UI
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  • Designed the raid bosses Karazhan, Black Temple, Zul’Aman
  • Designed the Outlands content
  • Hungarfen, Ghaz’an, Swamplord Musel’ik, and The Black Stalker
  • Designed the Hellfire Ramparts final bosses Nazan & Vazruden
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[GAME] StarCraft 2: Playtested and provided design feedback during prototyping and development

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[GAME] Overwatch:  Playtested and provided design feedback during prototyping and development

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  • Heavily expanded internal tools and features for design team
  • Improved UI indicators to improve clarity of allied behaviour

[OTHER GAMES] Under NDA:  Developed multiple unreleased projects in R&D

Game Design Instructor:  Coached and mentored associate designers on gameplay and mechanics

[STUDIO] Moon Studios: Senior game designer

[GAME] Ori & The Will of The Wisps:  2m total players (423k people finished it) with average 92.8/100 ratings by 23 top game rating sites (including Steam and Nintendo Switch).

  • Designed the weapon and Shard systems
  • Worked on combat balance
  • Designed most of the User Interface

[GAME] Unreleased RPG project

  • Designed core combat
  • High-level design content planning
  • Game systems design
  • Game design documentation
  • Gameplay systems engineering
  • Tools design
  • Photon Quantum implementation of gameplay

[VC FUNDED STARTUP] SnackPass: Social food ordering platform with 500k active users $400m+ valuation

[PROJECT] Tochi: Creative director (hybrid of game design, production and leading the product team)

  • Lead artists, engineers, and animators on the release the gamification system to incentivize long-term customers with social bonds and a shared experience through the app

[CONSULTING] Atomech: Founder / Game Design Consultant

[STUDIOS] Studio Pixanoh + 13 other indie game studios (under NDA):

  • Helped build, train and establish the design teams
  • Established unique combat niche and overall design philosophy
  • Tracked quality, consistency and feedback methods
  • Established company meeting structure and culture

Game Design Keynotes:

  • Tencent Studio
  • USC (University of Southern California)
  • RIT (Rochester Institute of Technology)
  • US AFCEA (Armed Forces Communications and Electronics Association)
  • UFIEA (University of Florida Interactive Entertainment Academy)
  • West Gaming Foundation
  • Kyoto Computer Gakuin – Kyoto, Japan

February 23, 2024

Flimsy Antiabortion Studies Cited in Case to Ban Mifepristone Are Retracted

Outside experts found that two studies cited in a federal case on medication abortion had serious design problems and that their authors had undisclosed conflicts of interest

By Liz Szabo

Mifepristone pill packaging on white table

Erin Hooley/Chicago Tribune/Tribune News Service via Getty Images

A medical journal has retracted two studies examining the safety of the abortion pill mifepristone after a federal judge in Texas cited them when ruling that the drug should be taken off the market.

The studies, both retracted because of methodology problems and conflicts of interest, claimed abortions involving mifepristone are associated with an increased risk of serious complications compared with procedural abortions. Those conclusions are in contrast with hundreds of studies in the past two decades that have found that mifepristone—currently approved by the U.S. Food and Drug Administration for use in abortion through 10 weeks of pregnancy—is safe and effective. Mifepristone is used in combination with the drug misoprostol in nearly all medication abortions in the U.S., and medication abortions constituted more than half of abortions nationwide in 2020.

A third study that was written by the same authors but not referenced by the judge was also retracted; it was about doctors who prescribe mifepristone. All three papers were published in Health Services Research and Managerial Epidemiology, which is published by Sage Journals. They appeared in the journal in 2019, 2021 and 2022.

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The papers drew attention after the Alliance for Hippocratic Medicine, a group of antiabortion doctors and organizations, sued the U.S. Food and Drug Administration in November 2022. The alliance claimed that the FDA did not follow proper procedures in approving the drug more than two decades ago and that it has downplayed mifepristone’s risks . When filing its suit, the alliance also asked for a preliminary injunction to immediately remove mifepristone from the market.

In court documents, the U.S. Department of Justice (which represents the FDA in legal matters) described that request as “extraordinary and unprecedented.” The DOJ argued that “plaintiffs have pointed to no case, and the government has been unable to locate any example, where a court has second-guessed FDA’s safety and efficacy determination and ordered a widely available FDA-approved drug to be removed from the market—much less an example that includes a two-decade delay.”

Last April Judge Matthew Kacsmaryk of the Northern District of Texas cited the 2021 and 2022 papers when he ruled that the alliance had standing to sue, agreeing with the plaintiffs’ claim that mifepristone puts a heavy burden on emergency room physicians treating pregnant people who experience medical complications. Kacsmaryk issued a preliminary ruling invalidating the FDA’s approval of mifepristone.

The Supreme Court halted the ruling until the U.S. Court of Appeals for the Fifth Circuit could issue a ruling. That court struck down part of Kacsmaryk’s ruling a few days later, allowing mifepristone to remain on the market with certain restrictions.

The appeals court ruling is on hold while the case is under consideration by the Supreme Court, which is scheduled to hear arguments about it in March.

For now, mifepristone remains available through 10 weeks of pregnancy, with prescriptions permitted by telemedicine and through the mail in states where abortion is legal.

Mifepristone’s Safety

Research shows that mifepristone, which has been used by more than five million pregnant people in the U.S. since it was approved in 2000 , has an excellent safety record, says Ushma Upadhyay, a professor and public health scientist at the University of California, San Francisco. “Judge Kacsmaryk’s decision ignored the science and relied on just the few cherry-picked research papers that supported his beliefs about abortion,” says Upadhyay, author of a new study, published last week in Nature Medicine , that found mifepristone can be safely prescribed through telemedicine.

A coalition of medical groups—including the American College of Obstetricians and Gynecologists and the American Medical Association —describe the evidence for mifepristone’s safety as “overwhelming.”

Serious side effects occur in fewer than 1 percent of those using the drug, according to a brief that the medical groups filed with the U.S. District Court for the Northern District of Texas before Kacsmaryk’s decision. Major adverse events such as significant infection, blood loss or hospitalization occur in fewer than 0.3 percent.

Deaths are even rarer. According to the FDA, of the estimated 3.7 million women who used mifepristone to terminate a pregnancy in the U.S. from 2000 to 2018, 24 died. This number includes those who had recently taken mifepristone and died from a cause that was not attributed to it, such as homicide, suicide or an overdose of another drug. That equates to a mortality rate of 0.00065 percent.

“The risk of death is almost non-existent,” the brief states. “Mifepristone is one of the most studied medications prescribed in the United States and has a safety profile comparable to [that of] ibuprofen.”

A study published in the journal Contraception last year found that the risk of death from pregnancy and childbirth is at least 35 times greater than from a legal abortion.

Controversial Studies

In a statement on its website, Sage Journals said it asked two independent experts to review the articles about mifepristone after a reader expressed concerns about the papers’ methodology and the authors’ undisclosed conflicts of interest.

In the 2021 study, which examined patient data from 1999 to 2015, the researchers found that abortion-related emergency department visits were 50 percent more likely after an abortion using mifepristone than a procedural abortion. This led them to conclude that “mifepristone abortion is consistently and progressively associated with increased morbidity” compared with procedural abortions.

But the study, which focused on people covered by Medicaid, provides little evidence that those individuals experienced an adverse event related to abortion, says Chris Adkins, an associate professor of pharmaceutical sciences at South University in Savannah, Ga., who has identified himself as the reader who questioned Sage Journals about the articles.

Pregnant people in the retracted 2021 study could have gone to the emergency department for any number of reasons, from food poisoning to earaches, Adkins says, adding that he doesn’t speak for his university. Research shows that half of emergency room visits made after an abortion are unrelated to abortion . And many people, often including those who qualify for Medicaid, go to the emergency room with nonemergency needs because they can’t access care anywhere else.

Some people who have medication abortions visit emergency departments “simply to determine if the amount of bleeding and cramping is normal,” Adkins says. “A significant number of these ER visits are just observational care and not a true abortion-related adverse event.”

The 2021 study also failed to provide important context, including the substantial increase in Medicaid enrollment during the study period (between 1999 and 2015), partly as a result of the Affordable Care Act, Adkins says. The number of Americans enrolled in Medicaid grew from 34.1 million in 2000 to 71.5 million in 2015.

Although the authors of the 2021 article declared that they had no conflicts of interest when they submitted it for publication, all but one were affiliated with antiabortion advocacy groups, including the Charlotte Lozier Institute, the Elliot Institute and American Association of Pro-Life Obstetricians and Gynecologists. That paper and a retracted study from 2022 by the same authors were funded by the Charlotte Lozier Institute, the research and education institute of Susan B. Anthony Pro-Life America, an influential antiabortion group.

A peer reviewer who originally evaluated the articles was also affiliated with the Charlotte Lozier Institute at the time, leading the publisher to later conclude that the reviewer’s work was “unreliable,” according to Sage Journals’ statement.

The independent experts who recommended the three retractions found that the articles from 2021 and 2022 contained “fundamental problems with the study design and methodology, unjustified or incorrect factual assumptions, material errors in the authors’ analysis of the data, and misleading presentations of the data that, in their opinions, demonstrate a lack of scientific rigor and invalidate the authors’ conclusions in whole or in part,” according to the statement.

James Studnicki, lead author of all three studies and vice president and director of data analytics at the Charlotte Lozier Institute, posted a point-by-point rebuttal of Sage Journals’ critique. He and his co-authors had made no attempt to hide their affiliations, he wrote. The articles did include a brief biography that noted researchers’ affiliations. In an e-mailed response to Scientific American, a Sage Journals spokesperson said it “relies on journal editors to make individual decisions on submitted works. These journal editors rely on peer reviewers to evaluate the quality of a submitted article and determine if it is rigorous and ultimately, if it is acceptable for publication. We work together to take corrective action when necessary.”

Studnicki and Tessa Longbons, a senior research associate at Charlotte Lozier Institute and a co-author of the three papers, claim their studies are being targeted because of politics. In a video posted online , Studnicki alleged that most medical journals are “virulently proabortion.”

“This incident points to a larger, newer phenomenon, which is that many of our scientific institutions and publications no longer stand in defense of open inquiry,” Studnicki and Longbons wrote in an e-mailed comment to Scientific American . “We’re seeing a biased elite faction across the medical community with all the power attempting to suppress any research that cuts against their approved, pro-abortion narrative. Scientific research and publication should be grounded in science, not driven by ideology.”

Critics of the retracted papers say their concerns are practical—not personal or political.

“This is not about ideology,” Upadhyay says. “The retraction of these studies is based on their flawed scientific approach which grossly distorts the safety rating for abortion.”

Effect on Future Legal Decisions

The retractions are “unlikely to make much difference legally” in terms of future court decisions or legislation, says Mary Ziegler, a professor at the University of California, Davis, School of Law, who studies the history of abortion.

State lawmakers trying to restrict or outlaw abortion generally seem more motivated by a desire to protect the fetus than by concerns about protecting pregnant people from potential adverse events, Ziegler says.

The Fifth Circuit Court of Appeals’ decision on mifepristone relied not on the retracted papers but on other testimony, she says.

The Supreme Court, which voted in 2022 to overturn Roe v. Wade (the landmark case that legalized abortion in 1973), is unlikely to be swayed by the retractions either, Ziegler says. “Given the problems with the plaintiffs’ case for standing, the Court may already be inclined to side against the Alliance for Hippocratic Medicine,” she says. “And if the justices are prepared to overlook other issues with standing and the weight of the evidence on mifepristone, the retractions will likely not do more than reinforce an existing position.”

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  25. Flimsy Antiabortion Studies Cited in Case to Ban Mifepristone Are

    The 2021 study also failed to provide important context, including the substantial increase in Medicaid enrollment during the study period (between 1999 and 2015), partly as a result of the ...