The Mixed-Methods Approach

Mixed-methods research can be defined as ‘the class of research which mixes or combines quantitative and qualitative research techniques, methods, approaches, concepts or language into a single study’ (Johnson and Onwuegbuzie, 2004). The mixed-methods approach utilises elements of both qualitative and quantitative paradigms in a

complimentary manner to offer additional insight into an area of inquiry. It is not a simple haphazard marriage of the approaches and all elements of the research need to be considered holistically.

Although it is a relatively new paradigm, mixed methods has in fact been practiced for some time but perhaps had not been labelled as such (Johnson et al., 2007). The relative novelty

of this paradigm and rapid adoption has resulted in a wide range of approaches to applying this paradigm in research (Schifferdecker and Reed, 2009). There are however some key common philosophical assumptions that underpin the use of mixed-methods. First, it is based on the premise that all methods (including those belonging to other research paradigms such as critical theory) can be classified into qualitative and quantitative

research. Secondly, it posits that both paradigms can and should co-exist in a single area of inquiry. Thirdly, the mixed-method approach is grounded in the philosophical stance of pragmatism, which recognises the absolute positivisitic perspective of the world yet acknowledging the importance of context and situation. Johnson & Onwuegbuzie (2004) summarised the main purposes for using the mixed-methods approach in research as follows:

Triangulation - in order to seek convergence, and verification of findings.

Complementarily - through the use of different approaches, greater clarification of findings can be achieved.

Initiation - paradoxes and contradictions can be found through a more holistic approach to research. Modification and new hypothesis generation through the process may be tested.

Development - through use of the findings form one method to help inform another method.

Expansion through increasing breath and depth of inquiry by using different approaches to inquiry.

Mixed-methods research can be conducted in a number of ways. Qualitative and

quantitative research can be conducted concurrently (in parallel) to produce research that has breath and depth as and for cross-validation between findings from the two arms of research (Leech and Onwuegbuzie, 2009). It can also be conducted sequentially to allow data from one part of a study to guide research in another. For example, qualitative

research such as interviews can be used to follow-up some quantitative research in order to better understand the “numbers”.

There are a number of criticisms against the use of mixed-methods. Many purists may argue that qualitative and quantitative paradigms are incompatible and cannot be mixed (Howe, 1988). However, some authors including myself would argue that even the purist

quantitative research has an element of subjectivity in terms of how data is ultimately interpreted and how inferences are drawn, according to the researchers belief and

understanding of the world (Johnson and Onwuegbuzie, 2004; Sale et al., 2002). Likewise, objectivity is often introduced into qualitative research whereby data is coded, quantified and sometimes subject to statistical testing. Therefore in some respect mixed-methods often takes place whereby quantitative and qualitative approaches are used in combination during inquiry even though it is not explicitly labelled as such. Even for clinicians, the

process of formulating different diagnoses of patients, which in itself can be considered a form of inquiry usually requires a mixed methods by combining more subjective elements such as history taking with more objective elements such as diagnostic tests (Schifferdecker and Reed, 2009).

Another criticism with mix-methods is the large variation of interpretations as discussed above resulting in inconsistencies in methodological approach. There are no strict formulas for conducting mixed-methods research, though this in itself should not be considered to be a criticism. The open nature of mixed-methods also allows researchers to gain. A further issue with mixed-methods is the practical limitations in terms of cost and resources. Due to the use of two or more research approaches, it is particularly labour intensive. Whilst conducting this type of research it is important that such constraints do not dilute the quality of the research (Johnson and Onwuegbuzie, 2004).

I will now revisit the key areas of empirical research of my thesis, and discuss how the mixed-methods approach will be applied to my research in relation to the key research questions proposed in Section 2.4, which I have presented again below.

1) The role of context in simulation-based assessments

A) Can clinical challenge in simulation-based assessment be simulated through modifying clinical context with PFHS

B) How do clinicians perceive and compare simulation-based assessment with PFHS to PTT used in isolation.

2 ) Comparing the Use of PFHS to Real Patients for training and assessment.

A) How do students who train with PFHS compare to those who train with real patients B) How does assessment of clinical skills with PFHS compare to assessment with real patients C) What are learners experience and process of training with PFHS and how does this

compare to when performing on real patients

For key question 1A, I am interested in seeing if clinical challenge can be simulated in procedural skills assessment with PFHS. Although there is some previous evidence of subjective increase in challenge, this needs to be evaluated objectively. Specifically, I am interested in the effect of the simulations’ design in terms of level of challenge on

participants’ performance. Therefore a predominately quantitative approach is used for this component of the study.

For key question 1B, I am primarily interested in the participants’ perceptions towards assessment of competence with PTT and PFHS. To explore this, I have chosen to use a quantitative approach (questionnaires with Likert-type questions) to quantify and compare aspects of participants’ perceptions towards to the two simulation approaches. In addition, I use qualitative approaches synchronously to explore participant’s perceptions in more detail with the aim of triangulation with the semi-quantitative component.

In order answer key research questions 2A and 2B, I aim to compare the training and

assessment of clinical skills with PFHS to that with real patients. For this purpose, I will need to employ a predominantly quantitative approach to measure effect of training on learners’ knowledge and performance and correlation between performance in assessments with PFHS and real patients objectively.

Finally, for question 2C, I am interested in the learners’ experience of training with PFHS and the underlying processes of learning. For this I employed a qualitative approach to gain

more in-depth insight into learners’ experience primarily through focus group and observations.

3.5 Summary

In summary, in this chapter I presented ontological and epistemological underpinnings of qualitative and quantitative research approaches. I argue that in view of my key research questions and given the complexity of simulation based medical education, that neither qualitative nor quantitative approach to inquiry is sufficient. I therefore proposed a mixed- methods approach and present my broad research strategy to the empirical components of this thesis. More specific details of the research methodology and methods for each study will be presented in the respective chapters. In the following chapters, I will present the research into these areas in detail.