Aaron 2015 Mixed Methods Research

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Abstract

Mixed methods research involves the use of qualitative and Mixed methods research involves the use of qualitative and quantitative data in a single research project. It represents an quantitative data in a single research project. It represents an alternat

alternative methodological approach, ive methodological approach, combining qualitative andcombining qualitative and quantitativ

quantitative research approaches, e research approaches, which enables nurse which enables nurse researchersresearchers to explore complex phenomena in detail. This

to explore complex phenomena in detail. This article provides aarticle provides a practical overview of mixed methods research and its application in practical overview of mixed methods research and its application in nursing, to guide the novice researcher considering a mixed methods nursing, to guide the novice researcher considering a mixed methods research project.

research project.

Authors

Elizabeth Halcomb

Elizabeth Halcomb Professor of primary health care nursing, School Professor of primary health care nursing, School of Nursing, University of Wollongong, Australia.

of Nursing, University of Wollongong, Australia. Louise Hickman

Louise Hickman Director of postgraduate nursing, Faculty of Health, Director of postgraduate nursing, Faculty of Health, University of Technology Sydney, Australia.

University of Technology Sydney, Australia. Correspondence to:

Correspondence to: ehalcomb@[email protected]

Keywords

Mixed methods research, multi-method research, nursing research, Mixed methods research, multi-method research, nursing research, qualitat

qualitative research, ive research, quantitativquantitative research, e research, research design,research design, research methodology, rigour

research methodology, rigour

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Mixed methods research

Halcomb E, Hickman L

Halcomb E, Hickman L (2015) Mixed methods research. Nursing Standard. 29, 32, 41-47.(2015) Mixed methods research. Nursing Standard. 29, 32, 41-47.

Date of submission: February 11 2014; date of acceptance: June 26 2014.

on mixed methods research in social science,

education and health (Glogowska 2011, Bowers

et al

et al _{2013). Mixed methods research offers nurse}_{2013). Mixed methods research offers nurse}

researchers a methodology to address complex

issues, which is more comprehensive than could

be achieved by either qualitative or qualitative

research methods alone (Simons and Lathlean

2010, Andrew and H

2010, Andrew and Halcomb 2012).alcomb 2012).

Paradigm differences have sometimes

Paradigm differences have sometimes preventpreventeded

the mixing of qualitative and quantitative research

in nursing inquiry, but such differences have

generally been overcome, with most researchers

adopting a pragmatic approach and implementing

whichever research methodologies are most

appropriate to answer their research question

(McEvoy and Richards 2006, Simons and

Lathle

Lathlean 2010, Glogowska an 2010, Glogowska 2011, Maudsley 20112011, Maudsley 2011).).

In addition, there has been a steady rise in t

In addition, there has been a steady rise in thehe

number of mixed

number of mixed methods manuscripts publishedmethods manuscripts published

in nursing journals in recent years (Lipscomb

2008, Simons and Lathlean 2010).

Deﬁnition of mixed methods research

Essentia

Essentially, lly, quantitative research involves thequantitative research involves the

collection and analysis of numerical data,

while qualitative research considers narrative

or experiential data (Hayes

or experiential data (Hayeset al et al _{2013). Mixed}_{2013). Mixed}

methods research refers to research that

integrates both qual

integrates both qualitative and quantitative dataitative and quantitative data

within a single study (Creswell and Plano Clark

2011, Wisdom

2011, Wisdomet al et al _2012)._2012)._{The mix}_{The mix}_{ing of the}_{ing of the}

qualitative and quantitative components within

a study is an important aspect of mixed methods

research (Simons and Lathlea

research (Simons and Lathlean 2010, n 2010, MaudsleyMaudsley

2011

2011). Qualitative and ). Qualitative and quantitative elementsquantitative elements

are interlinked during mix

are interlinked during mixing to provide ing to provide anan

integrated response to the research quest

integrated response to the research question thation that

is deeper than would be pos

is deeper than would be possible by eisible by either methodther method

alone (Glogowska 201

alone (Glogowska 2011, Zhang and Cres1, Zhang and Creswellwell

2013)

2013). Integration may occu. Integration may occur at any stage orr at any stage or

stages of the research process

stages of the research process, but , but is centralis central

to ensuring rigour in mixed methods research

(Glogowska 2011).

There is some discrepancy in the deﬁnitions

of mixed methods research a

of mixed methods research and multi-methodnd multi-method

research, and the differences between them.

However, there is general agreement that

mixed methods research differs subtly from

HEA

HEALTHCARE SYSTEMS ARLTHCARE SYSTEMS ARE becoE becomingming

more complex in response to people living

longer, the rise in chronic and complex diseases

and ﬁnite healthcare

and ﬁnite healthcare budgets. Social, political,budgets. Social, political,

environmental, cultural and economic forces may

also add complexity to healthcare issues (Lavelle

et al

et al _{2013). As healthcare systems increase in}_{2013). As healthcare systems increase in}

complexity, so do the research problems faced by

health rese

health researchers (Glogowska 2011archers (Glogowska 2011). Therefore,). Therefore,

researchers are

researchers are challenged to ﬁnd challenged to ﬁnd investigainvestigativetive

methods that

methods that encompass multidimensencompass multidimensional aspectsional aspects

of health issues (Andrew and Halcomb 2006,

Creswel

Creswell and Plano Clark 2011l and Plano Clark 2011). In response to). In response to

this challenge, there has been an increased focus

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multi-method research (Johnsonet al _2007).

Mixed methods research combines qualitative and quantitative research in a single study, while multi-method research involves data collection using two methods from the same paradigm, for example interviews and focus groups,

or quantitative surveys and medical record audit (Andrew and Halcomb 2009). Mixed methods research capitalises on the strengths of both

qualitative and quantitative research in combining qualitative and quantitative data collection, while compensating for their limitations, to provide an integrated understanding of the research topic

(Andrew and Halcomb 2009, Wisdomet al _2012,

Scammonet al _{2013). Multi-method research has}

the advantage of collecting data using multiple methods. Mixed methods research, in contrast, has the potential to combine qualitative

and quantitative characteristics throughout the research process, from its philosophical

underpinnings through to data collection, analysis and interpretation.

Core considerations

Mixed methods research involves more than the collection of qualitative and quantitative data within a single study. The methodological approach to mixed methods research requires various considerations to be addressed to ensure methodological rigour. This article presents eight core considerations for the novice researcher in planning and undertaking mixed methods research (Box 1).

Rationale for using mixed methods

Research questions should reﬂect the rationale for undertaking mixed methods research and demonstrate the qualitative and quantitative aspects of the project (Lavelleet al _{2013). A mixed}

methods study should not be undertaken simply because it is possible to collect both numerical and narrative data in relation to a research question. The researcher should consider which methodological approach would be the most

appropriate to address his or her speciﬁc research questions. The decision to use a mixed methods design should be based on the additional value that using both qualitative and quantitative methods of data collection would provide, above that using a single method of data collection, in answering the research question (Creswell

and Plano Clark 2011, Scammon et al _2013).

The feasibility of undertaking a mixed methods study should also be considered in terms of balancing the beneﬁts of a mixed methods research design against the increased skills and resources required (Halcomb and Andrew 2009).

The research problems that are best suited to mixed methods designs are those in which multiple perspectives on the research problem may be

able to provide a more detailed understanding than could be obtained from a single perspective (Simons and Lathlean 2010, Andrew and

Halcomb 2012). For example, a study that

developed an overall impression of a health service using quantitative data might overlook factors that affect individuals accessing the service. Adding a qualitative component, investigating the experiences of individuals accessing the service, would be likely to add signiﬁcant insights to such a study. Reasons for using mixed methods research designs are provided in Box 2.

Philosophical approach

A philosophical approach or world view is the lens through which one views the world. A range of philosophical approaches may be used in mixed methods research (Mesel 2013). The researcher should explore a philosophical approach, to understand how it ﬁts with their personal perceptions and with the proposed project, before using it. Creswell and Plano Clark (2011) advocate four stances on using world views in mixed

methods research.

First, a single world view may be selected to underpin the entire study. Generally, this would be either pragmatism, a transformative

(emancipatory) approach or critical realism (Andrew and Halcomb 2006, Creswell and Plano Clark 2011, Maudsley 2011, Andrew and Halcomb 2012, Walsh and Evans 2014). A pragmatic approach involves the researcher using ‘what works’ to seek answers to the research question (Creswell and Plano Clark 2011). Pragmatism views the research problem as the most important issue, valuing both subjective and objective observations to reveal the answers (Andrew and Halcomb 2006, Feilzer 2010, Creswell and Plano Clark 2011). In contrast, a transformative approach involves recognising cultural differences and injustices throughout

Core considerations of mixed methods research

 Rationale for using mixed methods.

 Philosophical approach. Mixed methods designs. Skills required.

 Project management.

 Integrating qualitative and quantitative aspects.

Demonstrating rigour.

 Dissemination of mixed methods research ﬁndings.

BOX 1

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Creswell and Plano Clark 2011, Maudsley 2011). A critical realist world view is well suited to mixed methods research, since critical realists undertake research to explore multiple outlooks and develop deeper understanding (McEvoy and Richards 2006).

Second, multiple world views may be used to underpin different aspects within mixed methods research, depending on how the researcher seeks to understand the social world (Creswell and Plano Clark 2011). Using this approach emphasises tensions and oppositions that reﬂect various ways of understanding the world. Researchers using this approach need to clearly articulate the ways in which the various world views are being used.

Third, multiple world views may be combined relating to the design of the mixed methods study (Creswell and Plano Clark 2011). For example, a sequential mixed methods study that commences with interviews followed by an online survey would begin the study with a naturalistic

(qualitative) perspective and then move towards a positivist (quantitative) world view. In this approach, mixed methods is purely a method of collecting data, and the respective world view guides each methodological approach (Creswell and Plano Clark 2011).

Finally, world views may be dependent on the shared beliefs within a scholarly community (Creswell and Plano Clark 2011). In this

perspective, researchers within a given ﬁeld have shared beliefs about meaningful research questions and appropriate procedures for answering

these questions.

Regardless of which philosophical stance is chosen for a mixed methods study, the study methods should be consistent with the chosen philosophy, and the tenets of the chosen philosophy should inform all aspects of the research process.

Mixed methods designs

There are various typologies (classiﬁcations

according to general type) of mixed methods designs in the research literature. The researcher should understand the implications of the various designs, and the principles that underlie them, before embarking on their research. Table 1 provides a summary of mixed methods designs commonly used in nursing research, with an example of how each design was used in a recent published study.

Four main characteristics deﬁne mixed methods research designs (Creswell and Plano Clark 2011).

collected independently of each other? The second design characteristic is the

implementation sequence for data collection. In a simultaneous or concurrent design, both qualitative and quantitative data are collected at the same time. This has the advantage of reducing the duration of the data collection period, but has the disadvantage of being resource intensive and not allowing collection of either data set to inform the collection of the other (Halcomb and Andrew 2009). A sequential design involves qualitative and quantitative data being collected separately, with the ﬁndings from one type of data collection, for example interviews, providing the basis for the collection of the second set of data, for example a survey. The disadvantage of sequential designs is that it takes longer for the data collection to be completed (Halcomb and Andrew 2009).

Third, designs may vary in the relative priority given to qualitative and quantitative data.

Exploratory studies usually prioritise qualitative data because little information is already known. However, explanatory studies where researchers seek complementarity often prioritise quantitative data (Andrew and Halcomb 2006). It is particularly important that the relative priority of each type of data is established before commencing the study.

Finally, mixed methods designs may vary in the timing of integrating qualitative and quantitative data. Such integration may occur at

Reasons for using mixed methods research designs

BOX 2

Corroboration – using the results of one method to substantiate the ﬁndings of another, about a single phenomenon.

Complementarity–_{using the results of one method to elaborate,}

enhance or clarify the results from another method.

– Process: quantitative results provide outcomes, qualitative results provide the processes.

– Unexpected results: surprising results obtained from one method, the other method provides explanation.

– Conﬁrmation: quantitative results test hypotheses generated by qualitative ﬁndings.

Development – using the results of one method to inform another method.

– Instrument development: qualitative results used to design a quantitative instrument, then the quantitative instrument is tested. – Sampling: one approach enables sampling for the other approach.

 Initiation – using one method to uncover the paradoxes and contradictions in ﬁndings from another method.

Expansion – expanding the depth and breadth of the study using

diﬀerent methods for various components of the research. (Greeneet al _{1989, Bryman 2006, Wisdom}et al ₂₀₁₂₎

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any point in the research process. For example, various philosophical approaches may be used to support the study; research questions may include both qualitative (why?) and quantitative (how often?) questions; data collection may combine open-ended questions that collect narrative data and rating scales; or the data

analysis may cross-tabulate themes and participant

demographics (Andrewet al _2008).

Skills required

Mixed methods research is seldom a solo endeavour (Bowerset al _{2013, Lavelle}et al

2013). Establishing a team to undertake a mixed methods project should be carefully thought out (Creswell and Plano Clark 2011). A broad range of skills is required to undertake mixed methods research and this should be considered

when establishing a research team (Halcomb and Andrew 2009). Limited attention has been paid to optimal models of teamwork or the optimal composition of mixed methods research teams, and they should include individuals with both quantitative and qualitative skills and knowledge, as well as those with experience in conducting mixed methods research (Bowerset al _2013).

Skills should be a particular consideration when mixed methods designs are used by postgraduate students (Halcomb and Andrew 2009). Undertaking a mixed methods research project as a postgraduate project requires the student to gain a broader range of research skills than would be required for a project using either qualitative or quantitative methods alone. Care should be given to the composition of

Mixed methods designs

Research design

Process Purpose Level of interaction Priority Example Convergent parallel Qualitative and quantitative (concurrent) To obtain diﬀerent but complementary data to answer a single research question. Data collected and analysed independently.

Equal Peters and Cotton (2013) collected postal surveys and undertook unstructured interviews with women with a physical disability to gain a broad understanding of the barriers and enabling factors associated with accessing and experiencing screening services for breast cancer and cervical cancer. Sequential explanatory Quantitative then qualitative Qualitative data are collected to explain the quantitative ﬁndings. Quantitative data frame qualitative data collection. Quantitative dominant

Pfaﬀet al _{(2014) used a postal survey}

to measure perceived confidence in interprofessional collaboration among new graduate nurses. Following analysis of the survey data, they conducted interviews with 16 new graduate nurses to explain the quantitative findings and expand on them. Sequential exploratory Qualitative then quantitative Quantitative data builds on qualitative findings to provide generalisability. Qualitative data frames quantitative data collection. Qualitative dominant

Hamshire et al _{(2013) conducted}

a series of interviews with nursing students to explore their experiences and expectations of their nursing course. The interview ﬁndings informed the development of an online survey that was completed by 1,080 students in nine UK universities. Embedded or nested Quantitative within qualitative or qualitative within quantitative To obtain diﬀerent data to answer a complementary research question. Embedded data set provides answers to a complementary research question. May be either qualitative or quantitative dominant.

Kinseret al _{(2013) conducted a}

randomised controlled trial of an

eight-week yoga intervention for women with major depression. Outcomes measured included depression severity, stress, anxiety and rumination. Qualitative interviews were embedded in the trial to explore the feasibility and acceptability of the intervention.

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and Andrew 2009). Project management

The practical implications of the chosen mixed methods design should be considered carefully. The main issues in project management

are: resources and ﬁnancial costs, time and management of data (Halcomb and Andrew 2009). Collecting two sets of data, rather than one, requires additional resources. Qualitative and quantitative data are also collected differently, so the range of resources needed for a mixed methods project will be greater than for one that is either qualitative or quantitative alone.

Therefore, a clear justiﬁcation should be

provided for the use of a mixed methods design, to substantiate the case for additional resources from funding bodies.

Time may be an issue in mixed methods research, particularly when the study is

conducted in fulfilment of a postgraduate degree (Halcomb and Andrew 2009). It is essential to allocate sufficient time for the project to be conducted successfully. A sequential project requires adequate time to collect and analyse the first data set, before commencing collection of the second data set (Halcomb and Andrew 2009). The second data set may not address important matters arising from the first data

and Andrew 2009).

Collecting both qualitative and quantitative data leads to a larger, more complex data set than would be gathered in a purely qualitative or quantitative project (Andrew and Halcomb 2009). The complexity is further increased when qualitative and quantitative data are integrated within the analysis phase. Such complexity affects the time required for data analysis, the range of skills required to manage the data and the resources required for data storage. Integrating qualitative and quantitative aspects The mixing of data within a mixed methods study is an important stage in the research process, but has received scant attention in the

literature (Bryman 2006, Andrewet al _2008,

Zhang and Creswell 2013). Zhang and Creswell (2013) identiﬁed three distinct procedures for mixing – integration, connection and embedding – in their review of how mixing occurs in

health services research. Table 2 provides a deﬁnition of the three procedures for mixing, with examples of each.

These approaches are not mutually exclusive and some projects may combine different methods of mixing within their design (Zhang and Creswell 2013). Evaluating which of these procedures is appropriate for an investigation and incorporating

Procedures for mixing qualitative and quantitative data

Procedure Deﬁnition Example

Integration Qualitative and quantitative data are collected concurrently and analysed separately. Integration occurs during the interpretation phase.

Rickardet al _{(2011) conducted a study to explore the roles}

of research nurses and possible career pathways. Data were collected via a 104-item survey tool that combined three

previously validated instruments and a series of semi-structured interviews. The qualitative and quantitative data were collected separately and only integrated during the reporting phase. Connection One approach is based on the ﬁndings of

the other approach.

Meixneret al _{(2013) surveyed providers of brain injury services}

within a region, asking about the barriers to accessing crisis intervention services. A second phase of the study involved a series of focus groups who investigated the survey ﬁndings to develop greater levels of understanding.

Embedding The analysis of one type of data is embedded within the other. Generally, this involves a small qualitative component nested within a quantitative study.

Zwaret al _{(2010) conducted a cluster randomised controlled}

trial to test the uptake and eﬀectiveness of a package of smoking cessation support provided primarily by the practice nurse. Qualitative interviews were conducted with patients, nurses and general practitioners who participated in the trial to evaluate the implementation, feasibility and acceptability of the intervention. (Adapted from Zhang and Creswell 2013)

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this into the research design before commencing the study is important when planning mixed methods research. The strategies used for mixing should be clearly articulated in publications and research reports (Maudsley 2011).

Demonstrating rigour

Methods of demonstrating rigour in studies that use mixed methods are still poorly deﬁned, despite the increasing popularity of mixed methods

research. While the use of mixed methods may enhance validity, the researcher should still demonstrate rigour in the research (Lavelleet al

2013). Creswell and Plano Clark (2011) advocate that mixed methods investigations should

demonstrate rigour using the criteria that would be seen in a quantitative or qualitative investigation, in addition to specific mixed methods criteria. Rigour in mixed methods research involves providing the reader with a clear audit trail and with well-considered, justified rationales for the decisions made throughout the research process, regardless of the specific tool or method used (Lavelleet al _2013).

Dissemination of mixed methods research ﬁndings

Disseminating mixed methods research is a signiﬁcant challenge for researchers (Glogowska 2011). An increase in mixed methods publications has led to improved acceptance of mixed

methods research articles. However, reviewers’ lack of familiarity with mixed methods, as well as audience expectations, word limits for journal articles and the decision to publish in a mixed methods or clinical journal are potential

barriers to publication that should be considered (Wisdomet al _2012).

Two models of dissemination, the segregated and integrated models, have been proposed

for mixed methods publications and theses (Halcomb and Andrew 2009, O’Cathain 2009). In the segregated model, qualitative and quantitative components of a study are kept separate, devoting separate chapters or articles to each. Any integration between qualitative and quantitative components of the study occurs only in the discussion of the report or in a separate article. In contrast, in the integrated model, ﬁndings from qualitative and quantitative methods are interwoven within a series of

articles or chapters, each of which is focused on a single aspect of the research question or theme. The choice of presentation method should reﬂect the nature of the research study to be disseminated (Halcomb and Andrew 2009).

Many publications reporting mixed methods research lack sufﬁcient detail of the methods

used (Wisdomet al _{(2012). Several frameworks}

have been developed to improve dissemination of mixed methods research and to guide authors in writing mixed methods articles for publication. One such framework is the Good Reporting of A Mixed Methods Study framework (O’Cathain

et al _{2008) (Box 3). Use of such frameworks}

may improve the quality of reporting research signiﬁcantly; however, authors should also be aware of the manuscript submission guidelines for the relevant journal.

Conclusion

Mixed methods research provides signiﬁcant opportunities for researchers to gain a deeper understanding of complex health issues than would be possible with the use of either quantitative or qualitative data alone. Researchers who use mixed methods should plan their study from a qualitative, quantitative and mixed methods perspective. The main considerations outlined in this article should be deliberated on before the mixed methods study commences. All phases of the research process should ﬂow logically and be clearly compatible. Reports and publications stemming from mixed methods research should explicitly detail the essential methodological components of the project. Mixed methods articles have the potential to extend nursing knowledge and to inform professional nursing practice in a wide range of complex

healthcare issues NS

Acknowledgement

Nursing Standard wishes to thank Leslie Gelling, reader in nursing at Anglia Ruskin University, for co-ordinating and developing the Research series.

Good Reporting of A Mixed Methods Study amework

1. Describe the justiﬁcation for using a mixed methods approach to the research question.

2. Describe the design in terms of the purpose, priority and sequence of methods.

3. Describe each method in terms of sampling, data collection and analysis.

4. Describe where integration has occurred, how it has occurred and who has participated in it.

5. Describe any limitation of one method associated with the presence of the other method.

6. Describe any insights gained from mixing or integrating methods.

(O’Cathainet al ₂₀₀₈₎

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