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14 Mixed Methods Research Jennifer R. Gray Quantitative research and qualitative research have different philosophical foundations. Because of these differences in philosophy, researchers do not always agree on the best approach with which to address a research problem. The convergence of technology with health disparities and the complexity of the healthcare system have given rise to several research problems that cannot be answered completely with either type of research (Morgan, 2014; Sadan, 2014; Shneerson & Gale, 2015; van Griensven, Moore, & Hall, 2014). As a result, researchers combine quantitative and qualitative designs into one study, with increasing frequency, using the methodology called mixed methods research (Creswell, 2014; 2015). Using mixed methods offers researchers the ability to use the strengths of both qualitative and quantitative research designs (Creswell, 2015) to answer different stages or parts of a complex research question. Although some research experts (Munhall, 2012) have argued that using two qualitative methodologies in a single study is mixed methods research, for this chapter we will be describing only designs in which quantitative and qualitative methods are combined. This chapter begins with a description of the philosophical foundation of mixed methods research and continues with descriptions of three mixed methods study designs, with an example of a published study for each type. The challenges of conducting a mixed methods enquiry will be discussed, followed by criteria by which mixed methods studies can be evaluated. Philosophical Foundations The philosophical underpinnings of mixed methods research and the paradigms that best fit these methods continue to evolve. At the foundation of the differences between qualitative and quantitative studies are philosophical differences regarding the question, “What is truth?” A philosophy's ontology (What is? or What is true?) shapes the epistemology (how we can know the truth), that then influences the methodology (research design) (Morgan, 2014). Over the last few years, many researchers have departed from the idea that one paradigm or one research strategy is superior, and instead have taken the position that the search for knowledge requires the use of all available strategies. Researchers who hold these views and seek answers using mixed methods may have exchanged the dichotomy of positivism and constructivism for the “epistemological middle ground” of pragmatism (Yardley & Bishop, 2015, p. 1). However, the interpretations of what pragmatism is, as applied to mixed methods research, have differed (Bishop, 2015). For our purposes, pragmatism refers to the researcher's consideration of the research question and the knowledge needed for the discipline (desired outcome) before selecting a methodology. The desired outcome guides the selection of a methodology that is most likely to address questions within a problem area (Florczak, 2014; Morgan, 2014). As discussed in previous chapters, the process of developing a study design is iterative and reflexive. Decisions are made tentatively about the question and the design and then reconsidered as each phase is developed. Because an in-depth analysis of pragmatism as a philosophy is beyond the scope of this chapter, we are basing our discussion on the goal of pragmatism, which is solving the problem by “choosing the appropriate design for the research aim” (Yardley & Bishop, 2015, p. 2). With mixed methods designs, the researcher can allow the

strengths of one method to compensate for the possible limitations of the other (Creswell, 2015). Stated in a more positive way, mixed methods research allows the strengths of each method to interact in a complementary way with the other. Overview of Mixed Methods Designs The focus on problem-solving or answering the research question means that a mixed methods research design is selected based on study purpose, timing of the quantitative and qualitative elements, and emphasis on one element over the other. Table 14-1 provides a description of mixed methods designs classified by the researcher's reason for combining methods. The purpose of combining two methods may result in a classification based on the order in which quantitative and qualitative elements of the study are implemented (Table 14-2). Another way to label mixed methods designs is according to which element is emphasized. In this classification, the emphasized element is noted in uppercase letters (QUANT or QUAL) and the other element in lowercase font (quant or qual). Table 14-3 provides an overview of this classification. TABLE 14-1 Mixed Methods Classified by Purpose Label Description Exploratory Qualitative methods are used to explore a new topic, followed by quantitative methods that measure aspects of what was learned qualitatively Explanatory Quantitative methods are used to establish evidence related to incidence, relationship, or causation. Then qualitative methods provide a more robust explanatory description of the human experience aspect of the quantitative results. Transformative Quantitative and qualitative methods are used with a community-based research team to address a social problem in the community. Advocacy Quantitative and qualitative methods are used, guided by feminism, disability theory, race/ethnicity theory, or other approach to providing information to raise awareness of the needs of a specific group; aspects of advocacy research may overlap with transformative designs. Data from Creswell, J. W. (2015). A concise introduction to mixed methods research. Los Angeles, CA: Sage; and Bishop, F. (2015). Using mixed methods research designs in health psychology: An illustrative discussion from a pragmatist perspective. British Journal of Health Psychology, 20(1), 5–20. TABLE 14-2 Typology of Mixed Methods Designs Based on Timing of Quantitative and Qualitative Elements Label Description Sequential Either the quantitative or the qualitative phase may be implemented first. Results from the first phase of the study are used to inform the specific methods of the second phase. Concurrent Qualitative and quantitative elements are implemented at the same time through the study. Findings are integrated at interpretation. Data from Creswell, J. W. (2015). A concise introduction to mixed methods research. Los Angeles, CA: Sage; and Bishop, F. (2015). Using mixed methods research designs in health psychology: An illustrative discussion from a pragmatist perspective. British Journal of Health Psychology, 20(1), 5–20. TABLE 14-3

Typology of Mixed Methods Designs by Emphasis, Sequence, and Integration Label Description QUANT + qual Quantitative elements are the primary methods used to answer the research question; at the same time, a supplementary aim or secondary question may be addressed by using qualitative methods. QUANT → qual Quantitative methods are implemented first, chronologically, and are emphasized in the analysis and in the reporting of findings. QUAL + quant Qualitative elements are the primary methods used to answer the research question; at the same time, a supplementary aim or secondary question may be addressed by using quantitative methods. QUAL → quant Qualitative methods are implemented first, chronologically, and are emphasized in the analysis and in the reporting of findings. quant → QUAL Quantitative methods are implemented first, chronologically, but qualitative methods are emphasized in the analysis and in the reporting of findings. qual → QUANT Qualitative methods are implemented first, chronologically, but quantitative methods are emphasized in the analysis and in the reporting of findings. Note: Uppercase font indicates the study element that is emphasized with lowercase font indicating the less emphasized element; + indicates concurrent implementation; → indicates sequential implementation. Data from Creswell, J. W. (2015). A concise introduction to mixed methods research. Los Angeles, CA: Sage; Bishop, F. (2015). Using mixed methods research designs in health psychology: An illustrative discussion from a pragmatist perspective. British Journal of Health Psychology, 20(1), 5–20; and Morse, J., & Nierhaus, L. (2009). Mixed method design: Principles and procedures. Walnut Creek, CA: Left Coast Press. Creswell (2014) presented three basic designs that are a combination of the other classifications: convergent parallel mixed methods, explanatory sequential mixed methods, and exploratory sequential mixed methods. Three advanced designs, according to Creswell (2014, 2015), are: (1) embedded mixed methods designs, also called intervention designs; (2) transformative mixed methods, also called social justice methods; and (3) multiphase mixed methods, also called multistage evaluation designs. Morgan (2014) described using the initial method (quantitative or qualitative) as prelude to the second, or using the initial method as the priority and using the second to clarify or follow up on the first phase's results. From this discussion, you can see that there are multiple perspectives from which you can describe mixed methods designs. For simplicity, we are limiting our discussion to the three approaches usually implemented in nursing and health research and consistent with Creswell's (2014) three basic designs: (1) exploratory sequential strategy, (2) explanatory sequential strategy, and (3) convergent concurrent strategy. To decide which design is appropriate, you should begin by contemplating the purpose for combining the methods. This decision will shape the study. A researcher may implement a sequential study design in which the results of the first phase, either quantitative or qualitative, will determine the specific methods for the second phase. To accomplish this, the findings of the first phase must be completed prior to beginning the second phase. When this is the goal of using the two methods, the design will be sequential (Morgan, 2014), but sequential studies can also be performed to expand findings by using two types of data, providing a more robust view

of the phenomenon of interest. In additive studies, data may be collected sequentially but could just as easily be collected concurrently, because integration of all data occurs during analysis. Mixed methods studies in which data are collected concurrently are called parallel designs by some research experts (Creswell, 2014, 2015), because convergence does not occur until interpretation. When convergence occurs at interpretation, each phase could stand alone as a separate study and may be published separately (Morgan, 2014). Concurrent mixed methods designs can also have multiple points of convergence with both types of data being examined throughout data collection and analysis. In this chapter, models of the three mixed methods approaches and examples of each are provided to expand your understanding of these designs. Exploratory Sequential Designs The exploratory sequential design begins with collection and analysis of qualitative data, followed by collection of quantitative data. Often, findings of the qualitative data analysis are used to design the quantitative phase (Figure 14-1). This approach may be used to design a quantitative tool (Morgan, 2014). For example, focus groups may be conducted with members of a target population and items for the quantitative tool developed using phrases and content generated qualitatively. Another reason to use this strategy is to collect data about patients' perspectives concerning an issue or problem, so that their point of view is represented. With this input, an intervention can be developed or refined, incorporating the patients' perspectives about the intervention. An example would be a research team planning to implement an educational intervention and seeking input from members of the target population to gain the patient's perspective concerning the content to be taught. Morgan (2014) noted also that qualitative findings may generate hypotheses for the quantitative phase. FIGURE 14-1 Exploratory sequential mixed methods. Exploratory sequential designs may be selected for reasons other than shaping of quantitative methods by qualitative findings. Exploratory sequential strategies also may be indicated when a topic has not been studied previously, and qualitative data are collected first so that participants will not be biased by the content of the quantitative instruments. Ladegard and Gjerde (2014) provide an example of an exploratory sequential study in which the qualitative findings along with the literature were used to determine the hypotheses and outcomes of a theory-based leadership coaching intervention. “A two-phase exploratory sequential design (Creswell & Clark, 2011) was chosen to address different research questions: What generic outcome criteria should be used to assess the effect of leadership coaching? Does leadership coaching have a positive effect on these outcome criteria? To what extent do differences in facilitative coach behavior influence this effect? An additional reason for choosing this research design was that it enables a more comprehensive account of leadership as a leadership development tool.” (Ladegard & Gjerde, 2014, pp. 632, 635) The qualitative phase of the study was a focus group to address the first research question. Through the focus group with five experienced leadership coaches, Lardegard and Gjerde (2014) identified the outcome to be assessed for the quantitative phase of the study. From the qualitative findings, the researchers integrated existing theory into two hypotheses. “Two valuable and appropriate outcome criteria for evaluating coaching effectiveness stood out from the focus group discussion: confidence in one's ability to be an effective leader, and

confidence in subordinates' ability to take on responsibility.” (Ladegard & Gjerde, 2014, pp. 632, 635) Ladegard and Gjerde (2014) placed their qualitative findings into a theoretical context and recognized that confidence in one's ability to be an effective leader was the same concept as self-efficacy. The researchers examined the literature related to self-efficacy in leadership roles and, based on their review, hypothesized that leadership coaching would “positively influence leader role-efficacy” (Ladegard & Gjerde, 2014, p. 636). The relational aspects of the leadership role had been articulated clearly in the literature, allowing the researchers to identify the concept to be measured as “trust in subordinates” (p. 636). The second hypothesis was that leadership coaching would positively “influence leaders' trust in subordinates” (p. 636). Based on their qualitative findings and examination of the literature, Ladegard and Gjerde (2014) proposed three additional hypotheses. “Hypothesis 3. A leader's increased trust in his/her subordinates is associated with (a) an increase in the subordinates' psychological empowerment and (b) a decrease in their turnover intentions … Hypothesis 4. Facilitative coach behavior will affect leader role-efficacy positively… Hypothesis 5. Facilitative coach behavior will affect trust in subordinates positively.” (Ladegard & Gjerde, 2014, pp. 637–638) Ladegard and Gjerde (2014) described the quantitative portion of their study as a field experiment. They described the sampling and the intervention given to the treatment group. “The second part of this study was a field experiment chosen to test the propositions and hypotheses developed in the first part of the study. The objective was to reveal the effect of coaching on LRE [leadership role-efficacy] and LTS [leader's trust in subordinates] compared with a control group (between-group analysis) and whether changes in trust had any effect on subordinates, and to test whether facilitative coach behavior would predict variation in the two leader outcome variables (within-group analysis). We collaborated with a small coaching company that invited coaches from their network into the project … The leader questionnaire developed during the first part of the study was distributed to the 34 participants one week before the coaching sessions started … a follow-up questionnaire was sent to the 30 participants who replied in the first round. Of these, six did not respond, and the final sample included 24 participating leaders, which represents a response rate of 73% … From the participating organizations, we received 192 email addresses to subordinates, to which we distributed a questionnaire at the same points of time as we did to the leaders. We then matched the subordinates to their leaders, a process that shrank the sample considerably … The resulting final sample of subordinates comprised 80 respondents, of which 63 belonged to the coaching group of leaders. The number of subordinates per leader in the final sample ranged from two to seven, with an average of 2.7 per leader.” (Ladegard & Gjerde, 2014, p. 638) The results of the quantitative data analysis supported all five hypotheses. Ladegard and Gjerde (2014) noted the practical and theoretical implications of their findings, as well as the study limitations. “Our study adds to the knowledge base of both formative and summative evaluation, and argues that leadership coaching is a valuable leadership development tool. The strength of our study lies in our use of a mixed methods design combining qualitative and quantitative methods, providing us with opportunities for expansion and development. Our combination of methods and data sources should give a more complete picture of the effects of leadership

coaching as a leadership development tool than any one of these alone.” (Ladegard & Gjerde, 2014, p. 644) The study exemplifies the benefits of using exploratory sequential designs for studies of topics about which little is known. The use of both qualitative and quantitative methods allowed the researchers to develop well-grounded hypotheses and test them in the same study. Explanatory Sequential Designs When using an explanatory sequential design, the researcher collects and analyzes quantitative data, and then collects and analyzes qualitative data to explain the quantitative findings (Figure 14-2). The findings represent integration of the data. Qualitative examination of the phenomenon facilitates a fuller understanding and is well suited to explaining and interpreting relationships. FIGURE 14-2 Explanatory sequential mixed methods. Explanatory sequential designs are easier to implement than are designs in which quantitative and qualitative data are collected at the same time. This type of approach shares the disadvantage of other sequential designs in that it also requires a longer period of time and more resources than would be needed for one single-method study. Published studies using this strategy are more difficult to identify in the literature because the two phases sometimes are published separately, as was the case for Lam, Twinn, and Chan's (2010) study of dietary adherence in patients with renal failure. Lam et al. (2010) reported the findings from the quantitative phase of a study of self-reported adherence with dialysis, medications, diet, and fluid restriction in a sample of 173 persons who were on a regimen of continuous peritoneal dialysis. The participants were asked if they would be willing to participate in a follow-up qualitative interview if selected. The patients reported being more adherent with medications and dialysis than with diet and fluid restrictions. Lam et al. (2010) also found relationships between adherence and gender, age, and the patients' length of time since beginning dialysis. Based on these findings, Lam, Lee, and Shiu (2014) designed the qualitative methods to include maximum variation sampling, selecting participants who exemplified different ages, genders, and time since dialysis treatment had begun. Lam et al.(2014) explored patients' perspectives on living with continuous ambulatory peritoneal dialysis. The researchers interviewed 36 persons (18 female, 18 male), analyzing data qualitatively as they continued their interviews with subsequent participants. One of the categories identified, the process of adherence, was the focus of the Lam et al. (2014) study report. The authors found that participants adjusted their adherence over time to fit with their lives. During the first 2 to 6 months of dialysis, participants followed instructions carefully for all aspects of the regimen. Most were completely adherent; however, some did not achieve strict adherence with respect to diet and fluids because of knowledge deficits about what they needed to do and how diet and fluid restrictions were related to the dialysis (Lam et al. 2014). Others attributed their partial adherence to an “inability to abstain from their desires to eat or drink” (Lam et al. 2014, p. 911). During these first few months, participants became increasingly aware of the restrictions imposed by their regimen and the requirements of adherence (Lam et al. 2014). Travel was difficult because of having to sequester time for three dialysate exchange periods every day. Favorite, easily available foods were not allowed. Participants began to adjust the regimen to be

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