A case report on using mixed methods in qualitative research Miriam E. Langridge, Edith Cowan University Kathy Ahern, University of Queensland

A case report on using mixed methods in qualitative research Miriam E. Langridge, Edith Cowan University Kathy Ahern, University of Queensland This article describes the methodological approach taken to explore issues surrounding advanced nurse specialisation (ANS) and education. Intentional phenomenology and postmodern discourse analysis were necessary to our study because they each dealt with the perspective of a phenomenon characterised by contradictory and opposing realities. Husserlian phenomenology of the advancing nurse specialists was limited because it did not provide sufficient information about the social and political context in which the nurses were experiencing the phenomenon. We therefore carried out an additional study using postmodern discourse analysis of ANS stakeholder interviews and triangulated the results. The result was what we believe are the most appropriate recommendations that take the individuals experiences and the existing socio-political context into account. The results of the interviews with the nurses and stakeholders in this study are to be published elsewhere. Keywords: advanced nurse specialisation, education, critical phenomenology, qualitative inquiry Miriam E. Langridge RN PhD MRCNA, Lecturer, School of Nursing & Public Health, Edith Cowan University, Western Australia. Email: m.langridge@ecu.edu.au Kathy Ahern RN RMHN PhD, Lecturer, School of Social Science, University of Queensland Introduction An important part of any research process is to select the best research methodology to answer the research question. This article describes processes by which a mixed methods approach was developed and applied to answer a research problem. The research problem in this case centred on individual and stakeholder concerns surrounding the phenomenon of advanced nurse specialisation (ANS) and education. In this study, a nurse working or studying in critical care or mental health, for example, was considered an advancing specialist who chose to undertake a formal continuing education program such as a postgraduate university degree. A stakeholder, for example, included a corporate nurse manager or educator from a large teaching hospital. Although we considered phenomenology would enable us to describe lived experiences of nurses undertaking ANS, we felt it would not sufficiently contextualise experiences in the broader social culture. Our feeling was that proliferation of fee-paying courses might be based more on financial or political interests of institutions offering them than on meeting the needs of individual nurses. We concluded that phenomenology was not sufficient to investigate this broader social context, and that we would need to augment the phenomenological analysis with another, more critical analysis. As a first step in this endeavour, it was necessary to review methodological approaches used to investigate a phenomenon that is socially contextual and includes social, political, economic, philosophical, and educational issues. While phenomenology would provide an understanding of people invested in nurse specialisation and education, critical analysis would enable us to gain the insights of people who felt marginalised, sceptical, and critical of ANS and education. This paper describes literature studied that helped us decide on a more critical complementary analysis to triangulate with phenomenology. It includes an overview of the limitations associated with using a single qualitative method and a discussion of what triangulation of methods brings to a qualitative analysis. Research problem and theoretical triangulation Rapid changes in nursing such as technology, finite health care resources, and higher education in nursing have led to a situa- 32 Collegian Vol 10 No 4 2003

A case report on using mixed methods in qualitative research Although we considered phenomenology would enable us to describe lived experiences of nurses undertaking ANS, we felt it would not sufficiently contextualise experiences in the broader social culture. tion where nurses find themselves in a tenuous position. Should they undertake ANS? Which course, of the plethora available, should they choose? How will becoming an advanced nurse specialist help them and their patients? In order to find answers to these and other questions, we found no single methodology was sufficient. The key research question remained: What is to be made of our concern, nurses and stakeholders, that there are problems associated with the demand for advanced nurse specialists? As the study progressed, we concluded that we needed to develop a mixed methodology based on rigorous qualitative methods supported by the literature. In the end, we found we had created a new generation research (Streubert & Carpenter 1995) study that used a triangulated interpretative, contextual, and socially critical theoretical framework. The commodification of knowledge (Stewart 2000), health services, and tertiary education led us to investigate how nurses could adjust to the ideology of consumerism (Parker 1999). In nursing, adjustment towards consumerism has seen the proliferation of fee-paying courses for nurses. Additionally, commodification of education and health care has seen a booming need for the credentialling of advanced nurse specialists (Pelletier & O Donoghue 1998). In order to understand this new world of ANS and education we decided to carry out a phenomenological study of nurses who undertake ANS. To understand the experiences nurses encounter while advancing, a question was posed to 13 nurses who were studying and advancing in a chosen area of nurse specialisation. Individual interviews were conducted. The question was: What is your experience as an advancing specialist nurse while working and studying? During the data analysis of first round interviews with the advancing registered nurses (RNs), it became apparent there were many external social and political issues affecting how and why nurses would take a particular course of action. Therefore, we felt we needed a greater understanding of the other players who had vested interests in ANS. As a result, we held a focus group interview with 10 executive nurses, who also had a vested interest in ANS and education. They were asked a similar question: What is to be made of the work practices of nurses who have undertaken an advanced specialty course of study? The data from these interviews was discursive in meaning and did not lend itself to a pure European phenomenological approach. Therefore, a critical sociological approach based on a Husserl/Crotty/Moustakas framework of discourse analysis was adopted. This triangulation of methods (Richardson 1994, Denzin & Lincoln 2000, Janesick 2000, Stake 2000) became a process of learning for us. The end result was a triangulation of methodologies offering an alternative inquiry rich in description and also providing a postmodern critique of the nature of ANS and education. Background to phenomenology and discourse analysis Phenomenology The 1800s and 1900s have seen a continued diversification of philosophical and scientific approaches to understanding and knowledge attainment. Philosophical movements comprised a new form of modern logic and the term phenomenology was first coined by an 18th century German mathematician, J H Lambert, to describe the science of appearances (Scruton 1995). This was the beginning of what was considered knowledge that was subjective in nature. Phenomenology had its origins in the European philosophical tradition, emerging from the philosophy of a late 19th century German philosopher and mathematician, Edmund Husserl. He thought description of phenomena by the objects of experience would provide knowledge of what constitutes the reality of lived existence in the world (Lowenberg 1993, Crotty 1996, Creswell 1998). This reality was embedded in what Husserl termed intentionality. His search for the foundations of knowledge was based on the assumption that beings had a conscious awareness of experiences that afforded structure in being. This conscious awareness accounted for descriptions of what is reality for the individual. As Levinas (1973 p41) stated, intentionality is what makes up the very subjectivity of subjects. Contemporarily, the term phenomenology has been used widely in research. However, confusion prevails as to the application of phenomenology. Is it a movement, a philosophy, or a method that can be used for research purposes? There is little consensus. For example, one of van Manen s (1990 p173) earlier writings indicated that phenomenology was not really a method but more a reflective grounding in a deep sense. By 1997, however, he wrote that phenomenology was a method that proceeds from epistemology to application... [and] from method to meaning (van Manen 1997 p350). In relation to our research on ANS, van Manen (1990) indicated how phenomenology is a kind of questioning that permits a rigorous interrogation of a phenomenon, and that there is a rethinking about things not well understood. In addition, phenomenology demonstrates capabilities of an author to see and show phenomena in a way that s/he is oriented, and permits new understandings to be gathered and viewed as collective thinking that is brought to speech. It was this aspect of van Manen s description that led us to choose phenomenology as a method for studying the experiences of nurses undertaking ANS. However, the use of phenomenology by nurse researchers has received criticism about ways researchers have imported phenomenological research that has evolved from the traditional European interpretation into a North American perspective (Crotty 1996, Collegian Vol 10 No 4 2003 33

Caelli 2000). Crotty (1996) questions researchers who have radically adapted phenomenology to their own ends because the common core of European phenomenology, intentionality, is overlooked and many nurses are, therefore, unable to justify the use of the term phenomenology. Caelli (2000) agrees with Crotty s (1996) analysis but indicates a clear delineation exists between the North American and traditional European philosophies and styles of phenomenology. She explains pre-reflective experience of individuals is Heideggarian (Heidegger 1962), and universal meanings of individual experiences are not sought by the North American phenomenologist. Rather, the North American philosophical approach has been to focus on participants lived experience evident within a culture, such as nursing, and not within the context of universal external conditions. As nurses and researchers, we wished to capture universal and cultural aspects of nursing from both cultural and universal experiences of individuals. We concluded this could only be done using a triangulated approach. In order to understand lived experiences of ANS and education from those nurses studying in a field of specialisation, we used Husserlian phenomenology of intentionality (Husserl 1931, 1948, 1960, 1970, 1999). This was because of the assumption that participants recruited in this study were consciously aware of their intent to advance in a chosen area of nurse specialisation. Husserl s approach emphasised a systematic methodology that used data based on participants conscious reflections of their subjective acts (Moustakas 1994). This conscious reflection includes the object/subject phenomenological perspectives described by Crotty (1996, 1998) and Moustakas (1994). That is, human understanding and meanings are an outcome of experience whereby object and subject are studied so that a phenomenon can be viewed from its entirety. Object in this study included the nurses experiences of ANS and education, such as working within the bureaucracy of a health care system. Subject included the way an individual structures the experiences of ANS, such as choices s/he makes to undertake a particular course of study. Both object and subject are a direct outcome of the nurses experiences, and should not be separated. This is because any separation of subject and object in qualitative research weakens the results of a study as researchers are limited in constructing a theory relevant to a phenomenon (Minichiello et al 1999). We concluded that a phenomenological approach based on a Husserl/Crotty/Moustakas theoretical framework was the best approach because both object and subject of human experiences would be explored. Discourse analysis and critical theory According to Lemert (1997), people find no realistic reason to vest hopes in a world that is not good or getting better. As a result, postmodernism is about the researcher questioning inevitable changes experienced by society and modern culture which may not always be for the better. The researcher therefore asks, What is to be made of the world-concern that preoccupies people outside the cloisters of privilege who believe the world is not what it used to be? (Lemert 1997 pxiii). Our study about ANS and education posed a similar postmodern question, that is, What is to be made of the anecdotal concerns of executive nurse stakeholders such as managers, educators, and researchers that there are deep, unspoken problems associated with the demand for advanced nurse specialists? We concluded that we needed a discursive approach from nurse stakeholders to enable us to further review the phenomenon of ANS from a postmodern perspective, using a critical discursive approach. This form of analysis is relatively new territory. Lupton (1999 p454) refers to discourse analysis as a form of content analysis that sees qualitative text as a meaningful whole. This means critical analysis, which focuses on a need for social change, should involve clarification of the role of researchers and identification of practical problems in everyday life, and construct a methodology for social change. We felt this focus on social change would enhance utility of the Husserlian phenomenology we had decided to undertake. The critical approach to philosophical thinking, writing, and research had its beginnings from the Frankfurt school in Germany after World War I (Stevens 1989). This was based on development of capitalist societies where taken-for-granted conditions and traditions of democracy, bureaucracies, and employee-employer relationships required exploration with an open and critical mind (Murray & Ozanne 1991). Discourse analysis as a critical approach to philosophical thinking involves an analysis and exposure of current sociocultural, political, and economic conditions of a modern society that can be extremely oppressive (Fiske 1994, Wells 1995). Researchers who embrace this approach are permitted to critique any form of tension or domination that may be experienced and interpreted by individuals. This may include changing activities and relationships of learners or change in education courses sold to consumers (Fairclough 1992). Other examples include the nature of relationships between politicians and the public, between health care professionals, and between employers and employees. Fairclough (1992) suggests changes in relationships are a part of discourse practices that are constructed. We adopted a postmodern discursive approach (Habermas 1987) in order to question issues surrounding ANS and education from a stakeholder s (powerful) perspective. According to Irvine (1998), postmodernity offers an opportunity to take a critical approach to an ideology that no longer seems transparent. The postmodern approach to research began in the 1970s as an enlightened reaction or critique of conditions of the world (Creswell 1998). According to Creswell (1998), learning to understand these conditions permits a discourse on those people or groups who may have considered themselves marginalised. We found this an especially important point when, quite unexpectedly, we discovered some executive nurses ( powerful stakeholders) in this study who felt they were marginalised, and continued to work and live with contradictions. Therefore, through our critical discourse analysis, we attempted 34 Collegian Vol 10 No 4 2003

A case report on using mixed methods in qualitative research to re-contextualise and redefine a modern era of nursing embedded in history and tradition. Indeed, nurse education remains embedded in tradition that has been institutionalised by accrediting government bodies (Hendricks-Thomas & Patterson 1995). In summary, we reflexively considered Husserlian phenomenology provided us with an understanding of nurses who had a vested interest in their own specialisation while critical phenomenology gained insights about people who felt marginalised, sceptical, and critical of ANS and education. Thus we were enabled to undertake an analysis that was critically and socially motivated to enhance a basically descriptive phenomenological approach. We decided to base our critical discourse on methodology that Crotty (1998) called critical phenomenology. Crotty s critical phenomenology Crotty (1998) believes the adoption of language as a research strategy has an affinity to Habermasian critical and social theory. That is, humankind is competent in the use of language based on a shared understanding (Brand 1990). What is common to phenomenology and central to Habermasian discourse is that shared meanings are competently expressed in language or conversation, and not exclusively in the written word. Overall, tenets of Habermas social theory are based on a scientific inquiry that is socially critical and emancipatory (Brand 1990, McCarthy 1990), although there have been many modifications to Habermas theory (White 1995). Despite these modifications, Habermasian concepts remain interrelated and generate more conceptual, moral, and empirical insight than alternative approaches (White 1995 p7). Therefore, we decided to use Crotty s critical phenomenology, which is based on Habermasian communicative competence that is discursive in approach. Habermas views knowledge as emancipatory (Ulrich 1983) because new knowledge that a nurse gains, for example, is enlightening. However, enlightenment is never pure, [and] always founded in universal human interests (Lemert 1997 p414). For example, it may be possible to have several interpretations of nursing s recent transition from an apprenticeship model of education to a higher education model. On one hand, the move to a higher education model is a result of social evolution. On the other, it is also a growth of the individual nurse from a traditional demand that nurses required a degree of personal humility, suffering, and subservience to all other professions of the day. Significantly, whether change to university education was through social evolution or personal growth, both processes are founded on universal human interests, namely empowerment. Our study of inter-subjective experience and knowledge was based on a premise that enlightenment enables people to empower themselves (Street 1990). Crotty s Habermasian critical phenomenology is a scientific inquiry that is socially critical and emancipatory. We feel we selected an approach which best permitted us to uncover distortions and constraints that impeded the empowerment of nurses as individuals or as a group. Conclusion We believe there is rarely a single methodology that can satisfy all elements of a research inquiry (Habermas 1984, Morse 1989, Streubert & Carpenter 1995). For our study on ANS education, an interpretive description of what was reality for nurses undertaking specialisation was considered appropriate using phenomenology. However, it was also limited because interpretation, on its own, could not provide a comprehensive picture of all possible factors impacting on these nurses. To overcome this limitation we turned to developments related to postmodern notions that were pervading the range of interpretive methodological approaches (Lowenberg 1993). We concluded the phenomenon of concern could equally be explained using a postmodern approach whereby the social world, in which nurses live and work, could be examined. The appropriateness of our combined methodology was confirmed during data analysis. This was because the nature of data that presented as a sociological discourse was oriented to political, educational, moral, social, and economic constraints of the day. The data from one-to-one interviews with advancing nurse specialists provided phenomenological thematic analysis. This data reflected the intentional reality and in-depth analysis of phenomena from those who lived the experience of interest. The data from a focus group of nurse stakeholders provided a discourse analysis of the phenomenon of ANS from the stakeholders perspective. In this instance, phenomenology and discourse analysis comprised two methods of choice to investigate a complex phenomenon. This methodological triangulation may have created a problematic framework for the research, because of the sociological complexity of the study. However, we considered the benefits of triangulation outweighed the problems. Others might disagree, and we welcome their discourse. We agree with Morse (1996) who posits it is the prerogative of researchers to decide which method, triangulated or otherwise, is essential for a study, and with other authors who feel qualitative research does not have a distinct and unique set of methods (van Manen 1990, Denzin & Lincoln 1994, Morse 1998). Our goal was to provide new knowledge and insights about a problem (Creswell 1998). To do this, we created a new generation research (Streubert & Carpenter 1995) study using a triangulated interpretative, contextual, and socially critical phenomenological theoretical framework to guide the study. Acknowledgments: Nurses Board of Western Australia - Research Fellowship, 2000 Edith Cowan University Higher Education Contribution Scheme Scholarship, 1999 References Brand A 1990 The force of reason. An introduction to Habermas theory of communicative action. Allen & Unwin, Sydney Caelli K 2000 The changing face of phenomenological research: traditional and American phenomenology in nursing. Qualitative Health Research 10(3):366-377 Creswell J 1998 Qualitative inquiry and research design. Choosing among five traditions. Sage, Thousand Oaks Collegian Vol 10 No 4 2003 35

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