CATEGORIES SIMPTOMÀTIQUES I MOTIUS CLÍNICS DE CONSULTA

Research paradigms

Philosophical stances or paradigms are important in research because differences in beliefs influence our interpretations of reality, our values and our research methodology (Doyle et al. 2009). Ultimately, this affects the research questions we ask and the methods selected to answer particular research questions (Morgan 2007). There are multiple definitions and uses of the word paradigm to describe alternative philosophical aspects of research. In this study, a paradigm is defined as a ‘worldview’ which is made up of a mutually exclusive formulation of reality (ontology), knowledge (epistemology), and how best to learn about the world

(methodology) (Guba and Lincoln 2004, Shaw et al. 2010).

Quantitative and qualitative research

Broadly, there are two main approaches to research: qualitative and quantitative, and each has distinct beliefs underpinning their use. Quantitative researchers tend to think in terms of a single objective reality and this view underpins their whole approach to quantitative research as they focus on understanding the ‘truth’ regardless of context, which is also known as positivism (Nicholls 2009a). Conversely, qualitative research tends to be underpinned by the belief that reality is subjective and dependent on context, which can be referred to as

constructivism or interpretivism (Nicholls 2009a). There are many other philosophies along the spectrum between these two approaches with many additional sub-types and variations (Nicholls 2009a).

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Qualitative research is generally distinct from quantitative research not only by the

underpinning ontological beliefs of the researchers but also in the purpose of the research. Quantitative research focuses on measuring and understanding quantifiable measures whereas qualitative research focuses away from quantifiable measures and particularly helps understanding of people’s views and perspectives (Dew 2007, Nicholls 2009b). Broadly speaking, qualitative research can include research that is not determined by statistical procedures or means of quantification (Hoepfl 1997). It is recognised to be particularly useful to seek insight, understanding, and exploration; it cannot examine causal determination (Hoepfl 1997). On the other hand, quantitative research is able to address these issues but it is not generally recognised to be able to explore the depth and complexity of phenomena, especially social inferences (Hoepfl 1997). On this basis, it is important that when choosing a research methodology the researchers consider the aims and purpose of the research alongside worldviews and ontological beliefs.

Pragmatism

Pragmatism is an approach to research that incorporates aspects from both quantitative and qualitative paradigms. The worldview of pragmatists tends to be problem-centered,

considering the consequence of actions and real-world implications. Rather than focusing on methodology, it emphasises the significance of the research problem and the need to use any available approach to understand the research question (Johnson and Onwuegbuzie 2004).

Pragmatism follows a pluralistic approach to derive knowledge as it draws on many different philosophies and approaches including both quantitative and qualitative paradigms. When this occurs however there should be a rationale for mixing and merging paradigms that considers the particular research question (Johnson and Onwuegbuzie 2004, Denzin 2010).

When using pragmatism, researchers focus on finding practical solutions to problems within the practical nature of reality (Denzin 2010, Shaw et al. 2010). Pragmatic researchers believe

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that all research occurs in context and this is where a practical approach to epistemology comes in to play (Morgan 2007, Shaw et al. 2010). Johnson and Onwuegbuzie (2007), discuss that a pragmatic philosophy partners well with mixed methods, stating that pragmatism is ‘’cognizant, appreciative, and inclusive of local and broader socio-political realities, resources, and needs‘’.

Historically, the debate between the paradigms has focused on differences between

qualitative and quantitative philosophies rather than similarities, for which there are multiple (Johnson and Onwuegbuzie 2004, Onwuegbuzie and Leech 2005). In one extreme, it has been argued that ‘pure’ methodologies are theoretical illusions and that all methodologies have a degree of being mixed (Onwuegbuzie 2010).

Considering in further detail the potential conflicting methodologies which are to be mixed in this study. In using pragmatism, the underlying methodologies typically associated with the chosen methods are not dismissed as dichotomous but rather can be described as

dimensionally different (Johnson and Onwuegbuzie 2007). Willems and Raush (1969), accessed via Onwuegbuzie and Leech (2005), discuss this in terms of the research using a bi-focal lense whereby pragmatic researchers are able to zoom in to microscopic detail or to zoom out to indefinite scope (Willems and Raush 1969). The use of pragmatism and mixed methods can be used a philosophy and method which aims to merge together the insights provided by

qualitative and quantitative research into a ‘’workable solution’’ (Johnson and Onwuegbuzie 2004); they should be seen as complimentrary rather than as rivals (Jick 1979).

Mixed methods

Teddlie and Tashakkori (2009), are two pragmatic researchers using mixed methods and they state that most mixed methods researchers work primarily within a pragmatic paradigm. This is the case for this research team as a pragmatic, mixed methods methodology was adopted throughout this study.

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There are many reasons for using mixed methods including where a single approach is inadequate to provide data on multiple perspectives and with the understanding desired (Doyle et al. 2009). Furthermore, researchers may want to contextualise findings, view problems from multiple perspectives, or provide complementary or illustrative context (Meissner et al. 2011). Another strong reason for mixed methods research is so that one data set can build on another in a sequential fashion (Meissner et al. 2011), which was the

approach adopted in this study.

Recognised disadvantages of mixed methods include that the research team requires an appropriate level of knowledge of the methods that are to be mixed and also the familiarity of how to merge them (Doyle et al. 2009). To minimise this mixed methods research should combine qualitative and quantitative elements so that the strengths of the two disciplines are complementary with nonoverlapping weaknesses (Johnson and Onwuegbuzie 2007). In this study the lead investigator (CR) underwent research methods training to gain knowledge and understanding of conducting mixed methods research.

Mixed methods research can address a range of questions both confirmatory and exploratory in nature and there is a greater opportunity for a larger assortment of divergent views than with some single method approaches (Teddlie and Tashakkori 2009). The use of two or more methods, such as questionnaires and interviews can give stronger understanding as one type of data provides insight into the extent of views and variables, and the other provides depth into understanding more of the variables, and together they yield useful results that would not be established with a single method (Teddlie and Tashakkori 2009), this approach is adopted in this evaluation. Johnson and Onwuegbuzie (2007), summarise this stating that mixed methods is a powerful choice that will often ‘’provide the most informative, complete, balanced, and useful research results.’’ (Johnson and Onwuegbuzie 2007).

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A further reason that some researchers may choose to use mixed methods is becuase the method can offer the chance to triangulate data. Triangulation can be defined as:

‘’The use of more than one method or source of data in the study of a social phenomenon so that findings may be cross-checked.” (Bryman 2016).

Commonly multiple methods are used in triangulation for the purpose of producing a more accurate, comprehensive and objective representation of a study (Silverman 2014). It can also be used as a technique for ‘confirming’ results or in mixed methods as a way of merging data (Mays and Pope 2000, Teddlie and Tashakkori 2009). Additionally, triangulation can help to identify patterns of convergence in order to corroborate findings and gain a better overall interpretation of study data (Mays and Pope 2000).

Triangulation closely links with ontology as qualitative researchers tend to not believe in a single objective reality, in this study this meant that close attention was paid to context when using triangulation, in line with a pragmatic methodology. This involved using multiple methods to measure and address different elements of the research objectives and

triangulating to establish a more comprehensive overview of the research topic. This approach to triangulation is supported by Morse (2015), who argued that as multiple methods use different perspectives this will not necessarily give the same results but, as different understandings can be gained through the use of different methods, the overall scope and depth of the study is enhanced. This method is also supported elsewhere in the literature where it has been suggested that triangulation not be used solely for testing validity but rather to encourage comprehensive research via allowing unexpected results to be addressed as to strengthen and merge findings (Teddlie and Tashakkori 2009, Morse 2015).

Triangulation can help contribute to the validity of research but it is not a measure of validity alone and additional validity measures should be used to help to ensure comprehensiveness

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and encourage reflexivity by the researchers (Mays and Pope 2000, Cameron 2009). This was adopted in this study and further discussed section 4.5.2.