Sobre las propuestas metodológicas y aportaciones al proceso

The diagram indicates that in pure mixed (the middle point); there should be a balance between qualitative and quantitative. In contrast, in pure qualitative, all paradigm characteristics of qualitative research will be followed. This also is the case for quantitative research which must follow all paradigm characteristics of quantitative research. In this PhD project, more data and analysis was obtained in order to answer the first two qualitative research objectives; therefore, qualitative is more dominant.

Alise and Teddlie (2010) revealed a figure of the use of mixed methods in a wide range of disciplines. In their report, they mentioned that mixed methods were more prevalent in applied disciplines such as nursing and education (16 %), than pure disciplines such as sociology and psychology (6%). Unfortunately to date, there is no clear figure of the number of mixed methods utilised in diabetes nursing.

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Tashakkori and Teddlie (2009) highlighted that the existence of mixed method research is not as well-known as qualitative or quantitative studies, again because it only started to emerge 20 years ago. This PhD research was expected to contribute to mixed methods particularly by giving an example of how a sequential design could be conducted in a health care research. The use of the findings from the first phase: QUAL to suggest the second phase: QUAN in this PhD research could also suggest the way in which the findings from the qualitative phase were further explored quantitatively. It was also hoped that the data integration from this PhD research would reveal another evidence of mixed methods data integration.

6.3. Research design

There are many ways to combine QUAL and QUAN. It is important to carefully look at the research question/s before the type or level of combination can be decided. Tashakkori and Teddlie (2009 p.26) offered two techniques using parallel mixed designs or sequential mixed designs. The first designs which are also named as concurrent mixed method designs, allocate QUAL and QUAN in a parallel pattern (Dawn et.al, 2005; Derwing, Munro and Thomson, 2008). Whereas in sequential mixed designs, the QUAN and QUAL are conducted in chronological order. Some use it by starting the investigation qualitatively, followed by a quantitative approach (Goodridge et al., 2009) or vice versa (Castro et.al, 2007; Goodridge et. al., 2009; Emlet, 2007, Andrew, et al., 2011). Table 13 indicates some of the research projects.

Similarly, Creswell (2009 p.208) indicated that if QUAN is followed by QUAL, the design will be explanatory in principle, whereas if the phases are reversed, it will be exploratory respectively. In explanatory design, Creswell (2009) suggested that QUAL could be used to investigate or to explain any matters obtained from QUAN which

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needed further explanation, whereas in exploratory design, QUAN could be conducted to expand or confirm the findings from the QUAL phase.

Within this project, the combination was in the manner of sequential mixed designs and was exploratory. The reasons to choose this type of combination are as follows:

1. In the first part of the study (QUAL), the focus was on establishing a good rapport with the research participants as well as to familiarise with the setting where this research was conducted. Following this approach, the research then continued by recruiting the required participants, obtaining the views from the patients and diabetes specialist nurses and observing consultations. This type of sequential design has been successfully implemented by previous mixed methods researchers such as Goodridge, et al. (2009).

2. The second part of the study (QUAN) aimed to expand the exploration on diabetes consultation from a wider perspective and to measure any correlation. Miles and Huberman (1994) suggested that researchers use quantitative phase in the later stage of the research and this suggestion was relevant to this PhD study, as the data and findings obtained from the first phase did suggest further issues for investigation. This method is also supported by Creswell (2009 p.212) who identified some advantages of using sequential exploratory strategies such as the ability to offer a clear and straightforward

implementation. As argued by Creswell (2012) the strategies could also help the researcher to expand the qualitative findings or develop an instrument. Alternatively, existing instruments could be modified to match the themes or statements revealed from QUAL. In this research, the Consultation Quality Index-2 (CQI-2) created by Mercer and Howie (2009) was modified and expanded by including findings from QUAL.

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3. The last phase of the study focused on QUAL and QUAN integration and interpretation, where the findings obtained from two methods were integrated or contrasted in order to obtain holistic views of the research findings.

The step by step exploratory design as mentioned above was conducted by following the recommendations from Creswell and Plano Clark (2011, pp. 218-219), who highlighted that in this design, qualitative phase could be carried out before quantitative stage and then ended with an interpretation phase.

Authors Topics Mixed methods

Bradley, et al.

(2009) The effects of interprofessional resuscitation skills teaching Observation using video tapes followed by group interviews Castro and Coe

(2007) Beliefs about self-care during pregnancy Quantitative followed by qualitative analysis Conaglen, et al.

(2009) Sexual dysfunction in female partners of men with erectile dysfunction

Questionnaire followed by interviews

Dubois and

Loiselle (2009) Cancer informational support mixed methods sequential design; quantitative followed by qualitative investigation Emlet (2007) Experiences of stigma in older

adults living with HIV/AIDS Quantitative followed by qualitative interviews Goodridge, et al.

(2009) The quality of dying of patients with COPD A sequential mixed method, focus groups followed by a survey Holden, et al.

(2009) Physical therapists' attitudes and beliefs regarding exercise and knee osteoarthritis

A survey followed by semi structured telephone interviews. Krein, et al. (2008) Health prevention Sequential explanatory study: a

survey followed by interviews and observations.

Ruffin, et al. (2009) Rowell and Polipnick (2008)

Patients’ choices, perspective

and satisfaction 10 focus group interviews and a survey of the 93 focus group participants. Qualitative

interviews: questionnaire, and the Patient Satisfaction Scale Dawn, et al.

(2005) The barriers and facilitators influencing the provision of decision support by call centre nurses

A mixed qualitative and quantitative descriptive study

Table 13 Selection of studies using mixed-methods sequential design

Table 13 shows some selected research which uses sequential designs (not necessarily focusing on diabetes) (Whiting et al., 2006). Some of the studies combined the

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integrated its methodological aspects. As reviewed previously, from the philosophical point of view, the qualitative research method is based on its interpretivist values whereas the quantitative research only merits if its process follows empirical

investigation originally developed from both philosophical positivism and statistics. Trochim and Donnelly (2007) suggested that in applied social research, combining qualitative and quantitative methods could give great value. This suggestion is similar to those from Alise and Teddlie (2010) who reported the more prevalence use of mixed methods in applied disciplines. The availability of examples from these

previous studies and the benefits obtained from utilising both methods have helped in structuring and applying the required steps in this PhD research. The next parts explain the way each stage of the research process was implemented. Diagram 6 shows how the research was sequentially conducted.

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