Combining the analysies of three qualitative data


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Combining the analysies of three qualitative data

  1. 1. Journal of Advanced Nursing, 1997, 26, 664–671Combining the analyses of three qualitative datasets in studying young caregiversNancy R. Lackey RN PhDProfessor, University of Missouri–Kansas City, Missouriand Marie F. Gates RN PhDAssociate Professor, University of Missouri-Kansas City, Missouri, USAAccepted for publication 20 September 1996 LACKEY N.R. & GATES M.F. (1997) Journal of Advanced Nursing 26, 664–671 Combining the analysis of three qualitative data sets in studying young caregivers Adolescent care of the adult with cancer led the authors to choose three qualitative methods to describe this unexplored phenomenon. In this study, phenomenology, ethnography and unstructured survey were combined to provide a more complete picture of the phenomenon. Data from interviews with 11 youngsters within seven family units, observations, and unstructured questionnaire, demographic data form and field notes were analysed and combined. The processes used in designing and conducting the study and analysing the data, rather than the findings, are emphasized. The data obtained by using these three methods have laid the foundation for further nursing research on caregiving by youngsters and raise questions about combining analyses of three qualitative data sets. Keywords: triangulation, qualitative, youngsters, caregiving theory (Wilson & Hutchinson 1991). A second paperI NTRODUCTI ON (Swanson-KauÂman 1986) delineates the process, pro-The past 10 years have seen an increased interest in using cedure and results of the combined aspects of phenomen-triangulation to explore nursing phenomena. Most defi- ology, ethnography and grounded theory to create anitions of triangulation refer to combining qualitative and unique nursing methodology to study women who hadquantitative methods (Knafl & Gallo 1995, Morse 1991, miscarried.DuÂy 1987, Hinds & Young 1987, Tripp-Reimer 1985). In a study in 1993 (Gates & Lackey, unpublished data),Although other authors do not specify the kinds of three qualitative methods — phenomenology, ethnogra-methods that are combined, the assumption is that they phy, and unstructured survey — were selected to exploreare referring to triangulation of qualitative and quantitative a phenomenon that is essentially absent in the literature:data (Kimchi et al. 1991, Mitchell 1986). care of the adult with cancer by children and adolescents. The authors of this paper believe that the definition of The purpose of this paper is to describe issues involvedtriangulation needs to include the combination of quali- in triangulating these three qualitative methods withtative methods as well. An extensive review of the litera- specific focus on combining the analyses of the three datature revealed only one paper that discusses combining sets. In order to understand these issues, an overview oftwo qualitative methods: hermeneutics and grounded the study will be included.Correspondence: Professor N.R. Lackey, University of Missouri–KansasCity, 2220 Holmes Street, Kansas City, Missouri 64108-2676, USA.664 © 1997 Blackwell Science Ltd
  2. 2. Studying young caregivers data sources refers to time, person or space. As Knafl &REVIEW OF THE LI TERATURE Gallo (1995) reported, this strategy involves combiningDenzin (1978) first categorized four basic types of triangu- data over time from more than one person in more thanlation: investigators, theories, methods and data sources. one context. Examples of triangulating unit of analysisKnafl & Breitmayer (1991) added unit of analysis as a cate- include individual and family unit and interactions, andgory. In addition, two more categories — analysis triangu- perceptions and behaviours of individuals (Knafl &lation and multiple triangulation — were identified Breitmayer 1991). Both unit of analysis and data source(Kimchi et al. 1991, Mitchell 1986). Discussion of the vari- triangulation are well documented and used in a varietyous kinds of triangulation details all except analysis of of triangulation sets, and almost exclusively relates to combiningqualitative and quantitative research. Analysis combination The use of more than one investigator is probably themost common type of triangulation. Kimchi et al. (1991) Analysis combination is the least documented type of tri-stated that triangulation of investigators occurs when two angulation. Kimchi et al. (1991) defined analysis triangu-or more researchers with divergent backgrounds study the lation as using two or more methods of analysis for onesame phenomenon. Combining areas of expertise related set of data, which they stated will enhance validation butto content, method or discipline in conducting research fail to delineate any process for accomplishing this. Waltzallows for breadth and depth of what needs to be done. et al. (1991) gave the most detailed process for combiningKnafl & Breitmayer (1991) support the contribution such analyses, but their approach tends to be more quantitat-diversity of backgrounds lends to a research study and to ively oriented.the other types of triangulation. Waltz et al. (1991) list four questions that should be Many authors list theory triangulation as important, but considered when combining data for analysis from diÂer-few really describe how this is done. Janesick (1994) ent methods: (a) ‘Does each method employed demonstratedefined theory triangulation as ‘the use of multiple per- reliability and validity in its own right?’; (b) ‘Should allspectives to interpret a single set of data’. Patton (1990) methods employed in the analysis be given equal weightstated that all phenomena can be viewed through many in terms of importance and usefulness? If not, on whattheoretical perspectives. He believes that viewing a basis should the data be weighted?’; (c) ‘What will consti-phenomenon through several diÂerent theories provides tute evidence for consistency or congruence of methods?’;expanded focus on the findings. Waltz et al. (1991) stated (d) ‘When diÂerent methods yield dissimilar or divergentthat hypotheses from competing theories should be tested results, how will the investigator reconcile and/or explainwith the same data set, as this process would allow for the diÂerences?’.diÂerent perspectives to emerge. Breitmayer et al. (1993) described an analysis that focuses on completeness and confirmation of a single con- struct. While they emphasize qualitative research, theirTriangulation of methods example triangulates results obtained from both qualitat-Triangulation of methods is the category most discussed. ive and quantitative data. Tripp-Reimer (1985) reportedConfusion exists over triangulation of methods, because the results from combining two complementary data setssome authors are referring to the way they collect data, but never combined them. In reviewing the literature, nosuch as interviews, use of instruments or observations, papers that discussed combining qualitative data sets forwhile others such as Patton (1990) talk about combining analysis were found.diÂerent methodologies, such as a naturalistic design withan experimental design. Multiple triangulation In the nursing literature, the discussion of triangulationof methods focuses on the triangulation of qualitative and Multiple triangulation is still another type. Mitchell (1986)quantitative research (Banik 1993, Breitmayer et al. 1993, described this triangulation as using more than one of theCowman 1993, Norman et al. 1992, Kimchi et al. 1991, following: several diÂerent data sources, more than oneKnafl & Breitmayer 1991, Morse 1991, Patton 1990, Hinds investigator, testing competing hypotheses, or using more1989, Sohier 1988, DuÂy 1987, Hinds & Young 1987, than one methodology. Analysing more than one data setTripp-Reimer 1985). Knafl & Breitmayer (1991) make the should also be that combining quantitative and qualitative methods In this study, multiple triangulation was used (Table 1).leads to confirmation and completeness in the domain of The combination of the three methods and two investi-interest. Few papers (Wilson & Hutchinson 1991, gators gave a richer, fuller description of the phenomenonSwanson-KauÂman 1986) discuss combining qualitative than could be accomplished by one method or investi-methods. gator alone. Denzin (1989) and Jick (1979) noted that triangulating Oberst (1993) stated that the ‘missing piece in most© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 664–671 665
  3. 3. N.R. Lackey and M.F. GatesTable 1 Types of triangulation used in young caregiver studyType of triangulation How and why used1. Investigator Two-investigator team: provided varying expertise in kinds of methods used, kinds of nursing (e.g. medical/surgical nursing, public health nursing), and content areas (e.g. hospice care, ambulatory care)2. Methods Phenomenology: description of caregiving from youngsters’ perspectives Ethnography: description of caregiving as influenced by context observation of caregiving within cultural milieu; field journal Unstructured survey: description of needs identified by youngster Demographic form: description of sample from youngster and family data3. Units of analysis and sources of Youngsters: phenomenological and ethnographic interviews, Object Content Test data identifying needs, answers to questions on demographic form, observations Family members: observations, responses to questions Adults with cancer: observations, responses to questions People outside family: observations, responses to questions Interactions: observations, journal notations4. Analysis Giorgi et al.’s (1975) five steps with outcome of phenomenological description of caregiving Leininger’s (1985) phases of analysis with identification of themes Content analysis with categorization of needs of young caregivers Descriptive statistics leading to demographic profile Combined analysis with synthesized description providing completeness based on uniqueness provided by each data set, confirmation based on similarities of data from each data set, and divergence based on diÂerences of data from each data settriangulated approaches,… is triangulation of investi- address the issue of adolescent caregiving. The only stud-gators’. Each of the authors was experienced in a diÂerent ies found on this phenomenon were those conducted inqualitative method and had a diÂerent nursing disciplin- Great Britain (Aldridge & Becker 1994, 1993).ary focus, expertise in diÂerent content areas, and the same Because the phenomenon had not been studied in theresearch philosophy and work ethic. The triangulation of United States, the authors decided to use three methods:methods enabled the authors to describe diÂerent aspects (a) phenomenology, to describe the experience from theof the phenomenon of caregiving by young caregivers adolescent’s point of view more fully; (b) ethnography, tothrough diÂerent approaches. understand the experience in the context of the family The first investigator could focus on the interior experi- and other environments of the adolescent; andence and feelings of the youngsters through phenomeno- (c) unstructured survey, to elicit the needs as describedlogical interviews, thereby providing the youngster- by the adolescent.centred description of caregiving and what it meant. The The purpose of this descriptive, exploratory study wassecond could focus on the eÂects of caregiving on the to describe as completely as possible the experiences,family and youngsters and vice versa through ethno- lifeways and needs of adolescent caregivers of adults withgraphic interviews and observations. Both investigators cancer. With the first family three young caregivers, twocould look at the needs as the youngsters described them of whom were younger than adolescent age, were written format. The use of the journals provided insight Permission was sought to include children in this studyand depth in the analysis. Analysis triangulation was the as well. Therefore, the terms ‘youngster’ or ‘young care-final type of triangulation used. giver’ were used to include both the older child and the This paper will focus on the values and problems of adolescent in this paper.combining the analysis of the data sets. A brief descriptionof the study is provided in order to focus the discussion Participants and settingof multiple analysis. Criteria for this purposive sample were: (a) 11–19 years of age; (b) caregiving for an adult with cancer for at least 3THE STUDY months; and (c) ability to understand and speak English.Greater numbers of adolescents are providing care for Eleven participants, aged 11 to 19 years, from seven famil-adults with cancer, but the caregiving literature does not ies were included in this study: three boys and eight girls,666 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 664–671
  4. 4. Studying young caregiversseven blacks and four whites. Their grades in school revealed patterns of caregiving experiences as guided byranged from fifth grade to college. Leininger’s sunrise model (1985). The patterns were syn- The adults had cancer of the lung, breast, pancreas, or thesized into the following selected themes.multiple myeloma. The ages of the adults ranged from 39to 70 years. The relationship of adults to the young caregiv- 1 Kinds of caregiving involved personal tasks, householders included grandfather, grandmother, mother and father. tasks, but not intimate caregiving; tasks were performed by single and multiple combinations of young caregivers.Procedures 2 Responsibility of caregiving was an expectation ofAfter obtaining parent consent and child or adolescent family life and of the child or adolescent role in thatassent, the investigators collected data using audio-taped family life.interviews; participant observation; the Object Content 3 Support in the home environment depended on whoTest (OCT) (Hartley 1970), an unstructured, self- had cancer, the presence of at least one other adult inadministered, paper and pencil test; and a demographic the home, and the relationship of the family with thedata form. The phenomenological interview asked the external environment.question: ‘What is it like to be a caregiver of [name of the 4 The school had the potential for the most social supportadult with cancer]?’. After the phenomenology interview, in terms of external influences in the situation. Thethe participant was asked to fill out the OCT, which asked potential for church, friends and health care providersthe question: ‘What are my needs as a caregiver of an adult as social supports was also present.with cancer?’. The demographic data form was also com-pleted at this time. COMBINING THE ANALYSIS OF THE THREE Ethnographic interviews and participant observation DATA SETSwere used to explore the youngster’s lifeways and caregiv-ing within the family and outside environmental milieu, The problem arose when the combination of the threeand the relationship of the youngster with the adult with analyses was attempted. Kimchi et al. (1991) definedcancer and others. In addition to observing the care of the analysis triangulation ‘as using two or more approaches toadult with cancer, such activities as school events, family the analysis of the same data set’. The task was diÂerenttimes and community suppers were included in the par- for this study. Analyses from three data sets had to beticipant/observation experiences. combined. Should the data sets or the results of the data sets be combined? Which analysis method would work best? What would the final outcome look like — a descrip-BRIEF ANALYSIS AND GENERAL RESULTS tion, a listing of themes? If themes were selected, howOF EACH DATA SET would they diÂer from the ethnographic themes?The phenomenological, ethnographic and needs survey At one point, the authors discussed analysing all the rawdata were transcribed verbatim. The demographic data data as one large data set but realized that in doing so thewere analysed with descriptive statistics. Each data set assumptions of each of the qualitative methods would bewas analysed separately. Content analysis of the needs violated. Phenomenology, for example, speaks to thelisted on the OCT by the youngsters led to the following experience from the person’s point of view. Therefore,categories: (a) focusing on self and personal needs; including observations of the investigator or other mem-(b) focusing on adult with cancer; (c) focusing on relation- bers of the family would be contradictory to theship with family and others. assumptions. Analysis of the phenomenological data followed Giorgi’s Therefore, the authors decided to triangulate the resultssteps (Giorgi et al. 1975). In the phenomenological descrip- of the analysis of each data set: the phenomenologicaltion, youngsters described caregiving as a dichotomy: description, the ethnographic themes and the categories ofhard, yet gratifying. It is hard because it not only adds needs. By combining the analysis from each data set, anyresponsibilities and interferes with normal activities, but assumptions of the qualitative methods would not bebecause stress and fear are involved. Stress occurs, for violated.instance, when the adult with cancer shouts at them or This approach is consistent with the process outlinedwhen the adult does not cooperate when the youngsters by Waltz et al. (1991) and reinforced by Breitmayer et al.carry out a specific responsibility, such as feeding. (1993) for triangulating qualitative and quantitative analy-Youngsters expressed fears regarding the possibility of sis sets. Waltz et al. (1991) talk about looking for conver-something happening to the adult, doing something wrong, gence and divergence across methodologies. Breitmayeror being left alone. Often the youngsters described feel- et al. (1993) spoke to confirmation and completenessing fatigued. in doing so. The authors see convergence and confirmation The ethnographic analysis of the youngster lifeways as referring to the same aspect of analysis. Three© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 664–671 667
  5. 5. N.R. Lackey and M.F. Gatesconsiderations were finally identified as important: con- noted in the ethnographic analysis, versus school as havenfirmation or convergence, divergence and completeness. from caregiving, as depicted in the phenomenological description; and (c) the self-centred versus other-centred focus as determined from the needs survey analysis. AsMatrix the authors were grappling with these dichotomies,A matrix (Miles & Huberman 1994) that identified the diÂerences in parent/youngster perception of caregivingmajor findings from each data set — phenomenological became apparent and suggested the need for includingdescription, ethnographic themes, demographic data and more defined perspectives from youngsters and othersurvey categories — was developed to assist with the family members in future work.analysis. First, the authors found that combining the datasets gave a broader depth and scope of the phenomenon Further explorationwhich deals with completeness. For example, the young-sters provided the authors with a phenomenological Finally, the combined analyses helped in identifyingdescription of their caregiving tasks and accompanying specific areas of youngster caregiving that required furtheremotional overlay. The ethnographic data analysis exploration. For example, in multiple caregiving situ-allowed the authors to see the categorization of these tasks ations, phenomenology focused on the bickering amongstwithin the role and milieu of the family and other environ- the youngsters, while ethnography provided the oppor-ments. The demographic data gave a description of the tunity to see the negotiation of tasks inherent when a groupyoungster, the adult with cancer, and the family. The of youngsters was present. Decision-making rules, auth-survey analysis reflected on the needs of the youngster for ority and the process by which youngsters become engagedmore information about tasks of caregiving. in caregiving tasks in multiple caregiving situations Table 2 shows the matrix devised as an aid in determin- emerged as research areas for further completeness, confirmation and divergence, as well as The qualitative methods of phenomenology, ethnogra-unique findings from the separate and combined analyses. phy and survey can be combined to give a richer, fuller Along with providing depth and scope, aspects of care- description of the phenomenon of youngster caregivinggiving such as daily routine, types of caregiving, the eÂect than could be accomplished by one method alone. Aspectsof caregiving on the life of the youngster, and vice versa of the phenomenon such as daily routine, and types ofprovided confirmation or convergence. For example, the caregiving, the life of the youngster, as well as the eÂectObject Content Test identified needs of the youngsters of the life of the youngster on the caregiving could be con-most completely. However, confirmation or convergence firmed. Other aspects such as varying perspectives ofwas identified through both phenomenological and ethno- youngsters and family regarding extent of caregiving couldgraphic interviews and observation of the youngsters in be challenged. Table 2 provides a composite picture of theschool and at home. emerging concepts and relationships between concepts From the combination column in Table 2, the authors identified from the separate analyses and triangulation ofbegan to note divergences. For example, divergence the results.occurred when inconsistency was found in the analysisresults. For example, a 13-year-old youngster stated in the DISCUSSIONphenomenological interview that she bathed and helpeddress her grandmother, but this activity was not observed The attempt to combine analyses of three diÂerent datain the ethnographic data analysis. Furthermore, the grand- sets from three diÂerent research approaches was a fruitful,mother stated that she did not need help with this activity. as well as a harrowing task. A matrix assisted in deter-Could this have been an example of youngster embellish- mining completeness, confirmation or convergence, andment or the grandmother’s forgetting that this activity divergence of the phenomenon. A higher level of concep-occurred earlier in her illness? In the families with mul- tualization was reached in combining the analyses bytiple caregivers, each of the youngsters stated that he or obtaining a broader description rather than portraying eachshe did the most caring for the adult in the phenomenologi- analysis alone. For example, the three dichotomies wouldcal interviews, but the ethnographic interviews and obser- not have been apparent in any of the separate analyses.vations demonstrated that, in essence, the older child had Furthermore, additional questions for further study werethe greater responsibility. derived, which would not have occurred on the basis of As the matrix was filled in, three dichotomies emerged one research method alone. For example, in order to ident-from the combination of the analyses: (a) the ‘hard yet ify more completely caregiving tasks in a future study, thegratifying’ work of caregiving as depicted in the phenom- authors would suggest including questions for the young-enological description, paralleled with the ‘challenging ster, the patient with cancer, and the family members, asand burdensome’ pattern of caregiving in the ethnographic this would permit more purposeful comparison ofinterviews; (b) the school as support for caregiving, as responses.668 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 664–671
  6. 6. Studying young caregiversTable 2 Matrix of completeness, confirmation and divergence of initial concepts and relationships found in separate and combinedanalysesConcept/relationship Phenomenology Ethnography Survey/demographic Combination data1. Caregiving: Unique: not found Synthesized in overall feelings in other data description; suggested questions for further study regarding youngsters’ feelings2. Caregiving: kinds Identified by Confirmed by Synthesized in overall youngsters in youngsters, family, description; suggested interviews patients, investigator questions for further through study regarding multiple observations and careivers and negotiation interviews; regarding who does contributed to caregiving; suggested completeness in kinds and tasks of adding kinds; caregiving not yet contributed to complete divergence by suggesting discrepancies in youngsters and family members3. Needs of Confirmed selected Confirmed selected Most complete in Synthesized in overall youngsters needs identified in needs identified in identification on Object description survey survey Content Test4. Influences of Unique in Unique in identifying Synthesized in overall environment of identifying family family rituals, rules description; suggested family on coping and and interactions as need to describe family caregiving feelings towards they influenced environment more fully youngsters as they caregiving influenced caregiving5. Influences of Unique in Unique in identifying Synthesized in overall outside identifying family members’ description; dichotomy environment on youngsters’ concerns about of youngster/family caregiving feelings related to support from school, views identified involvement of church, friends for divergence and suggested school, church and youngsters further study needs to friends as separate include perspectives of from caregiving both young caregiver and family6. Influences of Most complete in Confirmed via Synthesized in overall caregiving on interviews observations and description; suggested youngsters as comments of others areas for further study persons7. Influences of Confirmed through Most complete as Synthesized in overall caregiving on interviews noted in description; suggested child and observations of areas for further study adolescent roles, school, home and development interviews with youngsters and others© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 664–671 669
  7. 7. N.R. Lackey and M.F. GatesTable 2 (continued)Concept/relationship Phenomenology Ethnography Survey/demographic Combination data8. Multiple Identified by Identified by Synthesized in overall caregivers youngsters youngsters, family, description; suggested adults with cancer, need to stratify by age and investigator number of caregivers for further study9. Description of Unique as answered by Incorporated in overall youngsters, demographic data form description family, adults with cancer Using diÂerent qualitative methods and combining the Breitmayer B.J., Ayres L. & Knafl K.A. (1993) Triangulation inanalyses enabled the authors to stay true to each method. qualitative research: evaluation of completeness and confir-Too often, investigators say they are doing phenomenology mation purposes. Image: Journal of Nursing Scholarship 25, 237–243.but deal with the cultural and environmental contexts Cowman S. (1993) Triangulation: a means of reconciliation inwhich are not typically an aspect of true phenomenology. nursing research. Journal of Advanced Nursing 18, 788–792.Therefore, using diÂerent methods and remaining consist- Denzin N.K. (1978) The Research Act 2nd edn. McGraw-Hill,ent with each method’s assumptions yields valuable data. New York.These three methodologies would be useful in a larger DuÂy M.E. (1987) Methodological triangulation: a vehicle forstudy to further examine the phenomenon of child and merging quantitative and qualitative research methods. Image:adolescent caregiving of an adult with cancer. Journal of Nursing Scholarship 19, 130–133. Giorgi A., Fisher C. & Murray E. (eds) (1975) Duquesne Studies in Phenomenological Psychology. Duquesne University Press,Further research Pittsburgh, Pennsylvania. Hartley W.S. (1970) Manual for the Twenty-Statements ProblemIssues need to be addressed when analyses of qualitative (Who Am I). Greater Kansas City Mental Health Foundation,methods are combined. Qualitative researchers need to Kansas City, Missouri.discuss more completely the values and problems of com- Hinds P.S. (1989) Method triangulation to index change in clinicalbining qualitative analyses. Further work needs to be done phenomena. Western Journal of Nursing Research 11, 440– this area. While many think this has been addressed, Hinds P.S. & Young K.J. (1987) A triangulation of methods andanalyses really deal with triangulation of qualitative and paradigms to study nurse-given wellness care. Nursingquantitative data, not a combination of diÂerent types of Research 36, 195–198. Janesick V.J. (1994) The dance of qualitative research design:qualitative data. metaphor, methodolatry, and meaning. In Handbook of The process of analysis delineated by Waltz et al. (1991) Qualitative Research (Denzin N.K. & Lincoln Y.S. eds), Sage,would be useful as a guide, even though it is geared for Thousand Oaks, California, pp. 209–219.triangulation of qualitative and quantitative methods. Jick T.D. (1979) Mixing qualitative and quantitative methods: tri-Methods of analysing data obtained from more than one angulation in action. Administrative Science Quarterly 24,qualitative method need further development so that depth 602–611.and breadth of the results may be obtained. Kimchi J., Polivka B. & Stevenson J.S. (1991) Triangulation: oper- ational definitions. Nursing Research 40, 364–366. Knafl K.A. & Breitmayer B.J. (1991) Triangulation in qualitativeAcknowledgement research: issues of conceptual clarity. In Qualitative Nursing Research: A Contemporary Dialogue (Morse J.M. ed.) rev. edn,Funded by Sigma Theta Tau International Inc. Sage, Newbury Park, California, pp. 226–239. Knafl K.A. & Gallo K.A. (1995) Triangulation in nursing research.References In Principles and Practice of Nursing Research (Talbot L.A. ed.), Mosby-Year Book, St Louis, Missouri, pp. 492–509.Aldridge J. & Becker S. (1993) Children Who Care: Inside the Leininger M.M. (1985) Ethnography and ethnonursing: models World of Young Carers. Loughborough University, Nottingham. and modes of qualitative data analysis. In Qualitative ResearchAldridge J. & Becker S. (1994) My Child, My Carer: The Parents’ Methods in Nursing (Leininger M.M. ed.), Grune & Stratton, Perspective. Loughborough University, Nottingham. Orlando, Florida, pp. 33–71.Banik B.J. (1993) Applying triangulation in nursing research. Miles M.B. & Huberman A.M. (1994) Qualitative Data Analysis: Applied Nursing Research 6, 47–52. An Expanded Sourcebook. Sage, Thousand Oaks, California.670 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 664–671
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