|RESEARCH SERIES 20
|Year : 2019 | Volume
| Issue : 2 | Page : 125-130
Getting to know the person: Interviews as a tool in eliciting narratives in healthcare and research settings
Department of Psychology, St Joseph's Institutions, Bengaluru, Karnataka, India
|Date of Submission||06-Jan-2020|
|Date of Acceptance||12-Jan-2020|
|Date of Web Publication||01-Jun-2020|
Dr. Rekha Ahuja
Department of Psychology, St Joseph's Institutions, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Interviews are built on collaboration and effective conversational skill. In the health-care settings, it is imperative to address the whole person, i.e., the emotional, social and psycho-spiritual aspects along with the physical body and health-related concerns. Asking the right kind of questions and having the right information-eliciting skills can make or break an interaction. Interacting with people who are struggling with illness requires a sensitive approach. Rapport created from the early stages of treatment goes a long way in determining crucial factors such as decision-making and treatment adherence. Research on patient experiences, and qualitative aspects of treatment rests heavily on obtaining rich, in-depth data from interviews. Planning for follow-up care involves assessing patient needs by considering the person recovering from the illness and making effort towards psycho-social rehabilitation. Therefore, interviews are a useful tool used at various points in time during the treatment and caregiving process, as well as while researching health and illness. Preparation for the interview and appropriate skills of the interviewer are important factors on which the outcome is dependent. This paper aims to throw light on the process of interviewing as a clinical skill as well as a research method, in the context of health-care settings.
Keywords: Communication, healthcare, interviewing skills, interviews, narratives, person-centred approach, research
|How to cite this article:|
Ahuja R. Getting to know the person: Interviews as a tool in eliciting narratives in healthcare and research settings. Indian J Cont Nsg Edn 2019;20:125-30
|How to cite this URL:|
Ahuja R. Getting to know the person: Interviews as a tool in eliciting narratives in healthcare and research settings. Indian J Cont Nsg Edn [serial online] 2019 [cited 2020 Dec 3];20:125-30. Available from: https://www.ijcne.org/text.asp?2019/20/2/125/285587
| Introduction|| |
Interviews are the interface between health-care providers and recipients. From the moment of initial contact, right through the process of treatment and rehabilitation, interviews can be considered a vital source of information generation. Communication is built on rapport, and is influenced by factors such as the setting, duration of interaction, interviewee characteristics and interviewer skills. Other extraneous factors such as physical/mental health condition of the respondent, perception/attitude towards the need for information sharing, any distractions in the surroundings, the nature of the topics discussed (such as sensitive/personal/controversial topics) and the power structures implicit in the dynamic also determine the information that is elicited.
Interviews are goal-specific and intensive in approach, which makes the process more time consuming. However, depending on the type of interview in terms of structure, namely structured, semi-structured or unstructured, the depth of information and duration will vary. Structured interviews have less scope for respondents to elaborate or deviate too much. They are useful when time is short, respondents are many and when the information generated need not be in-depth. Semi-structured interviews follow a framework of domains to be covered while still allowing the emergence of data flexibly. These are the most commonly used format in health research. Unstructured interviews tend to have few open-ended questions and provide scope for the interviewee to lead the course of information generated. It is suitable for research topics which are relatively unexplored or new. The nature of interviews, for example, face to face or telephonic, individual or group will also determine the richness and depth of data generated. Interviews can also vary based on its purpose and function such as clinical interviews for the assessment of symptoms/diagnosis, intake interview, follow-up interview, customer satisfaction and feedback or interviews meant to understand experiential factors in depth. The nature of questions asked can be descriptive (describing a routine/procedure), narrative (a storyline or situation/context), evaluative (examining feelings/opinions about something) or comparative (contrasting between two or more things). Based on the type of questions used, the outcome of interviews and the data generated will vary. In this article, interviews are discussed both as a research method for data collection as well as a clinical method to gain information in the broader context of health-care settings.
| Interviews are Built on Collaboration and Interaction|| |
The dynamics between the interviewer and interviewee varies depending on the nature of interaction such as the first information taking the interview or follow-up interview, experience sharing or decision-making interactions. Interviews are a valuable strategy for rapport building, case history/intake assessments and data generation in health research. The domain of interviewer's skills and competencies, however, play a very crucial role in the process. Some strategies to make interviews more collaborative are presented below.
- Ensure polite verbal and nonverbal behaviour
- Facilitate communication to be patient-centred
- Probe for further information respectfully, without being intrusive
- Be familiar with the setting, topic and the questions to be asked
- Ensure adequate training is received for listening, observation and communication skills
- Ensure validation for the interviewee and clarity for the interview by appropriately reflecting meaning and feeling at significant points in time during the interview.
Polite verbal and nonverbal communication includes non-judgmental facial expressions, vocal quality, body gestures and consistent eye contact when attending to the responses of the interviewee. Beginning the interview by introducing oneself, explaining the need for the interview and building rapport will reduce any anxiety and apprehensions of the interviewee. Simple rules of courtesy must not be violated while trying to engage with a patient. For example, greeting patients and calling them by their name instead of their ID numbers or identifying them by their diagnosis goes a long way in making them feel comfortable. Asking the patient's consent to talk about any personal issue concerning them demonstrates respect for their privacy and a concern for their well-being. These behaviours set the stage for open and genuine conversation.,
Patient-centred communication is a skill that can be developed with training. Rubin and Rubin  have used the term 'responsive interview' to emphasise the importance of building a trustful relationship between the interviewer and interviewee that lends to a collaborative give-and-take style of conversation. They suggest that the tone of asking questions should be gentle and flexible to accommodate the experience of the interviewee. Attending behaviour and observation skills are vital parts of establishing good rapport. Attending behaviour includes nodding, making eye contact, demonstrating a keen interest and engagement in what the interviewee is saying by being tuned in to what is being expressed verbally and non-verbally. An empathetic stance should be inculcated to convey accurate perception and communication of what is expressed by the client.
While building a conversation, asking the right kind of questions and the appropriate timing of probes is crucial. It is helpful to start by clearly stating the reason for the interview, taking informed consent from the participants and giving them autonomy to quit the interview if they wish to do so. General questions should open the interview followed by more personal topics. The main questions are aided by the use of probes. Probes may be understood as prompts or cues to help get a more elaborate response to any question. It is advisable to use probes that generally are who, what, where, or how questions as a follow-up to what was stated. Avoid why questions as it may be too confrontational and can make the interviewer defensive. For example: Asking 'why are you doing that?' can make the person uncomfortable initially. Instead, a request for clarification on what was stated is a polite and respectful way to ask. 'Can you help me understand this better?' 'I would like to know the connection between what you said earlier and this point you mentioned now'. Therefore, probes can be spontaneous interruptions during the interview to clarify what was stated or they can be factored in as a follow-up to the questions being asked to gain more depth and detail at certain points in the interview. Setting goals (treatment/rehabilitation) mutually – involves effective and collaborative communication, which is an important determinant for patient outcomes.
Reflection of meaning by re-stating what the interviewee mentioned is a useful strategy while summarising the interview. This serves the purpose of clarifying the content and also makes the interviewee feel heard and understood. Reflection of feelings can be demonstrated at various levels. Expressions such as 'it is really painful' or 'I see you are very frustrated' can be mentioned; however, it is best to avoid over-reading or exaggerating their feelings. Non-verbal behaviour can also be used to acknowledge feeling. It is also important to note non-verbal behaviour of the interviewee while they describe feelings, for example, they may be clenching their fist or turning away. Listening skills are important to empower the interviewee to speak. It facilitates a non-judgemental environment in which the speaker feels heard/validated. Listening skills become especially important when dealing with emotionally charged situations. For example, while interacting with family members of a terminally ill patient or when conveying news of a disability, it is important to fully listen to all that is being spoken in reaction to the issue. Here, listening skills become a therapeutic tool to validate the speaker's feelings as well as provide a platform for venting out pent up emotions. Listening skills still play an important role even when the topic discussed is not so sensitive, because it helps the interviewer to interpret the context and background of the speaker's expressions.,
| Some Unhelpful Behaviours to be Avoided during an Interview|| |
Welfel and Patterson  have mentioned some non-helpful interview behaviour to be avoided. One of them is advice giving as this may cripple and disempower the interviewee. For example, while interviewing the patient on treatment decisions, it is best to ask them about their experiences without giving advice on what is considered best according to the interviewer's own opinions. Similalrly, it is best to avoid long lectures or explanations about the interviewer's personal views because the purpose of the interaction is to understand the interviewee better and not the other way around. Taylor  adds that care providers must avoid 'baby-talking' to the patient. A similar word of caution applies even while interviewing those with debilitating physical conditions. Their symptoms do not render them incapable of thinking and behaving like an adult, therefore, they must be treated accordingly. Engaging in telling long stories or describing instances from one's personal experience should be avoided by the interviewer, even though it may seem like a conversation, the focus is solely to enable interviewee responses. In some cases, the patient can assume an all-knowing role and may insist on being an expert of their own diagnosis. This can interfere with the rapport and nuances in the conversation. Training and experience are required to use these skills in practice, in which case role plays and rehearsals may be helpful. It is always preferable and recommended to aim towards a collaborative approach rather than any one member to assume an expert role while interviewing.
| Scripting the Interview|| |
While interviewing people with illnesses, the focus is often surrounding symptoms and its management. However, for effective interventions, it is important to get to know the person behind the symptoms. A good research interview, on the other hand, should contribute at two levels: thematically by producing knowledge and dynamically by creating an effective interpersonal relationship. Therefore, one must avoid asking conceptual questions in conversation. Interviews should be scripted with simple language, and the conversation should have smooth transitions from one topic to another. The data that emerges should then be analysed to gain conceptual clarity of the topic being studied. Ravindran  mentions that the process of data collection is iterative and involves the use of data, along with field notes and observations made during the interview.
Prior to entering the field from where data are to be obtained, preparation in terms of familiarity with the setting and topic is necessary. Planning for factors such as duration of interview, allowing buffer time for travel/commute of interviewees, arranging for resources to tackle any emergencies (medical or psychological) will ensure a smooth process of interviewing. While planning and envisioning the entire process, some factors that are to be kept in mind are as follows.
The setting: Most interviews that happen at health-care settings are not free from distractions in the environment. As much as possible, it is beneficial to choose a setting that is apt for conducting an interview. Patients can get emotional while describing their struggle with the illness, or they may want to share private/personal information without being intruded. Therefore, it is imperative to ensure minimal distractions to facilitate an in-depth understanding. Common architectural features can impact an interaction between interviewer and interviewee. Some of them are listed below:
- Furniture and seating arrangement: It is better to sit adjacent as it is less confrontational and more enabling in contrast to facing the interviewee directly
- The accessories in the room (objects, artefacts, pictures and religious symbols) can enable or hinder the information being shared
- Lighting, fragrances and sounds are important sensory aspects that can distract the interviewee if the experience is unpleasant
- Thermal conditions, ventilation, will influence how safe and comfortable the interviewee feels
- Accessibility to the setting by other people (except the interviewer) should be restricted to ensure a smooth flow of conversation. Hence, it may be better to choose a place that is away from common entry/exit points where the likelihood of other people moving around is less.
| Multicultural Aspects|| |
While interviewing or researching people from different cultural backgrounds, ethnicities and or locations, potential biases about their way of living, their behaviour and attitudes may creep in., Therefore, an important interviewing skill is the ability to display sensitivity to cultures to eliminate any form of superiority or cultural bias. The meaning of illness and experience of illness varies across cultures. While interacting with patients who come from different backgrounds, caution should be exercised to do away with pre-existing assumptions about their experiences. For example, the meaning of being diagnosed with gynaecological cancers will carry different meaning for women from a patriarchal culture than another who comes from an individualist culture.
| Interviews as a Tool of Data Generation in Research|| |
A qualitative research interview seeks to describe and understand the central themes in the life world of the subjects (participants/interviewees). The main task is to understand the meaning of what is said. It is a commonly used research tool in health-care settings  to collect qualitative data i.e., responses to open-ended questions with greater scope for in-depth explanations. Interviews can be used as a stand-alone tool or supplementary to other methods of data collection.
While designing interviews to answer research questions, it is imperative to strike a balance between what is investigated (the research questions) and how it is investigated (data collection - the interview questions). Consider the following example demonstrating the purpose of a research question versus interview questions. Research Question: How do clinicians communicate while addressing sexual concerns of patients? Interview questions and probes: What is your opinion on the need to address sexual concerns among the patients who are being treated for xyz? (Probes: Is it necessary? Is it common?); What barriers have you faced (if any) in your experience? (Probes: language barriers, hesitation to initiate the topic, patients being reluctant).
Here in this example, the research question is focused on the concern that has been identified in the health-care setting, and to answer this, an interaction with the relevant stakeholders is undertaken. The way questions are framed in an interview setting will be different from how the researcher conceptualises the question while writing the study protocol/proposal. Therefore, even after data collection, the researcher must weave a narrative and answer the research question that was posed, using the data generated from the interviews. This implies that research questions inform the interview questions, but the framing of questions will vary at both levels. Probes for the interview questions are also tied to the research question and are informed by the conceptual clarity of the variable being studied. In the above example, we find that the probes for seeking information on barriers faced by clinicians include language or turn-taking while talking. These probes are based on our understanding of the concept, i.e., barriers and it is intended to aid the respondent give comprehensive answers.
However, one must exercise caution to avoid leading on the participant or imposing any judgmental views. Probes are useful, especially during intake sessions while gathering information about the presenting problems or when patients/caregivers are reluctant to reveal information on their own.
| The Purpose and Function of an Interview Guide|| |
This section has more relevance to the use of interviews as a research tool to collect data. In contrast to a clinical interview where information is gathered in a more specific format, the research interview has better scope to elaborate on the processes and qualitative aspects of illness. In this context, an interview guide is helpful in providing direction and avoiding any digression from the main focus/variable being studied. The interview guide generally contains sufficient questions that cover the main purpose of the interview. The concerned topic, for example, is understanding the meaning of losing a limb due to amputation. In such a scenario, it is crucial to understand what it means to the patient who has lost the limb, the psycho-social impact, impact on their self-identity, issues such as anger, embarrassment and social stigma. In a study on women who had undergone mastectomy, interviews revealed a sense of depersonalisation and loss of identity as a woman. This loss of identity was relative to the gender roles of a wife and mother. An understanding of factors such as these will provide a basis for planning rehabilitation interventions.
The interview guide must provide scope for elaborate descriptive responses, with minimal restrictions/interruptions. The interviewer may want to build on responses such as 'unpleasant' and find out what made it so. Caution must also be undertaken while seeking depth and clarity as the patient always has a right to privacy and can decline to provide further elaboration, which should be respected. Many questions get answered implicitly and the interviewer should not ask the same questions that have already been answered earlier. Therefore, when the nature of the interview is in-depth, the interviewer may not follow the order of questions as per the guide strictly.
Flick  emphasises that there should be a continuous mediation between the interview guide and the course of the interview, and cautions against implementing the interview guide very bureaucratically. Especially among novice interviewers, the interview guide may be used in a manner that restricts the advantages of flexible/contextual information emerging. It may also cause un-timed interruptions in the responses of the interviewee. Adequate training should precede the interview to ensure the interviewer finds a balance to work around issues such as balancing time-pressure and achieving clarity on the information being sought; the fine art of using the guide and yet being flexible in approach, order and sequence of questions; and the judicial use of the guide as a protective mechanism to avoid diversions. The advantage of using a guide is that it makes the interview more structured and minimises variability across different interviewers meeting different patients.
| Reflexivity of an Interviewer|| |
Reflexivity refers to disciplined self-reflection through a critical lens. Researchers need to take stock of their own role in the process of data generation i.e., how they interact in the field and with the participants, how they determine the outcome of research and subsequent construction of knowledge. Reflexivity is aided by field notes, diaries and supervision, all of which are part of the audit trail that is maintained. This serves the function of validating the process of research by allowing an objective examination of the methods and procedures involved while collecting and analysing data. It also lends to the trustworthiness and accountability of the interviewer or researcher.
Reflexivity helps the interviewer/researcher to 'bracket' any biases that can creep in. It means that the interviewer should put away any biases by being aware of it at different points in time, such as before, during or after the interview. This can be done by auditing one's thoughts and assumptions while drafting the research questions while talking to the respondents and while examining data for the analysis. Preparation before the interview involves a keen eye for the setting, attire, people involved and any potential sources of bias. During and after the process of collecting data, it is important for the interviewer to balance the dynamic between one's own reflections, the interviewee's responses and be able to simultaneously steer the interview forward. It is a good practice to document these procedures, initial impressions and thoughts so that the reflection of meaning happens in a way that is true to the participants' perspective. As explained by Smith et al., 'actual stories told by participants are more chaotic than when they appear as findings' reflexivity should be evident in the nuances between a life story that is lived, that is told (by the participant) and that is re-told (by the researcher).
Some questions to aid reflexivity are as follows:
- What is the main objective of my study/of this interview? (Are the objectives being met sufficiently?)
- Why is the interview designed this way? (What am I trying to answer?)
- How does my presence in the field/interview setting affect the interview process? (Does it influence the respondents in a negative way? Do I come across as judgmental, intimidating, dominating or all-knowing?).
| Interview Skills are Developed with Time and Experience|| |
Despite conducting interviews regularly, there are some common mistakes that are made in the process. In conversation, one is often tempted to finish off another person's sentence. It may be an attempt to demonstrate that there is an understanding of the speaker's point of view, but there is also an implicit danger of assuming something about the content spoken or inducing our own biases and leading on the speaker (which will lower the validity of the data that is generated). Another thing to be avoided is interrupting the speaker with one's own thoughts or opinions. It takes skill and practice to smoothly transition between topics or different sections of the interview.
Often when novices conduct interviews, they may seem to be very 'rehearsed' because of their own emphasis on asking the right questions and checking off all the questions on the list. This can break the flow of the conversation. Seldom are the questions answered exactly in the same order as they are proposed in the interview guide. Unless it is a structured and brief information-taking session, other descriptive and process-based questions are mostly answered in relation to questions asked prior. Therefore, interviewers must avoid reading questions directly from the guide, and focus on building a conversation within the framework of the guide. In such cases, the interviewer can avoid repeating questions that convey a lack of attention or understanding of the narrative. Instead, probes used as a reflection of what was said can be a good follow-up strategy to confirm the meaning of content and clarify or add on to the narrative.
Another pitfall to be avoided is probing for too much information that may be related but unnecessary for the purpose of the interview or the research study. It is also imperative to avoid any judgemental gestures or responses to the interviewee's descriptions. Respondents look for confirmation cues such as nodding the head or intentful gaze while they speak. Therefore, it is best to avoid anything that conveys displeasure, disapproval or discouragement.
| Interviewing Groups of People|| |
Focus groups are a type of interview where there are more participants who share a similar experience and therefore come together as a group to deliberate and build on a topic. However, the ensuing discussion is not for the purpose of debate, but instead, the group dynamic is used to gain insight into the topic/problem at hand. This is the reason why focus group participants are not supposed to have any pre-existing social relationships. The conversation is facilitated to surround a specific topic which is usually less personal/private and more 'shared'. Not all topics are suitable for a focus group discussion. Seeking opinions and perspectives on emerging trends or talking about common issues such as burnout among clinicians/health-care professionals due to working with a certain illness group are examples of a good fit for focus groups. Another example could be asking patients how they cope with treatment side effects, where members share their strategies and also take cues from each other to build on their responses. The facilitator skills for focus groups include skills of moderation and often necessitate the help of an assistant to record responses and manage group processes. Care should be taken to ensure every member gets a chance to speak, feels heard and contributes meaningfully. Turn taking during the focus group, ensuring respectful communication and maintaining an ethical environment are some of the other responsibilities of the facilitator. These formats are useful to gather data from a bigger group at one instance and they capitalise on building the conservation with cues from different participant responses.
| Conclusion|| |
Interviews serve as a valuable tool to create rapport, collect information and generate data for various purposes such as clinical decision-making or research initiatives. If used in the right way, they can aid communication between physician–patient, nurse-patient or other stakeholders and guide the interaction to be effective and collaborative. Selection of the right interviewer, settings and questions to be the best fit for the respondents or interviewees will ensure effective outcomes. Preparation to deal with the whole person and not just the illness-related or topic-related identity of the interviewee should be the goal in health-care settings. Training and capacity building in the area of empathetic communication and skills for being an objective interviewer will go a long way in the area of healthcare.
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Conflicts of interest
There are no conflicts of interest.
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