CHRISTINE WEBB & MAGGIE DOMAN
Conducting Focus Groups: Experiences from Nursing Research

The focus group is a prevalent methodology in contemporary nursing research. Its favour amongst nursing graduate students probably reflects their perception that qualitative research in general is easier, and that focus groups in particular are simpler and more expedient than other approaches. A lack of confidence in their own ability to undertake statistical analysis adds to the attraction of this method.

As nurse educators, we too have used focus groups in a number of studies with nursing students, other educators and patients and, while we are convinced of their benefits, we have learned some valuable lessons about using focus groups – in some cases the hard way! In this paper we discuss some of these experiences in the hope that they may help others avoid some of the pits into which we have fallen.

FOCUS GROUPS

Focus groups are a form of interview used in qualitative research. They consist of small numbers of people brought together by the researcher to discuss a specific topic. The interview is guided by one or more “moderators” (usually the researcher) who “focus” the group discussion. The interview is normally tape-recorded and forms the main source of data, but the interactions within the group are also captured, as the group’s behaviours and views are also important because they draw attention to differences in opinions and the relative weight of different participants’ contributions.¹

Focus groups were used as a research method in the social sciences during the 1940s and ‘50s, but their popularity in this field diminished and instead they became associated with marketing research and advertising.² More recently, focus groups have again become popular, particularly in qualitative social science and health-related research ³ such as in psychology, education and nursing.

In nursing, focus groups have been used to explore a range of issues from clinical practice⁴ to educational and managerial or professional perspectives.⁵ They can also be used successfully to provide opportunities for the views of patients, carers or lay people to be investigated.⁶

There are a number of advantages to the use of focus groups in research. These include: their compatibility with other research methods; the opportunity they provide to observe and record interactions between participants; the possibility of more “security” than individual interviews; a wider range of views; and practical advantages such as saving time spent in actual data collection.⁷ However, there are also potential disadvantages. Despite setting ground rules about confidentiality at the start of a focus group, it is impossible to guarantee that participants will respect these outside the group. This may inhibit some people from contributing. Costs may be higher if travel expenses, room hire and catering are needed, and administrative time and costs may be greater.

Focus groups can be used alone or in combination with other methods such as surveys, participant observation or individual interviews,⁸ thus increasing their value. Indeed, Morgan⁹ recommends that focus groups be sometimes used to develop questionnaires or interview schedules, as they can help to ensure that the language, experiences and priorities of participants are represented rather than merely those of the researcher, and issues and views can be better clarified. Krueger ¹⁰ believes that focus groups are an effective qualitative method, as the data collected can provide insight into the perceptions, attitudes and opinions of participants.

The potential for democratising the research process by giving more control of the proceedings to the participants through the use of focus groups is highlighted by Kevern & Webb.¹¹ Citing work by Wilkinson ¹² and others, they discuss how group discussions can empower participants, using this argument to help underpin their rationale for the use of focus groups with mature nursing students. However, while the researcher exercises power through the questions posed, it may not be possible to control the group dynamics and prevent some participants dominating the discussion at the expense of quieter members.

The focus group gives more control of the process to the participants, with interaction between interviewer and interviewee being replaced by interaction between participants.¹³ Indeed, this is one of the principal reasons for selecting focus groups as a method. Kitzinger ¹⁴ and Webb and Kevern ¹⁵ recommend that data relating to group processes and procedures should be analysed and reported, as well as responses from individual participants. The advantages of analysing interactions and, in particular, “sequences of discussion,” are asserted by Reed and Payton¹⁶ and are illustrated clearly in the extracts and discussion in their paper. Interactions between participants were included in our study ¹⁷ and were of particular relevance in one of the interviews, as discussed later.

Breakwell ¹⁸ also highlights the potential for inaccurate or incomplete responses from participants in individual interviews, owing to embarrassment, dislike or distrust of the interviewer, lack of understanding or inability to remember details. On the other hand, some people may feel more able to disclose personal details in a one-to-one situation. In nursing, for example, admitting to experiences that may not have been managed as well as they could have been may be very painful or difficult for individuals, particularly if perceived as a deficiency in their practice or abilities. Nyamathi and Schuler ¹⁹ and Morgan and Krueger ²⁰ believe that involvement in a group interview can provide security for participants and thus encourage interaction and self-disclosure, especially when these experiences are familiar to or shared by other group members. Jackson ²¹ discusses similar views and also highlights the potential for participants to challenge one another’s opinions in a group interview.

There are other advantages to this research method. Krueger ²² believes that the presence of others in a group more closely mirrors a discussion among peers than do one-to-one interviews. The focus group interview is a more dynamic and social process than an individual interview, as it can facilitate and stimulate discussion, leading to greater spontaneity of responses. Other commentators suggest that it provides an opportunity to collect, probe and clarify a range of views which may not emerge from individual interviews.²³

It has also been argued that focus groups have the advantages of being relatively low-cost, able to produce speedier results with larger sample sizes, and easier to conduct than individual interviews.²⁴ To allow for diversity of responses without fragmentation of the group, Krueger²⁵ advocates the use of fairly small, homogeneous groups of six to ten people who, whilst not necessarily being strangers to one another, do not interact on a regular basis. The advantage of focus groups is the possibility of greater breadth of coverage of topics, while personal interviews may yield greater depth of data.

A number of advantages to the use of focus groups have been identified, but there are also drawbacks or limitations to this method, especially in relation to the role of the moderator. This is fundamental to the effectiveness of the focus group,²⁶ as discussed later. Krueger warns that the decreased amount of control of the course of discussion in some focus groups can be seen as a disadvantage. However, the purpose of a study may be to identify and explore the experiences of the participants with limited control of content by the moderator.

Similarly, Krueger argues that there are inevitably variations between groups, which arise from the differing interactions between individual participants in each group as well as from the group processes and that consensus of views is, therefore, not possible. Sim ²⁷ maintains that even if divergent views do not arise within a focus group interview, this may be due to group dynamics rather than actual consensus. If consensus is not being sought, however, this point can also be seen as an advantage in terms of the range of views which could be elicited, discussed and clarified using this method.

Another limitation highlighted by Krueger is the difficulty in assembling groups and finding a suitable venue for discussions to take place. This is more problematic for groups than individual interviews, where the needs of only one person have to be accommodated at any particular time.

RECRUITING PARTICIPANTS/PURPOSIVE SAMPLING

Purposive sampling can be used in an attempt to identify what Patton²⁸ and Sandelowski²⁹ refer to as “information-rich cases.” Sandelowski argues that it is possible for lone researchers with “limited resources” to produce credible findings with smaller samples by undertaking “purposeful sampling for demographic homogeneity and selected phenomenal variation.”³⁰ (182).

ROLE OF THE MODERATOR

The role of moderator in focus groups differs considerably from that of an interviewer, as the emphasis is on facilitation of interactions between participants and the discussions resulting from the suggested topics and/or questions. This is, of course, also dependent upon the degree to which the format of the group discussion is controlled and, if very structured with high moderator involvement, it can lead to problems and benefits similar to those for individual interviews. Millward ³¹ describes four types of moderator style, each of which exerts a varying amount of influence on the control of the process and content and thus the data derived from the discussions. She argues that low content control/high process control is most appropriate for the facilitation of focus groups.

Macleod Clark and colleagues ³² believe that the moderator should be seen as impartial and objective, with no vested interest in their responses. Morgan and Krueger ³³ and Millward ³⁴ assert that the skills of the moderator in relation to the management of the group processes and the ability to empower participants and maximise discussion are important, but take second place to the need for sensitivity to the research issues and methodological rigour. Indeed, Morgan and Krueger argue that it may be preferable to use a moderator who is involved with the project, either as a member of the research team or through familiarity with the participants’ views, rather than a “professional moderator.” Krueger ³⁵ maintains, however, that trained and skilled interviewers can “influence the odds” and so they should be used in preference to untrained moderators.

EXPERIENCES WITH FOCUS GROUPS

• focus groups versus individual interviews

In a practice discipline such as nursing, where the work is physically and emotionally demanding and many people do shift work, collecting research data in groups may seem an easier option than individual interviews – the “killing several birds with one stone” idea. The first issue here is that a focus group is not the same thing as a group interview. As discussed earlier, an important reason for choosing to use focus groups is to tap into the interactions between participants, whose comments may “spark off” others to say things that they would not otherwise have said. A graphic example of this occurred in one of our student’s focus groups with older people. The group was held at a lunch club for retirees and the topic was whether patients would like to be involved in their own decisions about their own resuscitation. The debate became heated, and one person declared that certain people did not “deserve” to be resuscitated, such as overweight people and those who smoked. This provoked strong responses among others in the group, who called the speaker – among other things – a “fascist”. It seems unlikely that such strength of feeling would have been revealed in individual interviews. A focus group differs from a group interview in that the former involves discussion among participants, facilitated by a moderator; however, in a group interview the aim is to obtain the individual views of each participant in a relatively economical way.

Another possibility in a group setting is that contributors may exaggerate or rival each other to tell the best story. Despite having conducted a number of studies with nurses, we have not encountered this. Rather, the emotion-laden quotes that are often reported in individual interview studies seem all the more poignant when reinforced by group members. In a recent study of mentoring with nursing students, the following exchange occurred between two students about the need for support in clinical situations. The example concerns a cardiac arrest:

Student A: We felt that when we had an arrest…we felt we needed something, that we weren’t offered anything.

Student B: Yes, but the problem with this arrest was that (the patient) was actually not for resuscitation, which we both knew, but it got thrown into complete confusion and we never, we still – not now – have not had a de-brief – because we thought we would have it soon after and we said, “We must track sister down and talk to her about it.” But we have never actually got down to doing that now.

Student A: And when I did speak to matron about it, she said, “You need to contact the resuscitation officer and his ’phone number is in the book.” And I said, “Do you know what his name is?” and she said, “No.”

Student B: But we reflected with each other, you know. We talked about it a lot but we felt that we needed something, and we needed someone to clarify to us, you know.

Student A: Because the doctor said, “Do chest compressions,” and I wouldn’t do them because I am only (a student), and that upset me because I didn’t know whether I should, and we needed clarification of exactly what we were meant to be doing. Even now we have not had that.

Moderator: But that was a situation where the support wasn’t there, and because it wasn’t there you have continued to mull over it.

Student B: But it’s still quite a big issue for me, really.

Nurse A: Even though it’s positive [opening of the HDU] – you’ll always get people who find it frightening. It attaches a label to children to some extent, and people become afraid of ever looking after them then, because they’ve been in a high dependency area.

Nurse B: Whether you want to go in there or not…you go into high dependency and work, without any choice – sorry (looking at other participants), this is my particular thing.

Nurse C: That’s all right if you enjoy it, that, as you say, there’s the choice…But there are people like me who absolutely hate it, and live in fear and trepidation each time you go on duty that you’re going to be put in high dependency.

• arranging focus groups

We have also learned that, with nurse participants, it can be very difficult to arrange a suitable time for a focus group and to get people actually to attend as agreed. Undoubtedly these participants lead very busy lives, often as women juggling dual work and family responsibilities. Furthermore, work shifts do not always end on time or nurses cannot leave work because an emergency has arisen. Our worst example was in a study where nurses were widely dispersed in a rural region. A car was hired for a 300-mile round trip by the moderator and observer, but only one of the “booked” participants turned up and so an individual interview was conducted.

In another study with nursing students, lunch was offered as an incentive for these low-income participants. However, despite email reminders the day before the group was to be held, only one or two people – and in one case, nobody – arrived. After several attempts the moderator reduced the expense by buying only cakes, but had to eat most of these himself!

• starting the discussion

Some researchers have used films or “warm-up” techniques to initiate the discussion in focus groups. It is, of course, essential to begin with the moderator, observer (if present) and participants introducing themselves to each other and establishing ground rules about confidentiality, trying to avoid talking across each other, respecting other people’s views and so on. However, we have always found that nursing participants are eager to talk once the topic is mentioned – perhaps because of the nature of the work and possibly because they see the group as a form of catharsis or getting a message across to someone who might be able to influence their situation.

This may have been the case with the students in the mentoring study mentioned earlier, or in another study of mentoring in midwifery education. This focus group was part of the MSc project of a midwifery educator who liaised with the mentors on behalf of the university. The focus group was therefore moderated by her supervisor (first author) to try to avoid “contamination” of the data. However, it seemed that participants did see the focus group as a way of having their opinions expressed within the university, one of which was a strong belief that midwives should be involved in student selection. There was debate about which kind of student was easier to work with, some midwives preferring women with personal experience of having a baby:

The (student) I’ve just had has two children of her own, lots of life experience. There was a tricky situation which was quite awkward. She offered to hold the baby and put herself out of the situation so I could deal with the woman. So she was very astute and very on the ball about what was going on.

However, having this experience might not always be helpful:

[The student] had too much life experience…and wanted to impose that on the [women].

However, there was consensus that young students who had just left school could be a challenging group:

I did have a girl [sic] who was really almost straight out from school, and it’s not only midwifery she was needing to learn. She needed to learn the social skills. How to go into somebody’s home and how to talk to a woman probably quite a bit older than herself.

• moderator and observer roles

The role of the moderator is to facilitate the discussion, but in a non-intrusive way so that participants are enabled to express their opinions as freely as possible. We have used only topic guides containing a list of issues that it is hoped may be covered after the overall topic has been introduced at the start of the group. Often, however, this guide is not needed as the discussion flows without much prompting. Indeed, it can take a different direction from that anticipated and result in obtaining rich if unexpected information, as in some of the previous examples. In the mentoring study, a critical incident approach was used; following that used by Benner,³⁶ and the topic guide is shown in Figure 1.

A ‘critical incident’ is one that stands out for you as an example of a ‘mentoring’ incident that was key in your mentor-student relationship:

Figure 1.
• Topic guide for the mentoring study.
• that went unusually well
• when there was a breakdown or things did not go as planned
• that was ordinary and typical
• that was particularly demanding
• an out of the ordinary mentoring event
• the piece of mentoring you are most proud of

• transcribing issues

Transcribing tape recordings of focus groups is very challenging and time-consuming. Normally in student projects, the student will do the transcription as part of the learning experience. It is essential to use the appropriate technology so that the tape can be run, re-run and stopped frequently because it can be difficult to pick up what is being said. Inevitably people speak over one another and the sound can be indistinct even if, as recommended, a multidirectional microphone has been used. A professional transcriber may do the work more quickly but is likely to make more errors or miss sections because of unfamiliarity with the material, particularly if technical terms are used, and the moderator will need to compare the transcript against the tape to correct errors and fill in gaps. This is obviously less likely if the moderator does the transcribing. Also, by doing the transcribing themselves, the students/researchers really get to know their data, which facilitates the analysis.

In either case, it is useful to establish transcribing conventions in advance. For example, Morse and Field ³⁷ suggest that a pause is indicated by a long dash; that editing to exclude irrelevant words (e.g. “you know”) or sentences is indicated by (…); and that square brackets are inserted to indicate emotional reactions or explanations of omitted names, locations, etc. Additionally, equal signs (=) can be used to identify sequences of discussion where there is no gap between lines, as recommended by Silverman.³⁸ Participants can be denoted by numbers representing the focus group and individual identity. However, it can be difficult or even impossible to identify speakers from the audiotapes, and it is more likely that only turn-taking can be noted.

LESSONS LEARNED

Conducting a successful focus group can be a very rewarding and stimulating experience, as well as a productive learning experience for students doing their first research projects – in terms of the substantive topic, the focus group method, and doing empirical research. However, some lessons are painfully learned and we hope that others can benefit from our experiences. Our suggestions are:

Consider carefully
• why a focus group is the most suitable method for the study, rather than individual interviews.

• Always over-recruit by 50% or more.

• Contact potential attendees by phone the day before to remind them and confirm attendance.

• Don’t rely on email reminders – they may not be read and are easy to ignore.

• Reduce your catering order accordingly, unless you have a large appetite!

• Prepare a parsimonious topic guide rather than a detailed interview schedule.

• Be prepared for the discussion to take unexpected turns.

• Have an observer to take notes and in case problems arise.

• Allow plenty of time for the initial transcription and for checking and correcting it.

1. D L Morgan, Focus Groups as Qualitative Research (London: Sage Publications, 1988); Successful Focus Groups: Advancing the State of the Art, ed. DL Morgan (London: Sage Publications, 1993); RA Krueger, Focus Groups: a Practical Guide for Applied Research, 2nd ed. (London: Sage Publications, 1994); LJ Millward, “Focus Groups,” in Research Methods in Psychology, ed. GM Breakwell, S Hammond and C Fife-Schaw (London: Sage Publications, 1995), 274-92; P Roberts, “Planning and Running a Focus Group,” Nurse Researcher, 4:4 (1997), 78-82; M Denscombe, The Good Research Guide (Buckingham: Open University Press, 1998); P Jackson, “Focus Group Interviews as a Methodology,” Nurse Researcher, 6:1 (1998), 72-84.
2. Morgan, Focus Groups; Denscombe, The Good Research Guide.
3. Millward, “Focus Groups.”
4. E Idvall and L Rooke, “Important Aspects of Nursing Care in Surgical Wards as Expressed by Nurses,” Journal of Clinical Nursing, 7: 6 (1998), 512-20; H McCutcheon and J Pincombe, “Intuition: an Important Tool in the Practice of Nursing,” Journal of Advanced Nursing, 35:3 (2001), 342-48; H Aveyard, “Implied Consent Prior to Nursing Care Procedures,” Journal of Advanced Nursing, 39:2 (2002), 201-07; AM Jones, “Changes in Practice at the Nurse-Doctor Interface: Using Focus Groups to Explore the Perceptions of First Level Nurses Working in an Acute Setting,” Journal of Clinical Nursing, 12:1 (2003), 124-31; M Doman, M Prowse and C Webb, “Exploring Nurses’ Experiences of Providing High Dependency Care in Children’s Wards,” Journal of Child Health Care, 8:3 (2004), 180-97.
5. H Cahill, “What Should Nurse Teachers be Doing? A Preliminary Study,” Journal of Advanced Nursing, 26:1 (1997), 146-53; M Gillespie, “Student-Teacher Connection in Clinical Nursing Education,” Journal of Advanced Nursing, 37:6 (2002), 566-76; J Reed and VR Payton, “Focus Groups: Issues of Analysis and Interpretation,” Journal of Advanced Nursing, 26:4 (1997), 765-71; A Torn and E McNichol, “A Qualitative Study Utilising a Focus Group to Explore the Role and Concept of the Nurse Practitioner,” Journal of Advanced Nursing, 27:6 (1998), 1202-11; GR Williamson and C Webb, “Supporting Students in Practice,” Journal of Clinical Nursing, 10:2 (2001), 284-92.
6. B Carter, K Lambrenos and J Thursfield, “A Pain Workshop: An Approach to Eliciting the Views of Young People with Chronic Pain,” Journal of Clinical Nursing, 11:6 (2002), 753-62; GM Chumbley, GM Hall and P Salmon, “Patient-Controlled Analgesia: What Information Does the Patient Want?,” Journal of Advanced Nursing, 39:5 (2002), 459-71.
7. Morgan, Focus Groups; Krueger, Focus Groups; Jackson, “Focus Group Interviews;” J Sim, “Collecting and Analysing Qualitative Data: Issues Raised by the Focus Group,” Journal of Advanced Nursing, 28:2 (1998), 345-52.
8. Morgan, Successful Focus Groups.
9. Morgan, Focus Groups.
10. Krueger, Focus Groups.
11. J Kevern and C Webb, “Focus Groups as a Tool for Critical Social Research in Nurse Education,” Nurse Education Today, 21 (2001), 323-33.
12. S Wilkinson, “Focus Groups in Feminist Research: Power, Interaction and the Co-Construction of Meaning,” Women’s Studies International Forum, 21:1 (1998), 111-125.
13. Morgan, Focus Groups.
14. J Kitzinger, “The Methodology of Focus Groups: The Importance of Interaction Between Research Participants,” Sociology of Health and Illness, 16:1 (1994), 103-21.
15. Kevern and Webb, “Focus Groups as a Tool.”
16. Reed and Payton, “Focus Groups: Issues of Analysis.”
17. Doman, Prowse and Webb, “Exploring Nurses’ Experiences.”
18. GM Breakwell, “Interviewing,” in Research Methods in Psychology, ed. GM Breakwell, S Hammond and C Fife-Schaw (London: Sage Publications, 1995), 230-42.
19. A Nyamathi and P Schuler, “Focus Group Interview: A Research Technique for Informed Nursing Practice,” Journal of Advanced Nursing, 15:11 (1990), 1281-88.
20. D L Morgan and R A Krueger, “When to Use Focus Groups and Why,” in Successful Focus Groups: Advancing the State of the Art, ed. D L Morgan (London: Sage Publications, 1993), 3-19.
21. Jackson, “Focus Group Interviews.”
22. Krueger, Focus Groups.
23. Krueger, Focus Groups; Roberts, “Planning and Running a Focus Group;” N Robinson, “The Use of Focus Group Methodology with Selected Examples from Sexual Health Research,” Journal of Advanced Nursing, 29:4 (1999), 905-13.
24. See previously cited Morgan, Focus Groups: Krueger, Focus Groups and Roberts, “Planning and Running a Focus Group.”
25. Krueger, Focus Groups.
26. See Millward, “Focus Groups,” and J MacLeod Clark, J Maben and K Jones, “The Use of Focus Group Interviews in Nursing Research,” NT Research, 1:2 (1996), 143-53.
27. Sim, “Collecting and Analysing Qualitative Data.”
28. MQ Patton, Qualitative Evaluation and Research Methods, 2nd ed. (Newbury Park: Sage Publications, 1990).
29. M Sandelowski “Focus on Qualitative Methods: Sample Size in Qualitative Research,” Research in Nursing and Health, 18 (1995),179-183.
30. Ibid., 182.
31. Millward, “Focus Groups.”
32. Clark, Maben and Jones, “The Use of Focus Group Interviews.”
33. Morgan and Krueger, “When to Use Focus Groups.”
34. Millward, “Focus Groups.”
35. R A Krueger, Moderating Focus Groups: Focus Group Kit, vol. 4 (London: Sage Publications, 1998).
36. P Benner, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Menlo Park, CA: Addison-Wesley, 1984).
37. J M Morse and P A Field, Nursing Research: The Application of Qualitative Approaches, 2nd ed. (Cheltenham: Stanley Thornes, 1996), 144.
38. D Silverman, Interpreting Qualitative Data: Methods for Analysing Talk, Text and Interaction, 2nd ed. (London: Sage Publications, 2001).

    ACKNOWLEDGEMENTS

    We are grateful to the following colleagues for allowing us to discuss and quote from their work: Professor Pam Shakespeare, Open University, UK; Margaret Fisher, Graham R Williamson and Lee Wright, University of Plymouth, UK; and Karen Phillips and Deirdre Denn, former MSc students, University of Plymouth, UK.

    Christine Webb is Professor of Health Studies in the School of Nursing and Community Studies at the University of Plymouth, UK, where she supervises postgraduate students and she is an editor of the Journal of Advanced Nursing. She has extensive research experience in nursing, and has carried out or supervised many student projects using focus groups.

    Maggie Doman is a nurse educator specialising in children’s acute and high dependency care. She is working on her PhD study on high dependency nursing and used focus groups as one of the methods. She is a lecturer in the School of Nursing and Community Studies at the University of Plymouth, UK.