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C H

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R 29 Focus Groups

Key points

� Focus groups are a useful data collection method when the aim is to clarify, explore or confirm ideas with a range of participants on a predefined set of issues.

� Group interactions are an important feature of focus groups and an integral part of the data collection process.

� It requires considerable preparation and skill to run a successful focus group; ideally one person should act as the moderator of the group while a second researcher acts as observer.

� Analysis of focus group data should ask specific questions about the group process and interaction, as well as the content of the discussion.

Claire Goodman and Catherine Evans

THE PURPOSE OF FOCUS GROUPS

A focus group is an in - depth, open - ended group dis- cussion that explores a specific set of issues on a predefined topic. Focus groups are used extensively as a research method in nursing research in two ways:

� to obtain the views and experiences of a selected group on an issue (see Research Examples 29.1 and 29.2 )

� to use the forum of a group discussion to increase understanding about a given topic (see Research Example 29.3 ).

Focus groups seldom aim to produce consensus between participants and are unlikely to be the method of choice if this is the study ’ s aim. The key premise of focus groups is that individuals in groups

do not respond to questions in the same way that they do in other settings, and it is the group interaction that enables participants to explore and clarify their expe- rience and insights on a specific issue. Participants can share and discuss their knowledge and even revise their original ideas and understanding. This data collection method allows the researcher to expose inconsistency within a group as well as pro- viding examples of conformity and agreement. Focus groups, therefore, have the potential to provide a rich source of data.

Focus groups were first developed for market research at Columbia University in the US and used to gauge audience responses to propaganda and radio broadcasts during the Second World War. Twohig and Putnam (2002) , in a review of studies that have used focus groups in healthcare research, did not identify any studies cited by MEDLINE before 1985

Gerrish, Kate, and Anne Lacey. The Research Process in Nursing, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/capella/detail.action?docID=1166315. Created from capella on 2017-10-07 07:45:19.

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29.1 The Use of Focus Groups with Marginalised Groups and to Address Sensitive Topics

Culley L et al . ( 2007 ) Using focus groups with minority ethnic communities: researching infertil- ity in British South Asian Communities . Qualitative Health Research 17 : 102 – 112 .

This study set out to explore community understandings of infertility and involuntary childless- ness in British South Asian communities. The study had two phases: the first explored a cross - section of public attributes and perceptions surrounding infertility and provided the context and insight for the second phase, which involved in - depth interviews with individuals who had experi- enced infertility problems. By not involving people with infertility problems in the focus groups the researchers were able to explore the social context and stigma and ask direct questions about their views of childless couples. Groups were single sex (important for the Muslim groups and older South Asians) and involved people of similar age. There were 14 focus groups that ranged in size from three to ten people, with a mode of six. The involvement of focus group facilitators from the different South Asian ethnic groups to work as translators, group facilitators and advi- sors on what was said in the discussions was costly. Recruitment to the groups was labour inten- sive. When leading the group discussions, attempts to ‘ depersonalise ’ what was a very sensitive topic by asking about community constructions of infertility were not always successful. Participants often ‘ repersonalised ’ the issue and gave examples of personal and family experi- ence. There was concern that this may have led to over - disclosure because there were so few opportunities in these communities to discuss these issues. They also had experience of people attending the groups to seek help for their own fertility problems. This posed ethical dilemmas for the researchers on how they should respond. The researchers concluded that focus groups were a powerful and versatile tool in accessing community attitudes, and allowed them to understand cultural norms and meanings. However, it was time - consuming, costly, and produced complex and messy data that was further complicated because multiple languages were involved.

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but noted it has been a widely used method in sociol- ogy, education and political science.

Focus groups are not aligned with a particular tra- dition of qualitative research. It is therefore important that researchers who use this method are sure that it fits with the overall research approach. As the discus- sion is organised outside the everyday experience and there is a pre - set focus to the interaction, there are inevitable tensions in employing focus group methods in studies that have a strong emphasis on naturalistic inquiry and immersion in the participants ’ lived expe- rience. For example, the researcher would need to justify how the use of focus groups would fit with a study that is based on grounded theory or phenome- nology (see Chapters 13 and 15 for more detailed consideration of this issue).

There is considerable variation in how focus groups are reported in nursing research literature and little

agreement about optimum group size and numbers of groups to include within a study. There is also criticism that focus groups encourage a superficial approach to enquiry and therefore have limited value as a stand - alone data collection method.

CONDUCTING A FOCUS GROUP

It is a misconception to regard focus group interviews as a simple way of gathering data from multiple par- ticipants. A focus group requires the researcher to give time to preparation and have skills in facilitating group discussion. It is labour intensive and often involves two researchers, one as moderator of the group discussion and the other as observer. Consideration is given here to sampling strategy and

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29.2 The Use of Focus Groups to Elaborate Upon Quantitative Research Findings

Kevern J , Webb C (2004) Mature women ’ s experiences of pre - registration nurse education . Journal of Advanced Nursing 45 : 297 – 306 .

Government policy in England has targeted the recruitment of mature women into nurse training as a way of addressing the shortage of qualified nurses. This study aimed to follow up a quantitative study of mature female pre - registration diploma students to gain a deeper understanding of their experiences of higher education and to identify appropriate organisa- tional support systems for them. A purposive sample of mature students (n = 40) was invited by letter to participate in the study. Five focus groups were held involving 32 women. The lead researcher moderated the groups; no observer was present. A list of six agenda items formed the broad framework for the focus groups. The group processes were recorded using audiotape and written notes. From the thematic analysis of the transcripts, the experiences of the mature women nursing students formed three major themes.

� ‘ Didn ’ t know what to expect ’ described the women ’ s uncertainty about entering nurse training.

� ‘ Reality shock ’ encompassed the competing demands of academic study, nursing placements and family commitments.

� ‘ Learning the game ’ referred to the strategies the women adopted to remain on the course, for example moderating their academic expectations of themselves.

The authors conclude that ideology and patriarchy restrict women ’ s activities in university. They identified the need to expand the options for women with multiple role demands by pro- viding, for example, more flexible and well - organised student - centred programmes.

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group size, developing a topic guide and how to conduct a focus group, including managing the dis- cussion and recording information.

Sampling s trategy and g roup s ize

Major challenges to using focus groups include iden- tifying, sampling and recruiting participants, group size and composition, and decisions on how many focus groups should be held.

The identification and sampling of members of the target population is guided by the aims or research questions for the study (see Chapter 2 ). It can be useful to develop a topic - specific sampling strategy to encompass the diversity of people involved in the subject area (Kitzinger & Barbour 1999 ). For example, to obtain a spread of views of how minority ethnic groups understood infertility and involuntary

childlessness, Culley et al . (2007) used a sampling strategy including participants from four main South Asian communities and involved group facilitators fluent in their different languages (Research Example 29.1 ).

There is an increasing use of focus groups in research with young people and children (Hennessy & Heary 2005 ). This requires a different approach to sampling and group composition. Gibson (2007) sug- gests that age should inform how large the group is and recommends only a 1 - to 2 - year age difference in members of the group, and that limited language ability and skills may mean that a focus group is not a suitable method for children under six years of age.

To gain access to the possible participants from the target population, it is often helpful to approach a stakeholder or group representative. For example, a director of nursing in a health trust is a useful stake- holder to gain access to NHS nurses. Ways of iden-

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29.3 The Use of Focus Groups to Increase Understanding of a Given Topic

Burt J et al . ( 2008 ) Nursing the dying within a generalist caseload: a focus group study of district nurses . International Journal of Nursing Studies 45 : 1470 – 1478 .

This study explored how community nurses understood their role in palliative care as one aspect of the care provided to people living at home. The study was informed by previous studies that had considered district nurses ’ palliative care work but had not considered it within the wider context of care. The aim was to explore with district nurses their perceptions of their palliative care role and their ability to provide end - of - life care as part of a generalist workload. The focus groups were part of a larger study on the needs of patients for palliative care services in primary care settings. The method was chosen as most likely to enable prac- titioners to share and discuss their experiences and views about their work. To capture different approaches to palliative care provision and recruit district nurses with a range of qualifications and clinical experience, participants were purposively sampled from four primary care organisa- tions in London. There were 51 participants in nine focus groups with four to seven participants in each group. Group discussions lasted for an average of one and half hours and were recorded and later transcribed. Thematic analysis focused on areas of agreement, dissent or expansion of particular themes. The findings confirmed earlier research that showed district nurses valued their palliative care work. It also explained in more depth the difficulties district nurses experienced. Specifically it showed:

� that district nurses felt their contribution was largely overlooked � the unpredictability of palliative care and how this could unbalance the case load � the emotional demands of the work and specifically the difficulties of constant role switching

between providing palliative care and routine care.

The findings indicated a need for research on different models of working, where generalist nurses can have access to more resources, specialist support and recognition for their contribution.

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tifying participants from populations not necessarily associated with an organisation, for example ‘ healthy ’ older people, include approaching places they visit, such as a drop - in centre, and advertising the project, and recruiting a pre - existing group.

Non - random sampling techniques such as purpo- sive and convenience sampling (see Chapter 12 ) are normally used because the intention of the focus group is usually to increase understanding of a phe- nomenon, not provide evidence directly generalisable to a wider population. Moreover, a randomly selected group may not hold a shared perspective on the research topic, prohibiting meaningful group discussion (Morgan 1997 ). Purposive sampling is preferable when sampling participants with specific

characteristics, experience or knowledge, such as dis- trict nurses (see Research Example 29.3 ). If the target population is small, difficult to identify or difficult to access, convenience sampling can be helpful. When all participants within the target population would be eligible to participate, selection can be based on inter- est in participating in the study and availability.

Group composition and size are both contentious issues within the focus group literature. Again, deci- sions are based on the nature of the enquiry, the study design, and the amount of time and funding available. Debates on group composition focus on homogeneity (similar participants) versus heterogeneity (diverse participants) and the use (or not) of pre - existing groups. Homogeneous groups segmented by, for

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example, a shared experience (see Research Example 29.3 ), language group or professional position (see Research Examples 29.1 & 29.2 ) are generally preferable to ensure free discussion and enable cross - group comparisons (Morgan 1997 ). However, differences between participants in a heterogeneous group are often illuminating and the use of pre - exist- ing groups can enable the context within which ideas are formed and decisions made to be captured (Kitzinger 1994 ). Using pre - existing groups can also be useful in recruiting people unlikely to come forward to participate in a focus group if they feel marginalised by society or are unwilling to partici- pate with people they do not know. However, in groups where participants are very familiar with each other, existing group norms and hierarchies may inhibit the contributions of members (Kitzinger & Barbour 1999 ).

The size of a focus group varies typically from between five members to no more than 12. The group must be large enough to ensure diversity of perspec- tives, and small enough to ensure everybody has a chance to participate. Decisions on group size are informed by:

� the nature of the subject area (the more sensi- tive the area the smaller the group)

� the level of group structure (the more structure the larger the group)

� the resources available (funding for more than one group, size of room space)

� moderator expertise (the less experienced the moderator the smaller the group).

Generally, it is advisable to invite more than the required number of group members to counter the inevitable problems of no - shows. Telephoning people who have agreed to participate a few days beforehand can reduce this problem. The focus group needs to be conducted at a convenient time in an accessible venue, and there may be value in interviewing people away from the institution they belong to (Kitzinger & Barbour 1999 ). In practice, it is often the financial resources and time available for the study that influ- ence venue choices.

Focus groups need more preparation and anticipa- tion than individual interviews. On the day of the focus group the moderator should arrive sufficiently

early to signpost the location, arrange the room and prepare refreshments for participants. An ideal room is one that is private, large enough to accommodate the group, quiet and comfortable. If working with an observer it is important to talk through the anticipated process and the topic guide, and agree seating arrangements.

Structuring g roup d iscussion and d eveloping a t opic g uide

The level of group structure depends on the intention of the focus group. A structured group using a topic guide is preferable when the research questions are clear, for example using focus groups to inform further research (see Research Example 29.1 ). A less - structured group framed around one or two topic areas is useful in exploratory research when little is known about the area of study (see Research Example 29.2 ). Both approaches have advantages and disad- vantages. The structured approach ensures consist- ency across groups, enabling comparisons to be made between groups, but a narrow set of questions may limit the discussion and inhibit contributions on related issues. Less structure often creates a livelier group discussion. A compromise between the two approaches may also be used. Morgan (1997) describes this as a ‘ funnel - based ’ approach in which

‘ each group begins with a less structured approach that emphasizes free discussion and then moves toward a more structured discussion of specific ques- tions ’ (Morgan 1997 : 41)

The research aims and the literature should inform the development of the topic guide (McLafferty 2004 ). The intention of the guide is to create a natural progression through the topic areas and stimulate group discussion without influencing the responses. A structured guide uses at most five to six questions. A less structured approach is to organise the guide around two or three broad discussion topics, loosely phrased as questions, like, ‘ We are interested in _____? What can you tell us about this area? ’ (Morgan 1997 ). In both instances, the questions are ordered to move from general to specific and non - sensitive to more sensitive, the aim being to enable all group members to participate. The topic area should be

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familiar to all, not be intimidating or require personal exposure. More sensitive or probing questions come nearer the middle of the interview. This provides participants with time to feel safe to speak within the group. Open - ended questions prefixed by either, how, what, where or why allow participants freedom to respond. Too many ‘ why ’ questions can be experi- enced as confrontational and provoke defensive responses (Nyamathi & Shuler 1990 ).

Managing the d iscussion

Sufficient time should be allowed to greet and seat participants. Begin the session by welcoming partici- pants, introducing yourself and the observer, and clarifying the purpose of the session and the antici- pated finish time. Ensure participants understand how the discussion will be recorded, who has access to these recordings and how confidentiality will be maintained. Ask if participants have any questions about the interview format and agree ground rules. Ground rules are intended to facilitate group discus- sion, not confine it. The agreed rules should be concise, few in number and displayed for participants (e.g. on flip chart). They may state:

� issues discussed in the group are confidential to the participants and the researchers

� only one person to speak at a time.

Introductions to the topic should be brief and clear, and instructions kept to a minimum. This helps par- ticipants to understand the focus of the session, without directing their thinking, and emphasises that the ownership of the group discussion belongs to both the participants and the moderator. Participant intro- ductions create an opportunity for all to speak and provides identification markers to differentiate par- ticipants for the observer and when transcribing the audiotapes. Plan for latecomers and ensure that par- ticipants are informed prior to the interview whether or not they will be able to take part if they arrive after the indicated start time.

Moderators should promote debate by asking open questions and probing for more detail on points of interest, reflecting a point made to confirm under- standing and summarising points to check that all

areas have been covered, particularly before chang- ing a topic. These techniques reinforce to participants that the points they make are valued and encourage participation in the discussion. The discussion should include all areas in the topic guide, particularly if conducting several focus groups. Incomplete data sets restrict comparative analysis between groups and may compromise the aims of the study.

Moderators need to encourage participation by inviting group members to comment on an individu- al ’ s views, especially if someone is dominating the discussion. Avoid expressing personal opinions or correcting participants ’ knowledge to prevent biasing the discussion towards a particular opinion or posi- tion (Gibbs 1997) . Correcting or supporting partici- pants ’ knowledge can be addressed at the end of the interview. For example, Roth et al . (2003) pro- vided a healthcare worker in HIV at the end of focus group sessions on bilingual health advocacy and ante- natal HIV testing to provide further information on HIV.

Group exercises may be used within the session to explore understanding about a particular issue or to indicate preferences. Kitzinger (1994) , for example, used cards with statements on them about HIV to explore participants ’ perceptions of risks. Such exer- cises encourage participants to focus on each other rather than the moderator. For young people and chil- dren, Gibson (2007) suggests that the inclusion of activities and exercises to maintain interest and con- centration as well as facilitate a sense of working together can help stimulate discussion and responses to research questions.

Time keeping is essential and shows respect for participants ’ time. Leave 5 – 10 minutes to round up the interview. This provides an opportunity for par- ticipants to offer further comments and reflect on their experience of participating in the group.

Recording i nformation

Group interactions are the crucial feature of focus groups and mark them as different from individual interviews. Audio tape, video tape and an observer can be used alone or in combination to record the group interaction. Ideally, transcribed audio tape is

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preferable, with an observer and/or video - taping. Video - tapings can be poor at recording speech and are normally used in combination with an audio tape. An observer is useful for recording, for example, the group ’ s seating arrangement and non - verbal cues of supportive or aggressive behaviour. An observation sheet with headings for particular areas of interest can help to structure the observations.

Audio and video equipment should be reliable and have a high - quality microphone for recording groups rather than individuals. The quality of the tape record- ing directly influences the precision of the transcrib- ing and the consequent validity of the transcript analysis. Ensure audio tapes are the correct length for the interview and labelled with an identification number, date and time, to prevent recording over data and as a reference point for transcribing (Bramley 2004 ).

DATA ANALYSIS

The principles and process of analysis for focus group data are very similar to those applied to qualita- tive data obtained from individual interviews (see Chapters 28 and 34 ). When undertaking analysis of a focus group discussion it is important, however, to be clear about the purpose of the analysis and whether it is the group discussion as a whole or the range of contributions to that discussion that is of interest. The research question and the rationale for using focus groups guide the analysis, and inform how the data are organised and read.

It is seldom practical to ask focus group partici- pants to check the validity of transcripts or prelimi- nary analysis. It is therefore useful to summarise at the end of the group what the moderator believes to be the main issues to emerge from the discussion for confirmation or clarification by the group. This not only helps understanding, but also represents the first stage in analysis where tentative themes can be iden- tified and subsequently tested within the detailed analysis of the group transcripts. At the end of the focus group it is also good practice for the group ’ s moderator to debrief with the observer to record initial impressions of how the group went and to

identify issues that may directly affect the analysis. Factors such as dominance of the discussion by par- ticular individuals, impressions of how engaged par- ticipants were with the issues raised and whether non - participation in the group indicated disagreement or affirmation with what was being said should be noted. These first impressions are useful as memo- randa that can subsequently inform analysis.

In contrast to analysis of individual interviews, an important part of the analytic process is identifying areas of agreement and controversy, and how views are modified or reinforced during the group discus- sion. When coding data it is helpful to think about the data as a group process. It is therefore sensible to organise the data to reflect how the discussion pro- gressed. Most groups will take some time to establish a rapport, and there will be some issues and questions that generate more interest and contributions than others. Coding the data into narrative units can be helpful, as there will be some major issues identified within the group discussion that either generate the most contributions or the strongest responses. This means that individual responses to a particular issue or question, the asides, challenges and elaborations that occur within the group are coded together and in relation to each other. Software that supports qualita- tive analysis is invaluable as it can track individual contributions as well as interactions and responses and allows interrogation of the data in different ways. Furthermore, by tracing the development and sequence of statements of the discussion on an issue it is possible to judge which of the ideas participants offered as tentative thoughts at the beginning of a focus group became, by the end of the group, estab- lished views.

In a review of the use of focus groups as a research method in nursing research, Webb and Kevern (2001) suggest that the approach to analysis of focus group data is often relatively unsophisticated and that the interaction that occurred within groups is rarely reported. They suggest that the analytic procedure should ask specific questions of the group process and interaction to deepen the understanding of the data obtained. In this way the researcher can identify statements that provoked the most emotion, reaction or conflict, how different statements related to each other, and if there were discernable alliances that

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emerged within the group or particular interests that were emphasised over others.

The use of descriptive statistics to summarise the frequency with which issues were raised and the amount of time spent discussing an issue can be helpful, particularly when comparing responses between different focus groups. When marked differ- ences are identified between groups this should prompt another look at what it was about these groups, their membership or setting, that could explain the variation. However, there should be con- siderable caution in suggesting that a particular subject or issue was more important or significant because it was raised more frequently than something else. Counting statements made on particular topics will generate a list of what participants said, but attributing meaning to this can be problematic unless the analysis also accounts for how people interacted within the group.

ISSUES OF VALIDITY AND RELIABILITY

Validity is the extent to which a procedure actually measures what it proposes to measure. Typically, focus groups have high face validity as a credible method that can directly capture the views of partici- pants in response to the study focus. Threats to face validity are those that threaten the accuracy of the participants ’ views on the topic areas of interest. These can include research questions that are unsuit- able for a focus group because they are concerned with the narrative on individual experience. Idiosyncratic and opportunistic recruitment from the population of interest can make it difficult to interpret findings. A lack of transparency in how the group discussion was organised, the prompts used, the amount of direction given to the group by the mod- erator and approaches to analysis can also threaten the confidence with which the results from focus group research can be interpreted.

Reliability concerns the degree of consistency in observing the area of interest over time. For focus groups, reliability is most relevant as it relates to the consistency in the data gathered within each respec- tive group. Threats to consistency across groups include:

� the structure and delivery of the topic guide � the impact of moderator bias � differences between the groups ’ membership,

for example regarding gender � the interview environment � accuracy in transcribing and analysing audio

tapes.

However, in groups where the emphasis is on dis- covery, the diversity of the participants may enhance the breadth of understanding.

ADVANTAGES OF FOCUS GROUPS

Although focus groups can appear to be a quick and flexible method of data collection, they are not an inexpensive or time - saving method (see Research Example 29.1 ). Considerable time is required to recruit participants, set up the groups, transcribe and analyse the data generated. There are, however, some clear advantages that focus group methods have over other data collection methods. In the early stages of a study the discussion and data generated by a focus group can identify complex problems and areas that need further exploration and clarification. A group discussion held at the end of the study provides the opportunity for participants to respond to the find- ings and offer explanations or alternative interpreta- tions. The exploratory and illuminatory function of focus groups can thus extend and challenge how researchers define their research questions and report their findings. Used in conjunction with other methods, such as interviews and observation, focus group data can confirm, extend and enrich under- standing and provide alternative narratives of events and beliefs.

Focus groups are frequently used when the opinions of lay people are sought. The method does not require participants to be able to read and write, and people can feel safe within a group. If facilitated well, participants can express their views in relation to the opinions and experiences of others without feeling pressure to respond all the time. It is partici- pant - driven and enables the language, priorities and attitudes of a group to be expressed. It is one of the few data collection methods that allow people

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to modify their initial thoughts and ideas as part of the data - gathering process. Paradoxically, focus groups can be a good way of researching topics that are taboo or controversial when participants who hold an experience in common can give each other permission to discuss. For example, focus groups may be used to enable people who are HIV - positive to discuss freely their attitudes to sexual health and the issues they encounter as a result of their health status.

The synergy generated from a group discussion often enables participants to consider the topic with more enthusiasm than an individual interview can achieve. However, questions examining feelings or requiring personal reflection may only be suited to a focus group approach when participants have self - selected or they know each other and are comfortable with that level of public self - disclosure such ques- tions require. It is the level of engagement expressed within a group, the range of participation and the ability to develop the discussion around certain issues that are often a good measure of how successful a focus group has been.

LIMITATIONS OF FOCUS GROUPS

Focus groups can have high credibility and face validity, but equally they can be susceptible to researcher manipulation and bias. The limitations of the method are the reliance on the skill of the group moderator, the risk of individual participants domi- nating discussion and excluding the contributions of others, and the possibility that the structure and format of focus groups excludes certain groups from participation.

Focus group facilitation is difficult. The novice researcher should take the opportunity to observe some focus groups before taking on the moderator role, consider training on group dynamics and talk through with an experienced colleague how they will lead the group. The moderator has to maintain a balance between encouraging discussion and partici- pation, and being careful not to bias responses by giving preference to speakers whose views are perceived as the most ‘ interesting ’ . The moderator

also needs the confidence to be able to refocus the group if participants break into two or three separate discussions at the same time, and intervene if the discussion threatens to become destructive or lead to conflict.

Most authors writing on the subject of focus groups raise the spectre of the dominant group member as a major limitation of the method. Participants who are very assertive in their views can discourage participa- tion from those who disagree or who are less certain in their opinions. Where participants have different levels or authority or education this too can affect willingness to participate. Nevertheless, if the focus group is seen as an opportunity to capture how a group of people express their opinions and if certain people can make statements that are unchallenged and allowed to dominate, then the analysis must capture this. Reed and Payton (1997) argue that if one considers focus groups as ‘ displays of group perspec- tives ’ then how groups negotiate and develop their views can be as revealing as what is said.

Focus groups can discriminate against an individ- ual ’ s ability to participate. Kitzinger (1994) described including people who had different communication disabilities such as deafness, partial paralysis affect- ing speech and dementia in a group. They could all converse individually with the researcher, but had difficulty communicating with each other, precluding meaningful interaction in a group setting. Most focus groups also require people to be able to communicate in the language of the researcher, which may exclude some people from minority ethnic groups who do not share a common language. It is possible to involve translators as an earlier example showed (Roth et al . 2003 ), although this can make the discussion more stilted and meanings harder to interpret. Halcomb et al . (2007) , in a review of studies that had used focus groups with linguistically diverse groups, found that focus groups are particularly useful for studies on service provision and community needs for minority and multicultural groups.

The location of focus groups may also affect the ability to participate and exclude some potential par- ticipants. For example, where a focus group is held may favour participation by people who have easy access to transport or live close to the proposed venue.

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ETHICAL ISSUES

The particular ethical issues that arise within focus group research are the maintenance of confidentiality, consent, the management of disclosure, and maintain- ing the respect and feelings of self - worth of each participant. It is important that participants agree that the discussions held within the group are confidential and not shared outside the group. The moderator needs to ensure that each participant agrees to this, especially in situations where the group members know each other.

The discussion format of a focus group can mean that people forget that the reason they are meeting is to participate in a research project. Frequently, dis- cussion will prompt disclosures that may not have been made within the context of an interview. Although this can interrupt the flow of the conversa- tion, it is the moderator ’ s responsibility to remind group members how the discussion will be used and why.

Consent is more problematic; apart from staying silent it is very difficult for an individual within a group to withdraw their consent to participate. The right to withdraw consent should be discussed prior to the focus group, and although silence can be a useful option it may be wrongly interpreted as a form of assent to what others are saying. Researchers should consider offering participants the opportunity to withdraw consent after the group has met if they believe that the discussion did not reflect their views or it was a process they no longer wanted to be associ- ated with. This would mean their contributions could not be reported.

The process of group participation can lead to unanticipated consequences. It can raise conscious- ness, expose underlying conflicts and falsely create an expectation that something will be done about the issues raised. Owen (2001) has discussed how dis- tinctions between focus groups and therapy groups can become blurred, especially if participants share painful personal experiences. She outlines the chal- lenges of facilitating a group where women shared the experience of having lost a child. Ensuring group members felt ‘ safe ’ was as important as obtaining the data; she describes taking the decision to sensitively

move the discussion on when participants were becoming distressed.

Although this kind of data is very rich, it is exploit- ative if people expose their feelings and reveal their needs but there is then no means of offering further support. It is therefore important to have mechanisms in place for individuals to revisit the issues raised and if necessary to discuss them further. As part of this process the moderator also needs to consider their role within the group discussion, ensuring that it is understood by participants, and consider the extent to which they are prepared to disclose their own views.

Finally, the moderator has a responsibility to ensure that participants do not feel devalued by their experience in the group. This can happen when opin- ions that are expressed are ridiculed or strongly opposed by other group members. In these situations the moderator should reinforce the right of each person to have an opinion and for it to be listened to, even if people are not in agreement. If this is not possible then the moderator should change the focus of the group ’ s discussion or bring it to a close.

CONCLUSIONS

This chapter has provided an overview of the purpose and usefulness of focus groups for nursing research. It has emphasised that this method of data collection requires careful preparation and skill in leading and managing group discussion. The method is particu- larly useful when researchers wish to understand and clarify thinking on a topic from a group perspective. The need to be transparent about the purpose and process of the focus group, and sensitive to the par- ticular ethical challenges this method poses, has been emphasised throughout. In conclusion, focus groups are a useful and versatile data collection method that can be used within a wide range of study settings and with diverse groups to great effect.

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