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  • What Is a Focus Group? | Step-by-Step Guide & Examples

What is a Focus Group | Step-by-Step Guide & Examples

Published on December 10, 2021 by Tegan George . Revised on June 22, 2023.

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest.

What is a focus group

Table of contents

What is a focus group, step 1: choose your topic of interest, step 2: define your research scope and hypotheses, step 3: determine your focus group questions, step 4: select a moderator or co-moderator, step 5: recruit your participants, step 6: set up your focus group, step 7: host your focus group, step 8: analyze your data and report your results, advantages and disadvantages of focus groups, other interesting articles, frequently asked questions about focus groups.

Focus groups are a type of qualitative research . Observations of the group’s dynamic, their answers to focus group questions, and even their body language can guide future research on consumer decisions, products and services, or controversial topics.

Focus groups are often used in marketing, library science, social science, and user research disciplines. They can provide more nuanced and natural feedback than individual interviews and are easier to organize than experiments or large-scale surveys .

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Focus groups are primarily considered a confirmatory research technique . In other words, their discussion-heavy setting is most useful for confirming or refuting preexisting beliefs. For this reason, they are great for conducting explanatory research , where you explore why something occurs when limited information is available.

A focus group may be a good choice for you if:

  • You’re interested in real-time, unfiltered responses on a given topic or in the dynamics of a discussion between participants
  • Your questions are rooted in feelings or perceptions , and cannot easily be answered with “yes” or “no”
  • You’re confident that a relatively small number of responses will answer your question
  • You’re seeking directional information that will help you uncover new questions or future research ideas
  • Structured interviews : The questions are predetermined in both topic and order.
  • Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.
  • Unstructured interviews : None of the questions are predetermined.

Differences between types of interviews

Make sure to choose the type of interview that suits your research best. This table shows the most important differences between the four types.

Topics favorable to focus groups

As a rule of thumb, research topics related to thoughts, beliefs, and feelings work well in focus groups. If you are seeking direction, explanation, or in-depth dialogue, a focus group could be a good fit.

However, if your questions are dichotomous or if you need to reach a large audience quickly, a survey may be a better option. If your question hinges upon behavior but you are worried about influencing responses, consider an observational study .

  • If you want to determine whether the student body would regularly consume vegan food, a survey would be a great way to gauge student preferences.

However, food is much more than just consumption and nourishment and can have emotional, cultural, and other implications on individuals.

  • If you’re interested in something less concrete, such as students’ perceptions of vegan food or the interplay between their choices at the dining hall and their feelings of homesickness or loneliness, perhaps a focus group would be best.

Once you have determined that a focus group is the right choice for your topic, you can start thinking about what you expect the group discussion to yield.

Perhaps literature already exists on your subject or a sufficiently similar topic that you can use as a starting point. If the topic isn’t well studied, use your instincts to determine what you think is most worthy of study.

Setting your scope will help you formulate intriguing hypotheses , set clear questions, and recruit the right participants.

  • Are you interested in a particular sector of the population, such as vegans or non-vegans?
  • Are you interested in including vegetarians in your analysis?
  • Perhaps not all students eat at the dining hall. Will your study exclude those who don’t?
  • Are you only interested in students who have strong opinions on the subject?

A benefit of focus groups is that your hypotheses can be open-ended. You can be open to a wide variety of opinions, which can lead to unexpected conclusions.

The questions that you ask your focus group are crucially important to your analysis. Take your time formulating them, paying special attention to phrasing. Be careful to avoid leading questions , which can affect your responses.

Overall, your focus group questions should be:

  • Open-ended and flexible
  • Impossible to answer with “yes” or “no” (questions that start with “why” or “how” are often best)
  • Unambiguous, getting straight to the point while still stimulating discussion
  • Unbiased and neutral

If you are discussing a controversial topic, be careful that your questions do not cause social desirability bias . Here, your respondents may lie about their true beliefs to mask any socially unacceptable or unpopular opinions. This and other demand characteristics can hurt your analysis and lead to several types of reseach bias in your results, particularly if your participants react in a different way once knowing they’re being observed. These include self-selection bias , the Hawthorne effect , the Pygmalion effect , and recall bias .

  • Engagement questions make your participants feel comfortable and at ease: “What is your favorite food at the dining hall?”
  • Exploration questions drill down to the focus of your analysis: “What pros and cons of offering vegan options do you see?”
  • Exit questions pick up on anything you may have previously missed in your discussion: “Is there anything you’d like to mention about vegan options in the dining hall that we haven’t discussed?”

It is important to have more than one moderator in the room. If you would like to take the lead asking questions, select a co-moderator who can coordinate the technology, take notes, and observe the behavior of the participants.

If your hypotheses have behavioral aspects, consider asking someone else to be lead moderator so that you are free to take a more observational role.

Depending on your topic, there are a few types of moderator roles that you can choose from.

  • The most common is the dual-moderator , introduced above.
  • Another common option is the dueling-moderator style . Here, you and your co-moderator take opposing sides on an issue to allow participants to see different perspectives and respond accordingly.

Depending on your research topic, there are a few sampling methods you can choose from to help you recruit and select participants.

  • Voluntary response sampling , such as posting a flyer on campus and finding participants based on responses
  • Convenience sampling of those who are most readily accessible to you, such as fellow students at your university
  • Stratified sampling of a particular age, race, ethnicity, gender identity, or other characteristic of interest to you
  • Judgment sampling of a specific set of participants that you already know you want to include

Beware of sampling bias and selection bias , which can occur when some members of the population are more likely to be included than others.

Number of participants

In most cases, one focus group will not be sufficient to answer your research question. It is likely that you will need to schedule three to four groups. A good rule of thumb is to stop when you’ve reached a saturation point (i.e., when you aren’t receiving new responses to your questions).

Most focus groups have 6–10 participants. It’s a good idea to over-recruit just in case someone doesn’t show up. As a rule of thumb, you shouldn’t have fewer than 6 or more than 12 participants, in order to get the most reliable results.

Lastly, it’s preferable for your participants not to know you or each other, as this can bias your results.

A focus group is not just a group of people coming together to discuss their opinions. While well-run focus groups have an enjoyable and relaxed atmosphere, they are backed up by rigorous methods to provide robust observations.

Confirm a time and date

Be sure to confirm a time and date with your participants well in advance. Focus groups usually meet for 45–90 minutes, but some can last longer. However, beware of the possibility of wandering attention spans. If you really think your session needs to last longer than 90 minutes, schedule a few breaks.

Confirm whether it will take place in person or online

You will also need to decide whether the group will meet in person or online. If you are hosting it in person, be sure to pick an appropriate location.

  • An uncomfortable or awkward location may affect the mood or level of participation of your group members.
  • Online sessions are convenient, as participants can join from home, but they can also lessen the connection between participants.

As a general rule, make sure you are in a noise-free environment that minimizes distractions and interruptions to your participants.

Consent and ethical considerations

It’s important to take into account ethical considerations and informed consent when conducting your research. Informed consent means that participants possess all the information they need to decide whether they want to participate in the research before it starts. This includes information about benefits, risks, funding, and institutional approval.

Participants should also sign a release form that states that they are comfortable with being audio- or video-recorded. While verbal consent may be sufficient, it is best to ask participants to sign a form.

A disadvantage of focus groups is that they are too small to provide true anonymity to participants. Make sure that your participants know this prior to participating.

There are a few things you can do to commit to keeping information private. You can secure confidentiality by removing all identifying information from your report or offer to pseudonymize the data later. Data pseudonymization entails replacing any identifying information about participants with pseudonymous or false identifiers.

Preparation prior to participation

If there is something you would like participants to read, study, or prepare beforehand, be sure to let them know well in advance. It’s also a good idea to call them the day before to ensure they will still be participating.

Consider conducting a tech check prior to the arrival of your participants, and note any environmental or external factors that could affect the mood of the group that day. Be sure that you are organized and ready, as a stressful atmosphere can be distracting and counterproductive.

Starting the focus group

Welcome individuals to the focus group by introducing the topic, yourself, and your co-moderator, and go over any ground rules or suggestions for a successful discussion. It’s important to make your participants feel at ease and forthcoming with their responses.

Consider starting out with an icebreaker, which will allow participants to relax and settle into the space a bit. Your icebreaker can be related to your study topic or not; it’s just an exercise to get participants talking.

Leading the discussion

Once you start asking your questions, try to keep response times equal between participants. Take note of the most and least talkative members of the group, as well as any participants with particularly strong or dominant personalities.

You can ask less talkative members questions directly to encourage them to participate or ask participants questions by name to even the playing field. Feel free to ask participants to elaborate on their answers or to give an example.

As a moderator, strive to remain neutral . Refrain from reacting to responses, and be aware of your body language (e.g., nodding, raising eyebrows) and the possibility for observer bias . Active listening skills, such as parroting back answers or asking for clarification, are good methods to encourage participation and signal that you’re listening.

Many focus groups offer a monetary incentive for participants. Depending on your research budget, this is a nice way to show appreciation for their time and commitment. To keep everyone feeling fresh, consider offering snacks or drinks as well.

After concluding your focus group, you and your co-moderator should debrief, recording initial impressions of the discussion as well as any highlights, issues, or immediate conclusions you’ve drawn.

The next step is to transcribe and clean your data . Assign each participant a number or pseudonym for organizational purposes. Transcribe the recordings and conduct content analysis to look for themes or categories of responses. The categories you choose can then form the basis for reporting your results.

Just like other research methods, focus groups come with advantages and disadvantages.

  • They are fairly straightforward to organize and results have strong face validity .
  • They are usually inexpensive, even if you compensate participant.
  • A focus group is much less time-consuming than a survey or experiment , and you get immediate results.
  • Focus group results are often more comprehensible and intuitive than raw data.

Disadvantages

  • It can be difficult to assemble a truly representative sample. Focus groups are generally not considered externally valid due to their small sample sizes.
  • Due to the small sample size, you cannot ensure the anonymity of respondents, which may influence their desire to speak freely.
  • Depth of analysis can be a concern, as it can be challenging to get honest opinions on controversial topics.
  • There is a lot of room for error in the data analysis and high potential for observer dependency in drawing conclusions. You have to be careful not to cherry-pick responses to fit a prior conclusion.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Student’s  t -distribution
  • Normal distribution
  • Null and Alternative Hypotheses
  • Chi square tests
  • Confidence interval
  • Quartiles & Quantiles
  • Cluster sampling
  • Stratified sampling
  • Data cleansing
  • Reproducibility vs Replicability
  • Peer review
  • Prospective cohort study

Research bias

  • Implicit bias
  • Cognitive bias
  • Placebo effect
  • Hawthorne effect
  • Hindsight bias
  • Affect heuristic
  • Social desirability bias

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest. It is one of 4 types of interviews .

As a rule of thumb, questions related to thoughts, beliefs, and feelings work well in focus groups. Take your time formulating strong questions, paying special attention to phrasing. Be careful to avoid leading questions , which can bias your responses.

There are various approaches to qualitative data analysis , but they all share five steps in common:

  • Prepare and organize your data.
  • Review and explore your data.
  • Develop a data coding system.
  • Assign codes to the data.
  • Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

Every dataset requires different techniques to clean dirty data , but you need to address these issues in a systematic way. You focus on finding and resolving data points that don’t agree or fit with the rest of your dataset.

These data might be missing values, outliers, duplicate values, incorrectly formatted, or irrelevant. You’ll start with screening and diagnosing your data. Then, you’ll often standardize and accept or remove data to make your dataset consistent and valid.

The four most common types of interviews are:

  • Structured interviews : The questions are predetermined in both topic and order. 
  • Focus group interviews : The questions are presented to a group instead of one individual.

It’s impossible to completely avoid observer bias in studies where data collection is done or recorded manually, but you can take steps to reduce this type of bias in your research .

Scope of research is determined at the beginning of your research process , prior to the data collection stage. Sometimes called “scope of study,” your scope delineates what will and will not be covered in your project. It helps you focus your work and your time, ensuring that you’ll be able to achieve your goals and outcomes.

Defining a scope can be very useful in any research project, from a research proposal to a thesis or dissertation . A scope is needed for all types of research: quantitative , qualitative , and mixed methods .

To define your scope of research, consider the following:

  • Budget constraints or any specifics of grant funding
  • Your proposed timeline and duration
  • Specifics about your population of study, your proposed sample size , and the research methodology you’ll pursue
  • Any inclusion and exclusion criteria
  • Any anticipated control , extraneous , or confounding variables that could bias your research if not accounted for properly.

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qualitative research online focus group

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Online focus group: What it is, types, and free examples

An in-depth guide to online focus groups

The online focus group software has become very popular with organizations looking to conduct market research, thanks to the great results that can be obtained from this small segment of people.

The information obtained when using a smaller number of participants in the focus groups is more robust and allows exploring the unconscious or often unexpressed preferences of consumers.

Participants in focus groups have also become more diverse to reflect a globalized and interconnected audience. This requires greater awareness on the part of the participants, which makes them feel welcome to share their true opinions during the research process.

What is an online focus group?

An online focus group is defined as a focus group conducted via the internet with the help of an online focus group software. An online focus group is one of the newer online research methods used primarily to conduct business research, consumer research, and other research that needs online qualitative research. 

Online focus group research is now widely used by brands, organizations, and researchers alike that cannot conduct offline focus groups or would better like to manage qualitative insights. To conduct an online focus group efficiently, you need to leverage a tool like online communities that best helps you manage your online qualitative research.

LEARN ABOUT: Qualitative Research Questions and Questionnaires

Examples of online focus groups 

An example is an apparel brand that managed consumer research to test consumer sentiments during new product launches. Moving focus groups online with the help of an online focus group software allows them to continue collecting insights from their audience and consumers and making sense of purchase decisions and purchase intent.

Another example of an organization that actively uses online qualitative research methods for in-depth monitoring is an airline that wants to make a better product. Using interactive groups with a close set of customers and brand promoters, the airline can collect and analyze sentiments and purchase decisions to better their product and services.

Every brand, researcher, and organization that conducts offline focus groups can be an example of online focus groups by making the switch with online focus group software . 

Steps and best practices to conduct and manage an online focus group

An online focus group is a wealth of research insights for researchers, brands, and organizations. However, managing them requires you to follow some fundamental steps to get the most out of your participant group. 

Steps to conduct online focus group research

To create an interactive focus group, it is essential to follow some necessary steps. The steps are as follows:

  • Define the research objective – For the success of online qualitative research, it is essential to define the research aim to not deviate from the central theme of the study. Defining the objective also helps to ensure that the qualitative data collected fulfills the researcher’s basic needs and the organization.

LEARN ABOUT: Qualitative Interview

  • Schedule the study – Bringing together people for online qualitative discussions is more accessible as it mitigates the need for a physical location. Since the discussions are online, respondents can be brought together without geographical boundaries. It is essential to schedule the study in advance so that the participants, observers, and other stakeholders make it to the research on time.
  • Research questions – It is important to get insights on your basic research questions to need responses. These could be leading questions, qualitative questions, co-creating questions, and more. Getting your questions together offer structure to the online discussion and ensure you collect the insights you are looking for from the research study.
  • Data collection & analysis – Since online focus groups are qualitative, collecting, and analyzing your online qualitative data is very important. Drawing insights, trends, and sentiments from this study help to meet your research objectives and goals.

Best practices of managing online focus groups

To conduct online qualitative research, you need to have the right tools to derive the right insights. Some best practices of managing an online focus group are:

  • Preparation – Since online focus groups are remote, plan, and prepare well. Right from time, tool, participants, questions, data analysis, have all of it tracked to attain your research goals.
  • Sampling – Sampling and getting the right people to an online focus group is essential. Use the proper sampling techniques and bring in a mix of customers and promoters to have a high data collection quality.
  • Size – Like offline focus groups, the size of online focus groups needs to be between 7-10 participants to derive the best insights and are easy to manage. 
  • Moderation – As a moderator, decide the role you want to use in the research study to bring the best out of the respondents and drive conversations in a way that offers the best insights.
  • Online focus group platform – The most critical aspect of online focus groups is the tool you use. Ensure you use the right research platform that serves your research objectives and offers the flexibility to analyze and report data. 

Types of online focus groups

Due to the nature of qualitatively oriented research, they are highly interactive. Even when external factors are detrimental to study, you can conduct no-pause research insights by moving your focus groups online . There are two types of online focus groups. They are:

Synchronous or real-time online focus groups

As the name suggests, synchronous online focus groups happen in real-time at a predefined time. Such focus groups span between 30-90 mins and consist of between 6-10 participants. A moderator curates these focus groups, and the qualitative data collection is only for the duration of the online discussion.

Such studies take place with software, tools, and platforms. Since this is in real-time, participants can interact with each and the moderator in real-time.  

Synchronous online focus groups find most use during concept testing and product or user research. An example of a synchronous or real-time focus group is a retail store looking to launch a new product on supermarket shelves and is looking for feedback on the product’s packaging.

Asynchronous or bulletin board online focus groups

Asynchronous or bulletin board online focus groups are not in real-time and help with longitudinal tracking in the form of online customer communities . This variant runs for weeks, days, and even years.

Users can respond to surveys and questionnaires, offer video feedback, and even post pictures, videos, and other rich media forms online. Users can interact with other users and moderators and help with insightful discussions in text, audio, and video.  

Asynchronous or bulletin board online focus groups are mostly used by brands for co-creation with select audiences and brand promoters. An example of these type of focus groups is an apparel brand that launches a new clothing line and then takes long-term feedback on various aspects, including pricing, store and purchase behavior, competitor benchmarking, product trends, etc. With the help of a market research online community , the apparel brand can tailor its products in the short, medium, and long-term. 

Online focus group questions

To conduct efficient online qualitative market research , it is essential to ask the right set of questions. The most common types of online focus group questions, with examples, are:

Recruitment questions

To target the right respondents, it is vital to ask the right demographic questions. Using online community software, the previously profiled respondents can join an online discussion. However, it is still best to ask the right questions to ensure you have the optimal respondents that add value to the online focus group study. An example of an online focus group recruitment question is – Please state your employment type. This question helps to filter optimal research respondents for a video focus group.

Engagement questions

The role of the community administrator or the online focus group manager is critical. Asking the right questions that elicit the insights that matter to the brand is an essential aspect of the online focus group. Following the plan and line of research, questioning is imperative to deriving optimal results. An example of an online focus group engagement question is – How recently have you used your organization’s product and please state your complete experience while using the product. 

Exploratory questions

Since online focus groups are virtual and not in person, it is crucial to make up for the lack of visual cues with exploratory questions. In this scenario, the online focus group moderator’s role is essential to ask the right probing questions. Most exploratory questions are open-ended, and it is the administrator’s responsibility to ensure that the correct items are put forth to the audience. An example of an online focus group exploratory question is – What do you love about our organization or brand?

Conclusion questions

To ensure that the brand collects the most important insights – if any research tracks get missed during the online focus group, the administrator must ask the right conclusion questions to collect answers that require answering. In most cases, these are open-ended questions. An example of a conclusion question is: Is there anything else you would like to add about your experience with this product?

Advantages of online focus group research

There are multiple advantages to conducting online focus group research. Some of the most notable benefits are:

  • No-pause insights: They are conducted anytime, anywhere, and even if in-person focus groups are on hold. Hence you can continuously monitor qualitative insights from members that are most important to your insights collection. 
  • Offers another dimension to qualitative research: While focus groups have their advantage, due to the ease of management of online focus groups, there are tangible benefits and hence offer another dimension to steps in qualitative research .
  • Efficient and high ROI: A significant advantage of online focus groups is that they are conducted without physical barriers. There are no restrictions on time or place, and the costs are negligible. To top that, there are no geographical and demographic restrictions with online focus group research.
  • Ease of analysis: With the help of online focus group tools, it is easier to transcribe focus groups, take notes, convert to different languages, analyze sentiments, watch reruns, etc. The analysis of online focus groups offers better reporting to all the relevant research stakeholders too. 
  • Paid online focus groups: Brands are increasingly conducting a paid online focus group to recruit and get insights from the people they can most likely co-create with. Due to the bonus of paid online focus groups, respondents are more likely to join and offer opinions, thoughts, and add value to the research process.

The most prominent advantages of moving your offline focus groups online are tangible and hence becoming a choice of conducting online qualitative research for brands and researchers alike. 

Conduct an online focus group with software – QuestionPro Communities

Managing an online focus group is easy if you use a powerful online focus group platform and tool like QuestionPro Communities. By using a comprehensive community management tool, you get access to run high-frequency studies and manage longitudinal studies . Not just that, get easy access to quantitative data and qualitative data and make informed decisions for your brand. 

We recently conducted an online webinar on how to best manage online focus groups by using the right software. 

Conducting focus groups online is, no doubt, the future of research. It is easy to manage, extremely powerful, and offers a high ROI. Move your focus groups online and harness the true potential of online qualitative research.

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  • Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

  • P. Gill 1 &
  • J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

You have full access to this article via your institution.

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Introduction

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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Qualitative Research: Introducing focus groups

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This paper introduces focus group methodology, gives advice on group composition, running the groups, and analysing the results. Focus groups have advantages for researchers in the field of health and medicine: they do not discriminate against people who cannot read or write and they can encourage participation from people reluctant to be interviewed on their own or who feel they have nothing to say.

This is the fifth in a series of seven articles describing non-quantitative techniques and showing their value in health research

**FIGURE OMITTED**

Rationale and uses of focus groups

Focus groups are a form of group interview that capitalises on communication between research participants in order to generate data. Although group interviews are often used simply as a quick and convenient way to collect data from several people simultaneously, focus groups explicitly use group interaction as part of the method. This means that instead of the researcher asking each person to respond to a question in turn, people are encouraged to talk to one another: asking questions, exchanging anecdotes and commenting on each other's experiences and points of view. 1 The method is particularly useful for exploring people's knowledge and experiences and can be used to examine not only what people think but how they think and why they think that way.

Focus groups were originally used within communication studies to explore the effects of films and television programmes, 2 and are a popular method for assessing health education messages and examining public understandings of illness and of health behaviours. 3 4 5 6 7 They are widely used to examine people's experiences of disease and of health services. 8 9 and are an effective technique for exploring the attitudes and needs of staff. 10 11

The idea behind the focus group method is that group processes can help people to explore and clarify their views in ways that would be less easily accessible in a one to one interview. Group discussion is particularly appropriate when the interviewer has a series of open ended questions and wishes to encourage research participants to explore the issues of importance to them, in their own vocabulary, generating their own questions and pursuing their own priorities. When group dynamics work well the participants work alongside the researcher, taking the research in new and often unexpected directions.

Group work also helps researchers tap into the many different forms of communication that people use in day to day interaction, including jokes, anecdotes, teasing, and arguing. Gaining access to such variety of communication is useful because people's knowledge and attitudes are not entirely encapsulated in reasoned responses to direct questions. Everyday forms of communication may tell us as much, if not more, about what people know or experience. In this sense focus groups reach the parts that other methods cannot reach, revealing dimensions of understanding that often remain untapped by more conventional data collection techniques.

Some potential sampling advantages with focus groups

Do not discriminate against people who cannot read or write

Can encourage participation from those who are reluctant to be interviewed on their own (such as those intimidated by the formality and isolation of a one to one interview)

Can encourage contributions from people who feel they have nothing to say or who are deemed “unresponsive patients” (but engage in the discussion generated by other group members)

Tapping into such interpersonal communication is also important because this can highlight (sub)cultural values or group norms. Through analysing the operation of humour, consensus, and dissent and examining different types of narrative used within the group, the researcher can identify shared and common knowledge. 12 This makes focus groups a data collection technique particularly sensitive to cultural variables—which is why it is so often used in cross cultural research and work with ethnic minorities. It also makes them useful in studies examining why different sections of the population make differential use of health services. 13 14 For similar reasons focus groups are useful for studying dominant cultural values (for example, exposing dominant narratives about sexuality 15 ) and for examining work place cultures—the ways in which, for example, staff cope with working with terminally ill patients or deal with the stresses of an accident and emergency department.

The downside of such group dynamics is that the articulation of group norms may silence individual voices of dissent. The presence of other research participants also compromises the confidentiality of the research session. For example, in group discussion with old people in long term residential care I found that some residents tried to prevent others from criticising staff—becoming agitated and repeatedly interrupting with cries of “you can't complain”; “the staff couldn't possibly be nicer.” On the one hand, such interactions highlighted certain aspects of these people's experiences. In this case, it showed some resident's fear of being “punished” by staff for, in the words of one woman, “being cheeky.” On the other hand, such group dynamics raise ethical issues (especially when the work is with “captive” populations) and may limit the usefulness of the data for certain purposes (Scottish Health Feedback, unpublished report).

However, it should not be assumed that groups are, by definition, inhibiting relative to the supposed privacy of an interview situation or that focus groups are inappropriate when researching sensitive topics. Quite the opposite may be true. Group work can actively facilitate the discussion of taboo topics because the less inhibited members of the group break the ice for shyer participants. Participants can also provide mutual support in expressing feelings that are common to their group but which they consider to deviate from mainstream culture (or the assumed culture of the researcher). This is particularly important when researching stigmatised or taboo experiences (for example, bereavement or sexual violence).

Focus group methods are also popular with those conducting action research and those concerned to “empower” research participants because the participants can become an active part of the process of analysis. Indeed, group participants may actually develop particular perspectives as a consequence of talking with other people who have similar experiences. For example, group dynamics can allow for a shift from personal, self blaming psychological explanations (“I'm stupid not to have understood what the doctor was telling me”; “I should have been stronger—I should have asked the right questions”) to the exploration of structural solutions (“If we've all felt confused about what we've been told maybe having a leaflet would help, or what about being able to take away a tape recording of the consultation?”).

Some researchers have also noted that group discussions can generate more critical comments than interviews. 16 For example, Geis et al, in their study of the lovers of people with AIDS, found that there were more angry comments about the medical community in the group discussions than in the individual interviews: “perhaps the synergism of the group ‘kept the anger going’ and allowed each participant to reinforce another's vented feelings of frustration and rage. 17 A method that facilitates the expression of criticism and the exploration of different types of solutions is invaluable if the aim of research is to improve services. Such a method is especially appropriate when working with particular disempowered patient populations who are often reluctant to give negative feedback or may feel that any problems result from their own inadequacies. 19

Conducting a focus group study

Sampling and group composition.

Focus group studies can consist of anything between half a dozen to over fifty groups, depending on the aims of the project and the resources available. Most studies involve just a few groups, and some combine this method with other data collection techniques. Focus group discussion of a questionnaire is ideal for testing the phrasing of questions and is also useful in explaining or exploring survey results. 19 20

Although it may be possible to work with a representative sample of a small population, most focus group studies use a theoretical sampling model (explained earlier in this series 21 ) whereby participants are selected to reflect a range of the total study population or to test particular hypotheses. Imaginative sampling is crucial. Most people now recognise class or ethnicity as important variables, and it is also worth considering other variables. For example, when exploring women's experiences of maternity care or cervical smears it may be advisable to include groups of lesbians or women who were sexually abused as children. 22

Most researchers recommend aiming for homogeneity within each group in order to capitalise on people's shared experiences. However, it can also be advantageous to bring together a diverse group (for example, from a range of professions) to maximise exploration of different perspectives within a group setting. However, it is important to be aware of how hierarchy within the group may affect the data (a nursing auxiliary, for example, is likely to be inhibited by the presence of a consultant from the same hospital).

The groups can be “naturally occurring” (for example, people who work together) or may be drawn together specifically for the research. Using preexisting groups allows observation of fragments of interactions that approximate to naturally occurring data (such as might have been collected by participant observation). An additional advantage is that friends and colleagues can relate each other's comments to incidents in their shared daily lives. They may challenge each other on contradictions between what they profess to believe and how they actually behave (for example, “how about that time you didn't use a glove while taking blood from a patient?”).

It would be naive to assume that group data are by definition “natural” in the sense that such interactions would have occurred without the group being convened for this purpose. Rather than assuming that sessions inevitably reflect everyday interactions (although sometimes they will), the group should be used to encourage people to engage with one another, formulate their ideas, and draw out the cognitive structures which previously have not been articulated.

Finally, it is important to consider the appropriateness of group work for different study populations and to think about how to overcome potential difficulties. Group work can facilitate collecting information from people who cannot read or write. The “safety in numbers factor” may also encourage the participation of those who are wary of an interviewer or who are anxious about talking. 23 However, group work can compound difficulties in communication if each person has a different disability. In the study assessing residential care for the elderly, I conducted a focus group that included one person who had impaired hearing, another with senile dementia, and a third with partial paralysis affecting her speech. This severely restricted interaction between research participants and confirmed some of the staff's predictions about the limitations of group work with this population. However, such problems could be resolved by thinking more carefully about the composition of the group, and sometimes group participants could help to translate for each other. It should also be noted that some of the old people who might have been unable to sustain a one to one interview were able to take part in the group, contributing intermittently. Even some residents who staff had suggested should be excluded from the research because they were “unresponsive” eventually responded to the lively conversations generated by their coresidents and were able to contribute their point of view. Communication difficulties should not rule out group work, but must be considered as a factor.

RUNNING THE GROUPS

Sessions should be relaxed: a comfortable setting, refreshments, and sitting round in a circle will help to establish the right atmosphere. The ideal group size is between four and eight people. Sessions may last one to two hours (or extend into a whole afternoon or a series of meetings). The facilitator should explain that the aim of focus groups is to encourage people to talk to each other rather than to address themselves to the researcher. The researcher may take a back seat at first, allowing for a type of “structured eavesdropping.” 24 Later on in the session, however, the researcher can adopt a more interventionist style: urging debate to continue beyond the stage it might otherwise have ended and encouraging the group to discuss the inconsistencies both between participants and within their own thinking. Disagreements within groups can be used to encourage participants to elucidate their point of view and to clarify why they think as they do. Differences between individual one off interviews have to be analysed by the researchers through armchair theorising; differences between members of focus groups should be explored in situ with the help of the research participants.

The facilitator may also use a range of group exercises. A common exercise consists of presenting the group with a series of statements on large cards. The group members are asked collectively to sort these cards into different piles depending on, for example, their degree of agreement or disagreement with that point of view or the importance they assign to that particular aspect of service. For example, I have used such cards to explore public understandings of HIV transmission (placing statements about “types” of people into different risk categories), old people's experiences of residential care (assigning degrees of importance to different statements about the quality of their care), and midwive's views of their professional responsibilities (placing a series of statements about midwive's roles along an agree-disagree continuum). Such exercises encourage participants to concentrate on one another (rather than on the group facilitator) and force them to explain their different perspectives. The final layout of the cards is less important than the discussion that it generates. 25 Researchers may also use such exercises as a way of checking out their own assessment of what has emerged from the group. In this case it is best to take along a series of blank cards and fill them out only towards the end of the session, using statements generated during the course of the discussion. Finally, it may be beneficial to present research participants with a brief questionnaire, or the opportunity to speak to the researcher privately, giving each one the opportunity to record private comments after the group session has been completed.

Ideally the group discussions should be tape recorded and transcribed. If this is not possible then it is vital to take careful notes and researchers may find it useful to involve the group in recording key issues on a flip chart.

ANALYSIS AND WRITING UP

Analysing focus groups is basically the same as analysing any other qualitative self report data. 21 26 At the very least, the researcher draws together and compares discussions of similar themes and examines how these relate to the variables within the sample population. In general, it is not appropriate to give percentages in reports of focus group data, and it is important to try to distinguish between individual opinions expressed in spite of the group from the actual group consensus. As in all qualitative analysis, deviant case analysis is important—that is, attention must be given to minority opinions and examples that do not fit with the researcher's overall theory.

The only distinct feature of working with focus group data is the need to indicate the impact of the group dynamic and analyse the sessions in ways that take full advantage of the interaction between research participants. In coding the script of a group discussion, it is worth using special categories for certain types of narrative, such as jokes and anecdotes, and types of interaction, such as “questions,” “deferring to the opinion of others,” “censorship,” or “changes of mind.” A focus group research report that is true to its data should also usually include at least some illustrations of the talk between participants, rather than simply presenting isolated quotations taken out of context.

Tapping into interpersonal communication can highlight cultural values or group norms

This paper has presented the factors to consider when designing or evaluating a focus group study. In particular, it has drawn attention to the overt exploitation and exploration of interactions in focus group discussion. Interaction between participants can be used to achieve seven main aims:

To highlight the respondent's attitudes, priorities, language, and framework of understanding;

To encourage research participants to generate and explore their own questions and develop their own analysis of common experiences;

To encourage a variety of communication from participants—tapping into a wide range and form of understanding;

To help to identify group norms and cultural values;

To provide insight into the operation of group social processes in the articulation of knowledge (for example, through the examination of what information is censured or muted within the group);

To encourage open conversation about embarrassing subjects and to permit the expression of criticism;

Generally to facilitate the expression of ideas and experiences that might be left underdeveloped in an interview and to illuminate the research participant's perspectives through the debate within the group.

Group data are neither more nor less authentic than data collected by other methods, but focus groups can be the most appropriate method for researching particular types of question. Direct observation may be more appropriate for studies of social roles and formal organisations 27 but focus groups are particularly suited to the study of attitudes and experiences. Interviews may be more appropriate for tapping into individual biographies, 27 but focus groups are more suitable for examining how knowledge, and more importantly, ideas, develop and operate within a given cultural context. Questionnaires are more appropriate for obtaining quantitative information and explaining how many people hold a certain (pre-defined) opinion; focus groups are better for exploring exactly how those opinions are constructed. Thus while surveys repeatedly identify gaps between health knowledge and health behaviour, only qualitative methods, such as focus groups, can actually fill these gaps and explain why these occur.

Focus groups are not an easy option. The data they generate can be as cumbersome as they are complex. Yet the method is basically straightforward and need not be intimidating for either the researcher or the researched. Perhaps the very best way of working out whether or not focus groups might be appropriate in any particular study is to try them out in practice.

Further reading

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The traditional, face-to-face focus group method has been a highly effective qualitative research tool (Collis, J., & Hussey, R. (2013). Business research: A practical guide for undergraduate and postgraduate students (Revised ed.). Palgrave Macmillan.); it makes possible the gathering of detailed information regarding participant perceptions, opinions, beliefs, and attitudes regarding particular phenomena.

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Morrison, D. (2023). Online Focus Groups. In: Okoko, J.M., Tunison, S., Walker, K.D. (eds) Varieties of Qualitative Research Methods. Springer Texts in Education. Springer, Cham. https://doi.org/10.1007/978-3-031-04394-9_55

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Methodological Aspects of Focus Groups in Health Research

Anja p. tausch.

1 GESIS–Leibniz Institute for the Social Sciences, Mannheim, Germany

Natalja Menold

Although focus groups are commonly used in health research to explore the perspectives of patients or health care professionals, few studies consider methodological aspects in this specific context. For this reason, we interviewed nine researchers who had conducted focus groups in the context of a project devoted to the development of an electronic personal health record. We performed qualitative content analysis on the interview data relating to recruitment, communication between the focus group participants, and appraisal of the focus group method. The interview data revealed aspects of the focus group method that are particularly relevant for health research and that should be considered in that context. They include, for example, the preferability of face-to-face recruitment, the necessity to allow participants in patient groups sufficient time to introduce themselves, and the use of methods such as participant-generated cards and prioritization.

Focus groups have been widely used in health research in recent years to explore the perspectives of patients and other groups in the health care system (e.g., Carr et al., 2003 ; Côté-Arsenault & Morrison-Beedy, 2005 ; Kitzinger, 2006 ). They are often included in mixed-methods studies to gain more information on how to construct questionnaires or interpret results ( Creswell & Plano Clark, 2007 ; Kroll, Neri, & Miller, 2005 ).

The fact that the group process helps people to identify and clarify their views is considered to be an important advantage of focus groups compared with individual interviews ( Kitzinger, 1995 ). The group functions as a promoter of synergy and spontaneity by encouraging the participants to comment, explain, disagree, and share their views. Thus, experiences are shared and opinions voiced that might not surface during individual interviews ( Carey, 1994 ; Stewart, Shamdasani, & Rook, 2007 ). Although focus groups allow participants to respond in their own words and to choose discussion topics themselves, they are not completely unstructured. Questions relating to the research topic are designed by the researchers and are used to guide the discussion ( Stewart et al., 2007 ). The degree of structure of the focus group depends on the openness of the research question(s). Hence, although it takes more time and effort to organize focus groups, and they cause greater logistical problems than individual interviews do, they might generate more ideas about, and yield deeper insights into, the problem under investigation ( Coenen, Stamm, Stucki, & Cieza, 2012 ; Kingry, Tiedje, & Friedman, 1990 ; Morgan, 2009 ).

Historically, focus groups were used mainly for market research before the method was adopted for application in qualitative research in the social sciences ( Morgan, 1996 ). The use of focus groups in health care research is even more recent. For this reason, methodological recommendations on using focus groups in the health care context are quite rare, and researchers rely mainly on general advice from the social sciences (e.g., Krueger, 1988 ; Morgan, 1993 ; Morgan & Krueger, 1998 ; Stewart et al., 2007 ). Even though focus groups have been used in a great variety of health research fields, such as patients’ treatments and perceptions in the context of specific illnesses (rheumatoid arthritis: for example, Feldthusen, Björk, Forsblad-d’Elia, & Mannerkorpi, 2013 ; cancer: for example, Gerber, Hamann, Rasco, Woodruff, & Lee, 2012 ; diabetes: for example, Nafees, Lloyd, Kennedy-Martin, & Hynd, 2006 ; heart failure: for example, Rasmusson et al., 2014 ), community health research (e.g., Daley et al., 2010 ; Rhodes, Hergenrather, Wilkin, Alegría-Ortega, & Montaño, 2006 ), or invention of new diagnostic or therapeutic methods (e.g., Vincent, Clark, Marquez Zimmer, & Sanchez, 2006 ), the method and its particular use in health research is rarely reflected. Methodological articles about the focus group method in health care journals mainly summarize general advice from the social sciences (e.g., Kingry et al., 1990 ; Kitzinger, 1995 , 2006 ), while field-specific aspects of the target groups (patients, doctors, other medical staff) and the research questions (not only sociological but often also medical or technical) are seldom addressed. Reports on participant recruitment and methods of conducting the focus groups are primarily episodic in nature (e.g., Coenen et al., 2012 ; Côté-Arsenault & Morrison-Beedy, 2005 ) and often focus on very specific aspects of the method (communication: for example, Lehoux, Poland, & Daudelin, 2006 ; activating methods: for example, Colucci, 2007 ) or aim at a comparison between face-to-face focus groups and other methods (individual interviews: for example, Coenen et al., 2012 ; telephone groups: for example, Frazier et al., 2010 ; Internet groups: for example, Nicholas et al., 2010 ). Thus, systematic reviews of factors influencing the results of focus groups as well as advantages, disadvantages, and pitfalls are missing. One consequence is that researchers might find it difficult to recruit enough participants or might be surprised by the communication styles of the target groups. Furthermore, in the tradition of classical clinical research, the group discussions might result in a question-and-answer situation or “resemble individual interviews done in group settings” ( Colucci, 2007 , p. 1,424), thereby missing out on the opportunity to use the group setting to activate all participants and to encourage a deeper elaboration of their ideas. Colucci, for example, proposed the use of exercises (e.g., activity-oriented questions) to focus the attention of the group on the core topic and to facilitate subsequent analyses.

Recommendations from the social sciences on using the focus group method can be subsumed under the following headings: subjects (target groups, composition of groups, recruitment), communication in the groups (discussion guide, moderator, moderating techniques), and analysis of focus groups (e.g., Morgan, 1993 ; Morgan & Krueger, 1998 ; Stewart et al., 2007 ). Specific requirements for health research can be identified in all three thematic fields: Recruitment might be facilitated by using registers of quality circles to recruit physicians or pharmacists, or by recruiting patients in outpatients departments. It might be hampered by heavy burdens on target groups—be they time burdens (e.g., clinical schedules, time-consuming therapy) or health constraints (e.g., physical fitness). With regard to communication in focus groups, finding suitable locations, identifying optimal group sizes, planning a good time line, as well as selecting suitable moderators (e.g., persons who are capable of translating medical terms into everyday language) might pose a challenge. The analysis of focus groups in health care research might also require special procedures because the focus group method is used to answer not only sociological research questions (e.g., related to the reconstruction of the perspectives of target groups) but also more specific research questions, such as user requirements with regard to written information or technical innovations.

The aim of our study was to gather more systematic methodological information for conducting focus groups in the context of health research in general and in the more specific context of the implementation of a technical innovation. To this end, we conducted interviews with focus group moderators about their experiences when planning and moderating focus groups. The groups in question were part of a research program aimed at developing and evaluating an electronic personal health record. We chose this program for several reasons: First, because it consisted of several subprojects devoted to different research topics related to the development of a personal electronic health record, it offered a variety of research content (cf. next section). Second, the focus groups were conducted to answer research questions of varying breadth, which can be regarded as typical of research in health care. Third, the focus groups comprised a variety of target groups—not only patients but also different types of health care professionals (general practitioners, independent specialists with different areas of specialization, hospital doctors, pharmacists, medical assistants, nursing staff).

In this article, we report the findings of these interviews in relation to the following questions: (a) What challenges associated with the characteristics of the target groups of health research (patients, physicians, other health care professionals) might be considered during the recruitment process? How should the specific research question relating to a technical innovation be taken into account during the recruitment process? (b) Should specific aspects of the communication styles of target groups be taken into account when planning and moderating focus groups in health care? Can additional challenges be identified in relation to the technical research question? and (c) How was the method appraised by the interviewees in their own research context?

Research Program and Description of Focus Groups

The “Information Technology for Patient-Centered Health Care” (INFOPAT) research program ( www.infopat.eu ) addresses the fact that, because patients with chronic conditions (e.g., colorectal cancer, type 2 diabetes) have complex health care needs, many personal health data are collected in different health care settings. The aim of the program is to develop and evaluate an electronic personal health record aimed at improving regional health care for chronically ill people and strengthening patients’ participation in their health care process. Subprojects are devoted, for example, to developing the personal electronic health record (Project Cluster 1), a medication platform (Project Cluster 2), and a case management system for chronically ill patients (Project Cluster 3). In the first, qualitative, phase, the researchers explored patients’ and health care professionals’ experiences with cross-sectoral health care and patient self-management, and their expectations regarding the advantages and disadvantages of a personal electronic health record. The information gathered in this phase of the program served as a basis for constructing a personal electronic health record prototype. This prototype was implemented as an intervention in a second, quantitative, phase dedicated to investigating the impact of such a record on a range of health care variables (e.g., self-management, health status, patient–doctor relationship, compliance). The University Hospital Heidelberg Ethics Committee approved the studies of the INFOPAT research program. All participants gave their written informed consent, and the participants’ anonymity and confidentiality were ensured throughout the studies according to the ethical standards of German Sociological Association. 1

Twenty-one focus groups were conducted during the qualitative phase of the program. Three groups consisted of colorectal cancer patients, four comprised type 2 diabetes patients, four were made up of physicians, three comprised physicians and pharmacists, four consisted of physicians and other health care professionals, and three consisted of other health care professionals (for more detailed information, see Tausch & Menold, 2015 ). Participants were recruited from urban and rural districts of the Rhine-Neckar region in Germany. Patients were approached in clinics, by their local general practitioners, or in self-help groups. Health care professionals were recruited in clinics, cooperating medical practices, and professional networks.

The focus groups took place at several locations at the National Center of Tumor Diseases (NCT) in Heidelberg, Germany, and the University of Heidelberg. The groups consisted of between four and seven participants and lasted between 1.5 and 2 hours. All focus groups were conducted by two researchers—a moderator and a co-moderator; a third researcher took notes. Semistructured discussion guides were used, and the groups were video- and audio recorded (cf., for example, Baudendistel et al., 2015 ; Kamradt et al., 2015 ). The researchers performed content analysis on the transcripts; the schema of categories was oriented toward the research questions. The focus groups addressed research questions of varying breadth, including, for example, individual health care experiences (comparatively broad), the expected impact of the record on the patient–doctor relationship (medium breadth), and technical requirements for such a personal health record (comparatively narrow). The variety of the research questions was important for our study because it proved to be of relevance for the interviewees’ appraisal of the usefulness of the focus group method.

Interviews With the Focus Group Moderators

We conducted qualitative interviews with nine of the 10 focus group moderators in the INFOPAT program (one moderator moved to a different department shortly after the completion of data collection and was not available for interview). The interviewees were aged between 30 and 54 years ( M age = 36 years; SD = 8.3 years). Their professions were health scientist, pharmacist, general practitioner, or medical ethicist. Their professional experience ranged from one to 23 years ( M = 7.1 years, SD = 7.7 years), and they had little or no previous experience of organizing and conducting focus groups. The moderators were interviewed in groups of one to three persons according to their project assignment (cf. Table 1 ).

Overview of Interviews and Interviewees.

The interviews lasted approximately 1 hour, and the interview questions were guided by the chronological order in which a focus group is organized and conducted (recruitment, preparation, moderation, methods) and by the utilization and usefulness of the results. We tape recorded the interviews, transcribed them verbatim, and performed qualitative content analysis on the transcripts ( Elo & Kyngäs, 2008 ; Mayring, 2015 ) with the help of the program MAXQDA 10.0.

The final system of categories 2 ( Tausch & Menold, 2015 ) consisted of two types of codes: All relevant text passages were coded with respect to the content of the statement. In addition, a second type of code was required if the statement related to a specific group of participants (e.g., patients, hospital doctors, men, women).

On the basis of the research questions, the contents of interview statements were classified into the three superordinate thematic categories: recruitment, communication in the focus groups, and appraisal of the focus group method. Consequently, the reporting of the results is structured according to three main topics.

Recruitment

Statements relating to the recruitment of the participants were sorted into the main categories “factors promoting participation”, “factors preventing participation”, and “general appraisal of the recruitment process”. Figure 1 shows the subcategories that were identified under these main categories. Because many of the statements referred only to patients or only to health care professionals (physicians, other health care professionals), the subcodes shown in Figure 1 are sorted by these two types of participants.

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Factors relating to the recruitment process.

Factors relevant for all target groups

As the following interviewee statement shows, addressing potential participants face-to-face (rather than in writing) proved crucial for the success of recruitment in all target groups:

Well, a really good tip when recruiting patients is . . . to address the people yourself. Not to get someone else to do it who . . . has nothing to do with [the project], because ultimately you really do have to explain a lot of things, also directly to the patient. And then it’s always good if the person [who does the recruiting] is actually involved in the project. 3

In the case of the clinicians, being addressed by a superior was even more effective for their willingness to participate: “And then top down. If the nursing director asks me, then it’s not so easy to say no.”

Furthermore, a positive response was more often achieved if the groups were scheduled at convenient times for the addressees, and they only had to choose between several alternatives. Patients welcomed times contiguous with their therapies: “And many [of the patients] said: ‘Yes, maybe we can do it after my chemotherapy, on that day when I’m in the clinic anyway?’” Whereas medical assistants were given the opportunity to take part in the groups during working hours, general practitioners preferred evening appointments on less busy weekdays (e.g., Wednesdays and Fridays):

Well, what I found quite good was to suggest a day and a time. And we concentrated on the fact that practices are often closed on Wednesday afternoons. So that’s a relatively convenient day. And then evenings for the pharmacists from seven-thirty onwards.

Interest in the topic of the discussion, or at least in research in general, was an important variable for participation. Together with lack of time, it turned out to be the main reason why sampling plans could not be realized. Among patients, men were much more interested in discussing a technical innovation such as an electronic personal health record, while women—besides their lesser interest—often declined because of family responsibilities: “Well, I’d say a higher proportion of women said: ‘I have a lot to do at home, housework and with the children, therefore I can’t do it.’”

Family physicians, physicians from cooperating medical practices, and hospital doctors showed more interest in discussing an electronic personal health record than did medical specialists in private practice, who often saw no personal gain in such an innovation. For example, one interviewee stated,

Family physicians generally have a greater willingness [to engage with] this [health] record topic. They see . . . also a personal benefit for themselves. . . . or they simply think it might be of relevance to them or they are interested in the topic for other reasons. Some of them even approached us themselves and said, “Oh, that interests me and I’d like to take part.”

In addition, because of heavy workload, private practitioners were difficult to reach (e.g., by telephone). This also lowered the participation of this target group on the focus groups.

Factors relevant only for patients

Two other variables that influenced patients’ willingness to participate were mentioned in the interviews. First, because this target group consisted of cancer patients and diabetes patients with multimorbidity, poor physical fitness also prevented several addressees from participating in the groups. The inability to climb stairs, or the general inability to leave the house, made it impossible for them to reach the location where the groups took place: “[They] immediately replied: ‘Well, no, . . . that’s really too much for me,’ and unfortunately they could not, therefore, be included in the groups.” Furthermore, unstable physical fitness often led to high drop-out rates. The moderators of the focus groups therefore proposed that up to twice as many participants as required should be recruited: “And depending on the severity of the illness, you have to expect a drop-out rate of up to fifty percent. So, if you want to have four people, you should invite eight.”

Second, moderators reported that patients’ liking for, or dislike of, talking and discussing influenced their tendency to join the groups. Participating patients were generally described as talkative. For example: “And with patients, all in all, I had the feeling that those who agreed [to participate] were all people who liked talking, because those who did not like talking refused out of hand.” Patients who refused to participate often argued that they felt uncomfortable speaking in front of a group: “And the men, when they declined they often said: ‘No, group discussion is not for me! I don’t like talking in front of a group.’”

The researchers eventually succeeded in recruiting sufficient participants. However, they were not able to realize the sampling plans according to a certain proportion of male and female patients or types of physicians. “Well, we finally managed to fill up our groups, but only as many [participants] as necessary.” Comparing the different target groups, recruiting patients was described as easier than recruiting physicians: “And that was much easier insofar as you just had to go to the clinic and each day there were five or six patients whom you could address.” However, only 10% of the patients who were addressed agreed to participate. In the health care professional group, the recruitment rates ranged between 0% and 30%, depending on the subgroup. This can be demonstrated by the following interviewee utterance:

And in the private practitioner sector it was rather . . . . Well, we tried to recruit specialists in private practice, in other words internists, gastroenterologists, and oncologists. The success [rate proved to be] extremely poor. . . . Well, on the whole, the willingness to take part, the interest, is not there. Or, well they don’t give the reasons, but they say they don’t want to take part. So that was difficult and, yes, it didn’t go too well.

Communication in the Focus Groups

With regard to the communication in the focus groups, the moderators identified factors that influenced communication in a positive or negative way. In addition, we discussed a number of factors with them that are often described in the social science literature as problematic when conducting focus groups. However, the interviewees considered that some of these factors had not influenced communication in the focus groups conducted within the framework of the INFOPAT program. In our system of categories, we also coded whether the factors in question were related to (a) the setting or (b) the moderation of the focus groups (cf. Figure 2 ).

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Influences on and characteristics of the focus group discussion.

Factors relating to the setting

As Figure 2 shows, communication was reported to be positively influenced by small group size, location, provision of food and beverages, and conducting the focus group without a break. In contrast to general recommendations on focus groups in the context of sociological research, the moderators in the INFOPAT program considered a smaller group size of between four and six participants to be ideal. With regard to location, the interviewees reported that, depending on the target group, different places were perceived as positive. Patients preferred locations inside the clinic because they were easy to reach and caused no additional effort. Furthermore, because these locations were familiar to them, they facilitated an atmosphere of security and ease, which was seen as an important prerequisite for an open and honest discussion. This is clear from the following quotation:

Well, the patient focus groups were all located at the clinic. We chose this location on purpose to make it easier for them, because they come to the clinic anyway for their therapy. And they know the place and they feel comfortable and in good hands.

By contrast, the clinician groups benefited from being located outside the clinic. In contrast to other common addressees of focus groups, these professionals were not only accustomed to participating in groups outside their familiar surroundings but also this location helped them to distance themselves from their professional duties and to engage more deeply in the discussion, as shown by the following quotation:

Yes, one was located at the O-Center. We chose this location on purpose so that the clinicians had to leave the hospital. It’s not too far, only a few yards away. But we wanted them to leave the clinic, and not to run back to the ward when they were called. And, well, I liked this location.

Food and beverages were welcome in all the groups and also helped to create a positive and trusting atmosphere. And finally, the interviewees found that it was better to omit the break, thereby avoiding the interruption of the ongoing discussion. This is reasonable considering the comparatively short duration of the focus group session (between 1.5 and 2 hours). Statements relating to a break might have been different in the case of longer focus group durations.

The interviewees reported that the size and temperature of the room and time pressure on the participants or the moderator had a negative impact on communication. Some of the focus groups in the project took place in midsummer and had to be held in rooms without blinds or air conditioning. The moderators of these groups had to work hard to maintain the participants’ (and their own) attention and concentration. Time pressure on the participants (e.g., the clinicians) led to an unwillingness to engage in active discussion and created a question-and-answer situation, as shown by the following statement:

And in one group of physicians . . . we never reached the point where they joined in fully. During the whole discussion they never completely arrived. And they had already cut the time short in advance. They were under so much time pressure that they were not able to discuss in an open manner.

Moderators reported that they, too, had experienced time pressure—namely, in situations where they did not have enough time to prepare the room and the recording devices. This had caused them to be nervous and stressed at the beginning of the discussion, which had negatively affected the mood of the participants, thereby rendering an honest and open discussion particularly difficult.

Factors relating to the moderation

Many of the positive factors reported by the interviewees have already been described for focus groups in general—for example, using open questions, directly addressing quiet participants, and handling the discussion guide in a flexible way. Furthermore, by showing interest in every statement, and by generating a feeling of security in every participant, moderators fostered a fruitful discussion:

I believe that another important point is that you are calm yourself. That you give the people the feeling “you can feel safe with me, you don’t have to worry that I will make fun of you . . . or that I won’t take you seriously.”

Interviewees also considered that building a bridge between the technical innovation under discussion (a web-based electronic personal health record) and everyday life (e.g., online banking) was an important factor in getting all participants to contribute to the discussion. As one interviewee noted,

We tried to anchor it in their everyday lives. And . . . the example that always worked was when we said: “Think of it as if it were a kind of online banking.” Everyone understands what online banking is. It’s about important data on the internet; they’re safe there somehow. I have my password. And people understood that. Well, it’s important to anchor it in their reality . . . because otherwise the topic is simply far too abstract.

In this context, the fact that the groups were moderated by the researchers themselves proved very helpful because they were able to answer all questions relating to the research topic. As the following quote shows, this was an important prerequisite for opinion formation on the part of participants:

Well, I think that a really important quality criterion . . . is that you have completely penetrated [the topic]. If you only know the process from the outside . . . and you then conduct the focus group about it. . . . Somewhere, at some stage, [one discussion] narrowly missed the point. . . . You simply have to be totally immersed in the topic, well, I believe that [someone who is totally immersed in the topic] is the ideal person for the job. And in our case the thinking was, okay, so I’m a doctor, but on balance it’s more important that both [moderators] are absolutely well informed because it’s a complex topic.

The more specific the research question was, the more useful the moderating strategy of inviting one participant after the other to express their opinion appeared to be. By using this strategy, the moderators ensured that every participant contributed to the discussion.

A point that was strongly emphasized by the interviewees was the duration of the round of introductions at the beginning of the focus group session. In the patient groups, introductions took much more time than the researchers had expected. Patients had a high need to express themselves and to tell the others about their illness and their experiences with the health system. Although this left less time to work through the topics in the discussion guide, the researchers came to realize that there were several good reasons not to limit these contributions: First, the introductions round proved important for helping the participants to “arrive” at the focus group, for creating a basis of trust, and for building up a sense of community among the participants. Second, the interviewees reported that, because many topics in the discussion guide (e.g., participants’ experiences with coordinating visits to different medical specialists) had already been brought up in the round of introductions, they did not have to be discussed further at a later stage:

And that is the crux of this general exchange of experiences at the beginning. Sure, it costs you a lot of time, but I almost think that if you don’t give them that time, you won’t get what you want from them, in the sense that you say: “I want to hear your frank opinion or attitude.” You don’t want them to simply answer you because they think that’s what you want to hear. You have to create an atmosphere in which they really forget where they are. I’m relatively convinced that you wouldn’t achieve that without such [a round of introductions].

The moderators’ experience in the physician groups was different. These groups benefited from having a rather short round of introductions. Giving participants too much time to introduce themselves meant that they presented their expertise rather than reporting their experiences. In contrast to the patient groups, this did not substantially contribute to the discussion of the research topics.

Depending on the context, status differences between the moderators and the participants, or among the participants, were appraised differently by interviewees. In one group comprising physicians and medical assistants, the moderators observed that status differences had a negative influence on communication. Very young female medical assistants, in particular, did not feel free to express their opinions in the presence of their superiors. By contrast, presumed differences in status between family doctors, hospital doctors, and medical specialists in private practice did not have any negative impact on communication. Nor did different forms of address (some participants in these groups were addressed by their first name and some by their last name, depending on the relationship between the moderator and the participants). Status differences between moderators (if medical doctors) and participants (patients) had an impact on communication when patients regarded doctors as an important source of information (e.g., about the meaning of their blood values) or as representatives of the health care system to whom complaints about the system should be addressed. The latter case was the subject of the following interview statement by a moderator who is a physician by profession:

And a lot [was said about] the kind of experiences they had had here at the NCT. And of course, when the patients have been treated here for many years—or even for not so many [years], but they have had many experiences—they sometimes reported at length. And I had the feeling that this had a bit of a feedback function, quite generally, for the NCT. Also the somehow frustrating experiences they had had, or a lot of things that had not gone that well in conversational exchanges [with the staff]. There was a relatively large amount of feedback that didn’t have a lot to do with the topic because I was, of course, involved as a senior physician and I am not an external researcher, but rather someone who is also seen as being jointly responsible, or at least as someone who can channel criticism.

Finally, because most of the moderators were not medical professionals, they did not experience the translation of medical or technical terms into everyday language as problematic. Rather, they automatically used terms that were also familiar to the participants.

Characteristics of the discussion

The factors described above resulted in focus group discussions that might be interpreted as characteristic of health research. The patient focus groups were characterized by a strong need to talk and a high need for information. In the health care professional focus groups, researchers experienced a greater variety of communication styles. Because of a lack of time, or because they falsely expected a question-and-answer situation, some groups demonstrated a low degree of willingness to engage in discussion:

Although, I believe that was partly due . . . well there was one [woman] who was very demanding; she wanted to know straight away: “Yes, what’s the issue here? What do I have to say to you?” Well, the three who came from the one practice, I think they really had the feeling that we would ask them questions and they would bravely answer them and then they could go home again. So, for them this principle that they were supposed to engage in a discussion, for them that was somehow a bit, I don’t know . . . disconcerting. . . . They really thought: “Okay, well we want to know now what this is all about. And they’ll ask us the questions and then we’ll say yes, no, don’t know, maybe. And then we’ll go home again.” Well, at least that was my impression.

Other groups, especially those consisting of different types of health care professionals (e.g., physicians with different areas of specialization, or physicians and pharmacists), were characterized by lively discussion and a great variety of opinions.

Appraisal of the Focus Group Method

We classified moderators’ statements relating to the appraisal of the focus group method into four main categories: “advantages of the method”, “disadvantages of the method”, “recommendations for other researchers in related research areas”, and “statements on how they used the results” (cf. Figure 3 ).

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Appraisal of the focus group method.

The researchers reported that the focus group method yielded a rich blend of perspectives and opinions, brought forth, in particular, by the interaction between the participants:

But for this question and the topic, and for our lack of knowledge, that was . . . a lot of new information . . . and very many good ideas and critical remarks that you naturally read in the literature from time to time. But, let’s say, because of the complexity of the participants’ reactions and the weight they attached to things, it’s different than reading in a literature review that [this or that] could be taken into account.

The results of the focus groups further enriched the researchers’ work by relating it to everyday life: “Well, what was nice was that the topic was related to the participants’ lives. That people said: ‘Now the topic is important for me.’” Furthermore, the method yielded information about which aspects were most important and how the variety of opinions should be prioritized. This was achieved, in particular, by using participant-generated cards:

And with regard to prioritization, we incorporated it using participant-generated cards. We said: “Look: If you could develop this record now, what would be the three most important things that must absolutely be taken into consideration, from your point of view, no matter what they relate to.” And they wrote them down on the cards. And after that they were asked to carry out their own prioritization—that is, what was most important to them personally. One person wrote “data protection” first, while another [wrote] “sharing with my wife.” . . . That was good. . . . That helped a lot because it was simply clear once again what things were important to them.

In cases where concrete questions had to be answered or decisions had to be made, the interviewees also welcomed the opportunity to use structuring methods such as presentations, flip-charts, and participant-generated cards to obtain the relevant information:

. . . Well, the aim was that at the end we [would] have a set of requirements for the engineering [people]. And the engineering [people] don’t so much want to know about experiences and desires and barriers, but rather they want to know should the button be green or red and can you click on it. And that’s why I thought at the beginning it will be difficult with a focus group and an open discussion. Now, if you say that one can also interpret a focus group the way we did, partly with very specific questions and these participant-generated cards, then I think it is indeed possible to answer such questions as well.

Disadvantages

The main disadvantages of the focus group method were seen in the considerable organizational effort and expenditure of time involved. A question raised by some of the interviewees was whether comparable results could have been achieved using less time-consuming and organizationally demanding methods.

It’s true to say that you lose time. Well, you could implement [the innovation] straight away and see whether it’s better. Maybe, in this case you’re wrong and you just think it’s better or in any case not worse than before. You basically lose a year on this whole focus groups thing.

Moreover, in some cases, the discussion went in an unwanted direction and the moderators never fully succeeded in bringing the group back to the intended topics.

Furthermore, like many other medical research projects, INFOPAT included quite specific research questions. In this connection, the moderators emphasized that open focus group discussions would not have succeeded in answering those questions. Only by using methods such as participant-generated cards and prioritization was it possible to answer at least some of them. Nonetheless, some interviewees did not consider the focus group method to be really suitable for this type of research questions:

Of course we also have our engineers as counterparts who . . . need very specific requirements at some point. The question is whether such a focus group . . . . [It] can’t answer that in detail in this first stage. It’s simply not practicable.

Recommendations

As described under the “Communication in the Focus Groups” section above, the round of introductions in the patient groups lasted much longer than planned, thereby shortening the time available for other topics in the discussion guide. As a result, the moderators decided to choose a different thematic focus in each group so that every topic was discussed more deeply in at least one group.

What we usually did was to consider what hadn’t been addressed that much in the previous focus group. That [topic] was given more room in the next focus group because the guide, well it was quite a lot. You could have easily gone on discussing for another hour or two.

Using the results

On the whole, the researchers were satisfied with the number of groups that were conducted and the results that they yielded. They did not agree that more groups would have led to better, or different, results—with one possible exception, namely, in the case of specific target groups (e.g., migrants). Only one group had been composed of patients with a migrant background, and, as one interviewee stated, “I just thought, the patients with a migrant background . . . now that was [only] one group, it by no means covers the whole range.”

In cases where the results of the focus groups were perceived as not being concrete enough to proceed to the next research step (e.g., formulating a specification sheet for the construction of the electronic personal health record), the researchers planned to bring experts together in a roundtable format to make decisions on the basis of the priorities, agreements, and disagreements that had emerged from the focus groups. Following the construction of a prototype, they intended to conduct further focus groups to validate or adapt the usability of the electronic personal health record system.

Our analysis of interviews with focus group moderators yielded considerable insights into methodological aspects of conducting focus groups in health research. Our first research question related to characteristics of the target groups that should be considered during the recruitment process. We identified face-to-face contact as an important factor promoting focus group participation. The interviewees considered this type of contact to be better suited to answering target persons’ questions and explaining the method and aims of the focus groups. Moreover, they felt that addressees might find it more difficult to decline a face-to-face invitation than a written one. With regard to health care professionals, an invitation issued by a hierarchically higher person was most effective, even though ethical aspects should be considered in this case, and voluntary participation should nevertheless be ensured. Otherwise, the order to participate might prevent an atmosphere of open communication and might lead to a lower quantity or to more negative statements.

Furthermore, whereas physicians are usually accustomed to discussing topics with others, an important characteristic that influenced willingness to participate on the part of members of other target groups (other health care professionals, patients) was a liking for, or a dislike of, talking. Researchers might take account of this fact by explaining the method in more detail, by developing arguments to overcome fears, or, as suggested, for example, by Colucci (2007) , by convincing the addressees with other activities implemented in the focus groups. Other relevant personal characteristics—be they related to the research topic (e.g., technical interest in the case of an electronic innovation) or to the specific target group (e.g., physical fitness on the part of patients or lack of time on the part of health care professionals)—should be anticipated when planning recruitment. These characteristics might be taken into account by preparing arguments, providing incentives, giving thought to favorable dates and times, and choosing easily accessible locations. An interesting finding was that, depending on the target group, different locations were considered to have a positive influence on the discussion. Whereas locations inside the clinic were preferred in the case of the patient focus groups because of familiarity and easy accessibility, hospital doctors were more engaged in the discussion when the focus group site was located at least some yards away from their workplace.

Finally, the experience of our researchers that up to 50% of the patients had to cancel at short notice because of health problems does not appear to be uncommon in this research context. That overrecruitment is an effective strategy—particularly in health care research—has been reported by other authors (e.g., Coenen et al., 2012 ).

With our second research question, we focused on aspects of communication in the focus groups. The interviews revealed several factors specific to research topics and addressees of health care studies that influenced the discussions. Consequently, in addition to considering general recommendations regarding the organization and moderation of focus groups (e.g., choosing adequate rooms with a pleasant atmosphere, serving food and beverages, using open questions, showing interest in all contributions, and directly addressing quiet participants), these health care specific aspects should be taken into account. Relevant factors that should be addressed when moderating focus groups in this context are (a) the strong need to talk and the high need for information in the patient groups, (b) status differences between the participants or between the moderators and the participants, (c) the size of the focus group, and (d) the specificity of the topic of discussion. The interview data revealed that these factors influenced the discussions and thus the results achieved with the groups. In addition, the following four possibilities of addressing these factors were identified:

First, the moderators had to devote more time to the round of introductions in the patient groups, which served as a warm-up, created an atmosphere of fellowship and openness, and accommodated this target group’s strong need to talk. Second, with respect to status differences between the moderator and the participants, no definite recommendations can be derived from the interviews. The interviewees found that it was less favorable when the moderator was perceived not only in that role but also in other roles (e.g., physician), because this might hamper a goal-oriented discussion. However, they considered deep insight into the research topic on the part of the moderators to be beneficial, at least for certain research topics. Thus, one should carefully weigh up whether it is more advantageous or more disadvantageous when the group moderator is a physician. Interviewees considered status differences between participants to be disadvantageous only in one case, where—because of organizational constraints—medical assistants and their superiors joined the same focus group, which gave rise to some reticence on the part of the young assistants. Similar problems have been reported by other authors, for example, Côté-Arsenault and Morrison-Beedy (2005 ; see also Hollander, 2004 ). However, interviewees did not experience as problematic status differences between physicians with different areas of specialization.

Third, with respect to group size, interviewees found comparatively small focus groups appropriate to give all participants enough time to tell their stories. In contrast to social science research, where groups of between eight and 20 participants are recommended, our interviewees considered groups of between four and six persons to be optimal. This is in line with Côté-Arsenault and Morrison-Beedy (2005) , who recommended small groups for health research, especially when sensitive topics are discussed. Our interview data revealed that this recommendation might also be useful for other health research topics.

Fourth, with regard to the topic of the discussion, interviewees found it helpful to structure different phases of the discussion in different ways, depending on the specificity of the research questions. In contrast to social science research, certain types of research questions in health research require comparatively specific answers. Some of the focus groups in our study were aimed at collecting participants’ expectations regarding an electronic personal health record or—even more specifically—at developing a product specifications document. Conducting focus groups during the development of a technical innovation is a method that is being increasingly used in health care research. Hence, the experiences of the interviewees with regard to these aspects of their research might be relevant for many other research programs. For this type of research questions, it proved useful to include more structured parts in the discussion, for example, having certain questions answered by each participant in turn, or using methods such as participant-generated cards and prioritization. This made it easier to obtain the opinion of each participant and to cover as many concerns and expectations as possible. This finding is in line with recommendations by Colucci (2007) , who proposed the use of activity-oriented questions for health research topics as an enrichment of data collection and a means of making it easier to talk about sensitive and complex topics.

All the moderators found that their discussion guides contained too many questions and too many topics. This might have been due, at least partly, to a desire to determine all relevant aspects in advance—a tendency that might be typical of health research. However, Morgan (1995) also addressed this phenomenon in relation to social research in general: “A common error in focus group question guidelines is too much emphasis on what is of interest to the researcher and not enough emphasis on what is of interest to the participants” (p. 520).

With our third research question, we addressed the appraisal of the focus group method in the interviewees’ research context. Our results show that one should think carefully before using focus groups in the field of health research. The impression that they are quick and easy to conduct might be a misconception, especially in this research context. In fact, the appraisal of the method by the moderators revealed both advantages and disadvantages. The main advantages were the rich blend of perspectives and opinions obtained and the opportunity to have them prioritized by the target groups. For their research topics, the interviewees saw a further important advantage in the fact that they were able to relate their scientific research to everyday life, a point that might be of general importance for a number of research questions in health research, especially those that refer to new medical diagnostics or technical innovations.

The interviewees considered that the main disadvantages of focus groups were the substantial organizational effort and expenditure of time they required. They raised the question whether comparable results could have been achieved using less costly methods. Fortunately, we conducted our interviews with researchers from a research program aimed at answering research questions of different degrees of specificity. As a result, the moderators were able to compare the usefulness of focus groups for different types of research questions. Their statements revealed that they were satisfied with the results relating to more open research questions such as experiences with cross-sectoral health care. For more specific research questions, the interviewees valued the possibility of organizing the discussions in a more structured way and using methods that activated all participants (e.g., participant-generated cards, prioritizations). Nonetheless, they considered meetings of experts to be a necessary intermediate step, for example, on the way to a product specifications document. We recommend that, depending on the specificity of the results that are projected, consideration should be given to including such intermediate steps in the planning stage.

Limitations of the Study

Our analysis of the interviews with the focus group moderators revealed a number of methodological problems that typically occur when focus groups are used in a health research context and yielded recommendations on using such groups in this context. However, some limitations of the present study should also be discussed: First, we conducted our research with focus group moderators, all of whom worked in the same research program. Even though the INFOPAT program consists of several subprojects, they all deal to a greater or lesser extent with the advantages and disadvantages of an electronic support system (electronic personal health record). Furthermore, the moderators were mainly health scientists and had little or no experience with conducting focus groups. This might also have been specific for the research program in which our study was conducted. In other health care programs, focus groups might be moderated mainly by physicists or lay persons (e.g., in participatory health research). Consequently, had we also conducted interviews with focus group moderators from other research areas or included moderators with other professions or more focus group experience, this might have led to different results. However, our research project is rather typical for applied qualitative research in medical science when developing new technologies. Here, focus groups are used by the researchers to find out the potential requirements for the new technology. The researchers are often experts in a specific scientific topic and have no or only limited experience in conducting qualitative research in terms of focus groups. Therefore, our findings are of a particular importance for the researchers with little experiences in conducting focus groups, which can apply to every research, conducted first time. In addition, the little experience of our focus group moderators was a special advantage and strength of the study. More experienced moderators would have prevented some of the problems our moderators—as other unexperienced moderators—faced. As a result, the moderators would not have named these potential problems in the interviews and given no advice for preventing them.

Second, the study was conducted in Germany and thus represents problems and challenges of the German health care system. In other countries, physicians might have different work-shifts or there might be different possibilities in the health care system to reach the target groups. Therefore, more research on the methodology of focus groups in the context of the development of new technologies in health care in other countries and cultures with a consideration of additional relevant groups is needed.

Third, in our interviews, we focused mainly on the organization and conducting of focus groups. For two reasons, we did not address the aspect of data analysis: First, we conducted the interviews shortly after the focus groups had been completed, at a time when data analysis was still in progress. Second, analysis of qualitative data can be carried out in many different ways, depending on research questions and preferences of researchers, and some of the recommended methods are very complex. Had we discussed them in detail, it would have been too time-consuming in the interviews.

Concluding Remarks

Our results revealed a number of methodological challenges that might be typical of conducting focus groups in health research. We hope that our findings will be of use to researchers in similar research fields. Furthermore, we encourage other researchers who are interested in health research topics to gather more information about methodological aspects specific to this research field. Our results were achieved in the context of the development of a technical innovation. It might be interesting to endeavor to replicate them in other health care research projects dealing with technical innovations. Moreover, we would encourage researchers of other topics in health research to interview focus group moderators about their experiences in their specific research context. We hope that our results will serve as a useful basis for comparing results in different areas of health research.

Acknowledgments

We thank the focus group moderators in the INFOPAT program for their great willingness to share their experiences and for their openness during the interviews.

Author Biographies

Anja P. Tausch , PhD, is senior researcher at GESIS–Leibniz Institute for the Social Sciences, Mannheim, Germany.

Natalja Menold , PhD, is senior researcher and head of the Survey Instruments Unit at GESIS–Leibniz Institute for the Social Sciences, Mannheim, Germany.

1. http://www.soziologie.de/en/gsa/ethik-kommission/code-of-ethics.html , retrieved on 05/10/2015.

2. The language of the research project, focus groups, and interviews was German. The scheme was developed in German on the basis of the German text material from the transcribed interviews. The scheme and the citations were translated for the purpose of international publication by an experienced, qualified, and fully bilingual translator, whose mother tongue is English and who also has an MA in sociology from a German university. A German version of the full categorial system can be found in Tausch and Menold (2015) .

3. All citations included in this publication were translated from German.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the German Federal Ministry of Education and Research (BMBF; FKZ 01KQ1003D).

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  • Open access
  • Published: 20 February 2024

Educating the nurses of tomorrow: exploring first-year nursing students’ reflections on a one-week senior peer-mentor supervised inspiration practice in nursing homes

  • Daniela Lillekroken   ORCID: orcid.org/0000-0002-7463-8977 1 ,
  • Heidi M. Kvalvaag 1 ,
  • Katrin Lindeflaten 1 ,
  • Tone Nygaard Flølo 1 ,
  • Kristine Krogstad 1 &
  • Elisabeth Hessevaagbakke 1  

BMC Nursing volume  23 , Article number:  132 ( 2024 ) Cite this article

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Worldwide, the healthcare system stresses a severe deficit of nurses because of elevated levels of work-induced stress, burnout and turnover rates, as well as the ageing of the nursing workforce. The diminishing number of nursing students opting for a career in nursing older people has exacerbated this shortage. A determining factor in the choice of a career within the field of residential care for nursing students is educational institutions offering students learning opportunities with positive learning experiences. Therefore, educational institutions must develop programmes that employ student active learning methods during clinical periods. Although much focus has been given to the development of new educational programs, insufficient consideration has been given to the value of peer mentoring and students’ interactions during the clinical placement at nursing homes. The aim of the present study is to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing home.

The study employed a qualitative exploratory and descriptive research design. Data collection took place in October 2022 using focus group interviews. A total of 53 students in their first year of the bachelor’s programme at the Oslo Metropolitan University participated in eight focus group interviews. The data were analysed following the principles of inductive content analysis.

The analysis resulted in one main category, ‘Being inspired—keep learning and moving forward’, representing first-year nursing students’ common perceptions of being mentored by third-year students. The main category is supported by two categories: ‘Closeness to the mentor’ and ‘Confidence in mentors’ professional knowledge and teaching and supervision methods’, which are interpreted as the drivers that enabled first-year students to learn more about nurses’ roles and responsibilities in the nursing home.

Mentorship enhances the learning transfer from third-year nursing students over to first-year nursing students by providing them with real-world exposure and guidance from their more experienced peers. This hands-on approach allows them to bridge the gap between theory and practice more effectively, boosting first-year nursing students’ confidence and competence in nursing and caring for older people living in nursing homes.

Peer Review reports

Nursing is one of the main professions that provides care to older people [ 1 ]. To meet society’s challenges of providing quality healthcare to older people, knowledgeable and skilled future generations of nurses are needed [ 2 ]. International research reveals that one of the key challenges for nursing in residential care is recruiting and retaining knowledgeable and skilled nurses [ 3 ]. Although nursing students have positive [ 4 ], or moderately positive attitudes towards nursing older people [ 5 ], they generally do not see caring for older people as an interesting area of their future careers [ 6 ]. Students may lack the motivation to study and work in this field; therefore, it is necessary to increase the attractiveness of working within the gerontological nursing field [ 7 ].

Generation Z nurses, born 1995 or later (aged ≤ 24 years of age), have introduced new expectations and ideals of life and work into the nursing profession [ 8 ]. People belonging to generation Z exhibit traits such as tolerance, respect, social-change oriented, collaboration and confidence but with caution while embracing diversity and growing up with friends from various ethnic backgrounds [ 9 , 10 ]. To meet their expectations and retain them into the nursing profession, it is vital to design educational programmes and work conditions accordingly. Moreover, to ensure that graduating nurses possess the necessary levels of gerontological nursing competence, nursing education programmes must prepare future nurses accordingly. This implies that faculties must emphasise the importance of having gerontological nursing knowledge and competences among nursing students right from the early years of training [ 11 ]. This may contribute to providing comprehensive education to nursing students and instil a positive attitude towards nursing older adult patients [ 7 ].

Nursing education in Norway, as well as in other European countries, complies with the European Union’s (EU) directives [ 12 , 13 ], and is completed in accordance with the Bologna Process [ 14 ], requiring bachelor’s and master’s degrees as the norm. This means that it takes 180 ECTS (European Credit Transfer System) to obtain a bachelor’s degree and a further 120 ECTS to complete a master’s degree. In Norway, nursing education consists of at least 4,600 h, including theoretical knowledge and clinical practice, in which clinical practice represents half of the education period; therefore, clinical practice must cover a minimum of 2,300 h [ 12 ]. As required by the EU [ 12 , 13 ], theoretical and clinical studies alternate during these three years, and students intertwine theoretical and clinical knowledge during lectures, seminars, workshops and clinical periods conducted in different clinical contexts. After attending a three-year nursing education programme, the student achieves a bachelor’s degree in nursing as a registered nurse (RN) with competence at a general level. For students to obtain a nursing degree, they must demonstrate the knowledge and ability required in the national goals to become RNs at the end of their education, consisting of three main goals: knowledge, skills and general competence [ 15 ].

Since 2020, Oslo Metropolitan University [OsloMet], as well as other Norwegian universities, has implemented a new bachelor’s programme in nursing. The programme aims to qualify candidates for practicing professional nursing based on up-to-date evidence-based knowledge, professional suitability and respect for human autonomy and participation [ 16 ].

To educate knowledgeable and skilled nurses to meet Norwegian society’s healthcare challenges, knowledge and skills of how to provide better and safer fundamental care are part of the curriculum of the first year during the bachelor’s programme in nursing [ 15 ], and clinical placements in nursing homes where students learn to plan and provide fundamental care to older people are mandatory courses [ 12 , 17 ]. During the course ‘Theoretical Foundations of Nursing’ (SYK1000) that is taken in the students’ first term, the first-year students have a one-week clinical period (inspiration practice) in nursing homes. This one-week inspiration practice period is in addition to their six-week clinical placement during the second term. The focus of the inspiration practice is to observe and gain knowledge about the nurse’s role and responsibilities in nursing homes, including planning and participating in providing fundamental care to nursing home residents. During this period, the third-year nursing students attend the clinical period ‘Nursing Patients with Complex Health Challenges’ (SYKPRA60) in nursing homes. One of the learning outcomes of this course is related to students developing skills and knowledge about learning, mastering and changing processes, as well as supervising and teaching patients, next-of-kin, students and healthcare personnel. To pass the clinical period, as a mandatory learning activity, the third-year students will supervise, plan and carry out supervision for one or a group of two to three first-year students in cooperation with the nurse preceptor and nurse educator from the university [ 16 ], hence employing peer mentoring as a learning and teaching method during the clinical period at nursing home for both student groups.

Mentoring is an encouraging and supportive one-to-one relationship with a more experienced worker or peer student and is characterised by positive role modelling, promoting aspirations, positive reinforcement, open-ended counselling and joint problem-solving [ 18 ]. Peer mentoring is a relational process where a more experienced individual (mentor) contributes to the professional and personal development of a less experienced individual (mentee) [ 19 ]. This approach aligns with the educational philosophy of peer-assisted learning, which engages students in the teaching process [ 20 ]. However, it is worth noting that the term ‘peer mentoring’ lacks a consistent definition [ 21 ]; therefore, various interchangeable terms, such as ‘peer learning’, ‘peer coaching’ and ‘near-peer teaching’, are utilised in the literature [ 22 ]. In the present study, ‘peer mentors’ or ‘mentors’ refers to senior nursing students possessing more extensive experience than their junior counterparts, the ‘mentees’, and ‘peer mentoring’ refers to the process of learning transfer from mentors to their mentees.

The inspiration practice period has been implemented to provide first-year students with insights into the nurse’s role and responsibilities in nursing homes, hence, to prepare them for their first clinical placement period at nursing home and all subsequent clinical periods throughout their education. This preparation aims to prevent the occurrence of what is termed ‘reality shock’ [ 23 ], a phenomenon that may lead to negative consequences for their continuing nursing education and influence their choice of whether to pursue a career in nursing [ 24 ].

Despite the growing number of studies revealing the importance of the professional development of nursing students in clinical studies, little is known about the peer mentoring process used by students in learning from each other in higher education [ 25 ]. Results from previous studies reveal that peer mentoring increases mentees’ integration, academic success, class retention, self-esteem, psychosocial wellness, reduces anxiety in clinical setting, increases self-worth for both the mentee and the mentor [ 26 , 27 , 28 , 29 , 30 ]. Furthermore, positive outcomes for mentors have been observed, ranging from enhanced problem-solving abilities to heightened coping skills [ 31 , 32 ]. Recently, results from a longitudinal study indicate that a one-on-one mentorship program is beneficial for the retention of new graduate nurses, particularly during the first year [ 33 , 34 ].

Learning environment quality in clinical placement is vital for how nursing students achieve competence through reflection on their experiences [ 35 ]. Similarly, positive learning experiences in residential care are vital for their future choices regarding where to work and therefore crucial for employers striving to recruit newly qualified nurses. Facilitating optimal clinical mentoring is therefore of high priority in nursing education [ 36 ].

As shown above, although peer mentoring has been reviewed in many studies, several gaps on the effects the mentor program has in the context of nursing home as teaching and learning context remain. Specifically, no programs focus mentoring on a targeted discipline or degree of interest to cultivate specific gerontological professional development. Because of this, there is a lack of literature focusing on the first-year experience of a nursing student. Likewise, there is limited available research exploring the benefits of mentoring specifically for first-year nursing students during the clinical placement at nursing homes as a learning context. Therefore, the aim of the present study is to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing home.

Theoretical framework

To the best of the researchers’ knowledge, the application of peer mentoring as a learning and teaching strategy for first-year students within the context of nursing home learning is a novel approach. Therefore, the application of innovative and active learning strategies in clinical settings necessitates educational research. For the present study, the theory of learning transfer described by Wahlgren and Aarkrog [ 37 ] was chosen as the theoretical framework. The theory of transfer of learning is defined as the application or adaptation of previously learned knowledge, skills or understanding to new situations or contexts. Moreover, it involves the ability to make connections and use what a student has learned in one context to solve problems or understand concepts in different contexts. However, little is known about the processes used by students to transfer learning from each other and to apply or adapt knowledge to practice.

The theory of transfer of learning is influenced by three factors that may be seen as facilitators or barriers that promote or hinder students’ learning in clinical settings: (i) person-related transfer factors, which include motivation, the ability to set goals, having confidence and knowing how to apply the new knowledge and reflecting on how to apply the new knowledge [ 38 ]; (ii) teaching-related transfer factors, which refer to how the ‘teacher’ organises the learning situation, by, for example, giving theoretical and examples and demonstrating how to apply theoretical knowledge into real-life situations [ 38 ]; and (iii) factors related to the situation where the knowledge is applied [ 37 ], such as the context of where the knowledge is applied, that is, willingness to include the workers’ new knowledge and skills in the workplace, leadership characterised by openness to positive changes and willingness of using the necessary resources. During the analysis, the content of the processes described by students when learning from each other revealed similarities with the theory of transfer of learning [ 37 ]; therefore, the researchers decided to choose this theory as a framework for discussing the study’s findings.

Aim of the study

This study aims to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing homes.

Study design

The present study has a qualitative exploratory descriptive design [ 39 ]. The design was appropriate because it allowed the researchers to contextualise how the first-year students perceived peer mentoring and nursing home as learning environment and their role as mentees within the context of nursing home, thus providing a picture of what naturally occurred between the mentors and mentees.

Study setting

The study was conducted at Oslo Metropolitan University during the one-week inspiration practice at nursing homes for first-year nursing students.

Study population and sampling

All the students enrolled in the first year of the bachelor’s programme in nursing at the Department of Nursing and Health Promotion in the academic year 2022–2023 were informed about the study and invited to participate. All six researchers were engaged in providing information about the study and in the process of recruiting potential participants.

The students were provided with verbal and written information about the study during a face-to-face first meeting before and after inspiration practice week. For inclusion, the students should: (i) be enrolled in the academic year 2022–2023, (ii) voluntary to attend the study, (iii) agreed to be recorded during the interviews. If the students were interested and expressed their wish to participate, they were asked to contact the researchers by email and agree upon the date for the interview. When distributing the participants in focus groups, to make the participants feel confident and comfortable during the interviews, the researchers considered the students’ class affiliation and formed groups with students belonging to the same class, thus fostering a sense of familiarity and ease among the participants.

Of a total of 488 students enrolled in the academic year 2022–2023, only 53 expressed their interest and agreed to participate. The ages of the participants ranged between 19 and 54 years. Although most had no work experience in the field of healthcare/nursing, some had up to 13 years of clinical experience working in nursing homes or home care. The researchers strived to provide a gender balance among the participants; therefore, an equal proportion of female and male participants was encouraged to participate. Even so, only seven participants were males. As the research literature has demonstrated, nursing is a female-dominated profession with individuals still choosing gender role stereotypes for their careers [ 40 , 41 ] This may explain the large number of females among the participants.

Data collection

Data were collected during the fall semester of 2022, one week after the students conducted their inspiration practice week. Eight focus group interviews were conducted to collect data during October– November 2022. Focus groups involve people with similar characteristics coming together in a relaxed and permissive environment to share their thoughts, experiences and insights [ 42 ]. The choice of using focus group interviews as data collection methods was because allows participants share their own views and experiences, but also listen to and reflect on the experiences of other group members [ 42 ]. This synergistic process of group members interacting with each other promotes and refines participants’ viewpoints to a deeper and more considered level and produces data and insights that would not be accessible without the interaction found in a group [ 42 , 43 ]. Prior to conducting the interviews, a semistructured interview guide inspired by peer mentoring in nursing literature was developed and used to guide the interviews. The interview guide used in the present study was developed based on recommendations from previous studies for further research to achieve a comprehensive understanding of how peer mentoring can be effectively employed in the context of nursing home [ 22 , 23 , 26 ]. The themes and questions that were posed during the interviews are presented in Table  1 .

The number of participants in each focus group ranged between 3 and 12. Depending on the number of participants in each focus group and on their verbal dynamism during the interviews, each focus group interview lasted between 30 and 55 min. The focus group interviews were held in a quiet classroom after a seminar class. As recommended by Krueger and Casey [ 42 ], the researchers planned to conduct each focus group interview in pairs. However, because of the busy work schedules among researchers, only two focus group interviews were conducted by two researchers, one acting as a moderator and the other as a ‘secretary’. While the moderator’s role was to pose questions and follow up the answers, the secretary’s role was to take notes, observe the group dynamic and use the recording device. During the interviews, the participants were encouraged to talk openly, share their thoughts and experiences with one week of inspiration practice in a nursing home and offer suggestions for improvement for the course. Hence, the participants offered deep and rich answers that contributed to the detailed expression of opinions.

Data analysis

All eight focus group interviews were digitally recorded and transcribed verbatim by the researchers immediately after completion. Except for one researcher (KK) who transcribed four focus group interviews, all authors transcribed each one to two focus group interviews. However, depending on the length of the interviews and the richness of the dialogs, the transcription process lasted between 6 and 8 weeks. The data generated from eight focus group interviews consisted of 106 A4 pages taped with 1.5 line spacing and Times New Roman font size. The analysis process has additionally taken eight weeks.

When conducting a focus group interview, it is the group rather than the individual that is the focus of analysis because data generated from focus groups represents situated accounts that can provide in-depth insights into contextualised social interactions [ 43 ]. The transcripts from the interviews were analysed following the three steps of inductive content analysis outlined by Kyngäs [ 44 ]: preparation, organising and reporting the findings.

As part of the first step, data analysis began during data collection through careful group moderation. By following transcription, reflexive engagement with the data enabled researchers’ familiarity with it as a whole before the coding process. The empirical data generated from eight focus groups were analysed independently by two researchers (DL & HK) to identify the key categories coded onto transcripts. At this step, the coding process helped reduce the amount of data. These codes were subsequently subjected to a more detailed subcoding of meaningful content, such as one word or a shorter sentence. At this step, no theoretical understanding influenced the selection of the units of analysis. Unit selection was based on the themes from the interview guide and derived from the data. Both authors then met and discussed the similarities and differences between the coded data from each interview, sharing their overall understanding of the data. If discrepancies occurred, they were solved by discussing before making a final decision.

In the second step, the researchers discussed, analysed and decided which codes should be grouped together into subcategories and determining the hallmarks of the categories. Following a discussion about the open coding process, a coding tree was developed to facilitate comparisons within and between groups. To validate and maximise the trustworthiness of the initial findings, a descriptive overview of the final analysis was presented to the other researchers, that is, the coauthors of the present paper, to confirm that it was a realistic interpretation of their views. For example, the code ‘following the mentors everywhere’ has gradually been incorporated into the subcategory ‘Spending time with mentors.’ In this step, influenced by the learning transfer theory [ 37 ] this subcategory was further placed under a category labeled ‘Closeness to the Mentor.’ It was interpreted as a person-related factor that facilitates learning transfer, thereby inspiring first-year students to continue learning and moving forward.

The third step was to present the findings by describing the content of the subcategories and categories as supported by participant quotes. An example of the coding tree is shown in Table  2 .

Rigour of the study

Rigour was ensured by employing several strategies. First, to ensure trustworthiness and rigour, the criteria described by Lincoln and Guba [ 45 ], known as credibility, dependability, confirmability and transferability, were employed.

To ensure transferability and dependability, the researchers clearly described the study’s theoretical framework, the recruitment and the characteristics of the participants, the research context, data collection and analysis processes so that readers could assess whether findings were applicable to their specific contexts and, if desired, repeating the study.

The data analysis was iterative and continued until all members of the research team agreed on a relevant and trustworthy formulation of the categories. To enhance trustworthiness, the consistency and dependability of data analysis was optimised by researcher triangulation. Two members of the research team (DL & HK), who independently coded interview transcripts and managed the coding and developed categories and subcategories that were assessed, verified and amended by all the members of the research team. Discrepancies in the coding were resolved through discussions until a consensus for each interview transcript was reached.

Confirmability is ensured by researchers presenting quotes from the participants that support the findings. The researchers strived to accurately represent the information provided by the participants, hence indicating that the interpretations of the data were not invented or based on preconceived notions.

In qualitative research, reflexivity should be oriented towards personal, interpersonal, methodological and contextual issues in the research [ 46 ]. Personal reflexivity refers to researchers reflecting on and clarifying their expectations, assumptions, and conscious and unconscious reactions to contexts, participants, and data [ 46 ]. The research team was composed of six women, all of whom had teaching experience with and knowledge of the first-year curriculum. Five of the research team members had experience with designing and conducting qualitative studies and collecting and analysing qualitative data. Although the analysis was performed by two researchers, all the researchers brought important contextual knowledge and insights to the analysis discussion, thus strengthening the study’s dependability. However, the researchers’ professional backgrounds as nurse educators who had knowledge of the curriculum and the course’s expected learning outcomes could address certain topics or follow-up questions during the focus group interviews, thus influencing the answers. Therefore, to minimize bias, the researchers discussed their prior experiences with interviewing, reflected on how questions were asked, and simultaneously managed their assumptions around how participants thought about and experienced being in the one-week inspiration practice.

Interpersonal reflexivity refers to the existing relationships and power dynamics between researcher and participants [ 46 ]. The participants in this study were first-year students, and some of the researchers who conducted the interviews were their teachers. Consequently, during the interviews, the power balance between researchers and participants could result in participants feeling that they were being evaluated, potentially leading to a focus on more positive experiences. To avoid this, researchers reinforced to participants that their participation is voluntary and that their answers will not influence their study progression. Moreover, during the interviews, researchers encouraged quieter participants to answer and allowed for differences of opinion.

Methodological reflexivity refers to researchers critically consider the nuances and impacts of their methodological decisions [ 46 ]. To strengthen methodological reflexivity, researchers discussed whether the study’s aim aligns with the chosen design and whether the data collection method and interview guide will generate data to answer questions posed during the focus group interviews. Another method to enhance methodological reflexivity was discussing the theoretical framework’s relevance to the study. After considerable discussions, the researchers decided to choose the theory of learning transfer [ 37 ] as it was considered the best theory to inform the data.

Contextual reflexivity entails researchers understanding the unique setting of the study [ 46 ]. To strengthen the study’s contextual reflexivity, researchers discussed which aspects of the context could influence the research and people involved, as well as how the research impacts the context. The study was conducted at a Norwegian university, and participants were enrolled in the first year of the nursing bachelor’s program. Although the interview guide was inspired by previous literature on peer-mentoring, the questions posed were developed to gain knowledge about students’ experiences with a one-week inspiration practice at a nursing home. This means that the research was influenced by the curriculum and mandatory courses conducted at this university. During discussions, some researchers mentioned that most focus group participants reflected on their clinical development and were looking forward to their turn being a mentor for first-year students. It was evident that this study also had a positive impact on participants.

Ethical approval

The present study was granted approval to be conducted from the researchers’ institution, Department of Nursing and Health Promotion at Oslo Metropolitan University and from the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. number 334855). The study was conducted in accordance with the Helsinki Declaration [ 47 ]. Informed consent, consequences and confidentiality were all obtained and maintained. All participants received verbal and written information about the study and written informed consent was obtained from all the participants prior to data collection. The participants were also informed that they would not receive any financial or other benefits for participating in the study. All participants were assured that, should they choose to withdraw from the study at any time and for any reason, there would be no negative consequences for their education at the university. Nevertheless, the researchers were mindful of the students’ potential vulnerability due to their role as students, which might discourage them from withdrawing. However, despite no reported discomfort during interviews, the potential for discomfort or reluctance to express negative experiences exists. Therefore, before each focus group interview, the students were reminded of their option to withdraw from the interview, providing them with additional opportunities to assent to or withdraw from the study. None of the students who agreed to be interviewed reported any discomfort during the interviews, and none chose to withdraw.

Following data analysis, one main category was generated, ‘Being inspired—keep learning and moving forward’, which was interpreted as the first-year nursing students’ common perception of being supervised by third-year students for one week of inspiration practice at nursing homes. During the interviews, the first-year students mentioned several times that they perceived third-year students as their mentors. To differentiate between first-year students and those in their third year, the third-year students will be referred to as ‘mentors’ throughout the manuscript.

Two categories—(i) ‘Closeness to the mentor’ and (ii) ‘Confidence in mentors’ professional knowledge and teaching and supervision methods’—were interpreted as the drivers enabling first-year students to learn more about nurses’ roles and responsibilities in nursing homes. Each category is supported by several subcategories.

In the following section, the findings are presented with excerpts from the participants’ statements. The statements end with a number representing the code each participant (i.e., P1) and focus group (i.e., FG2) were given before conducting the focus group interviews, meaning participant 1 in focus group 2.

Closeness to the mentor

This category was supported by four subcategories: spending time with mentors, perceiving mentors as role models, feelings of insecurity and mutual learning– learning from each other.

Spending time with mentors

The first subcategory was related to the time first-year students spent with their mentors. Because the mentors could allocate more time to spending with the first-year students, this time allowed mentors to share formal and informal knowledge and create learning opportunities for first-year students. Being close to the mentor and spending time together was decisive for several first-year students to experience a positive relationship with their mentor. This positive mentor-first-year student relationship was highlighted as one of the participants’ positive experiences in the inspiration practice. They experienced that their mentors were aware of their own roles and responsibilities and encouraged first-year students to follow them everywhere to gain insights into how it is to be a nurse employed at a nursing home. One of the participants said the following:

We were following the mentors everywhere… They explained us everything… However, we were only six students at that nursing home, so we get one mentor each… and I followed my mentor all the time, and she explained me a lot about how to help the resident with personal hygiene or how to use a Hoyer lift to help the resident to move from bed to wheelchair. I feel that I learned a lot.… (P4, FG1).

Other first-year students were grateful that, by being with mentors, they had the opportunity to be introduced to more complicated procedures, such as changing a stoma bag or measurements of vital signs or even weighing the residents. One participant shared her experience:

Yes, we have experienced a lot! We contributed to making breakfast and served it, we helped residents with personal hygiene… we weighed the residents and documented in their journal, and we learned how to document everything we did to or with a resident, in generally… However, I learned a new word: stoma and… [stoma bag]. I observed how my mentor changed the stoma bag to a resident. You know, I get the opportunity to meet the residents face-to-face and the life at that ward. (P1, FG3)

The first-year students stated that, with this type of supervision, they would be much more likely to reach their learning outcomes for the inspiration practice. One of the participants stated the following:

I feel that, for me, everything was good. They [mentors] showed us that they have knowledge… they were very open and receptive if we had some questions: ‘Just ask me!’ and they were honest if they could not provide the answer. It wasn’t like at school: ‘Use the contact form’ [laughter]… we got the answer at once, so this was OK. They were also very creative. They made cases about things we already had knowledge about, and I learned to use several measurement instruments, such as QSOFA [Quick Sepsis Related Organ Failure Assessment] and this kind of thing.… (P1, FG8).

Perceiving mentors as role models

The second subcategory was related to first-year students perceiving the mentors as role models. Being close to the mentor, the first-year students could engage in informal discussions, hence finding that mentors were people who had been in their shoes, who had journeyed close to where they wanted to be and who had made their own mistakes in their learning but also gained practical knowledge. They perceived mentors as someone who was close enough to them, willing to share their wisdom and experience, and could help them avoid certain pitfalls. These perceptions contributed to developing a positive relationship with the mentors, which positively influenced their learning. One of the participants said the following:

I am happy that my first encounter with practice was through third-year students. It is not a long time since they were in our situation, so they know how it feels. They explain in an easier way… and you get a kind of insider information… yes, they provide us with information that nurses don’t say because they believe that we already know things… I think that because they were in this situation, they explain or teach us things in the same way they wish they have been told… They have established good routines for learning to achieve learning outcomes.… (P3, FG5).

Feelings of insecurity

The third subcategory was related to feelings of insecurity among first-year students. Several first-year students asserted that they were not confident when they had to help the residents with their fundamental needs, such as toileting, changing diapers, personal hygiene or eating and drinking. One of the participants shared her experience:

I have never assisted someone with personal hygiene before… It was quite an experience…I felt hesitant, but I had to manage somehow… (P4, FG2).

Being close to the mentor offered opportunities to seek support. They appreciated that mentors accepted their insecurity, lack of experience and theoretical knowledge limitations. One of the participants said the following:

Going together with my mentor, I felt safe to fail… [laughter]. I am happy that I gained the opportunity to try and experience the challenges that came with… They asked questions and they sensed that we were not sure about the answer, but we gradually became confident when they ‘pushed’ us to try it on our own.… (P3, FG6).

Mutual learning– learning from each other

The last subcategory was related to the learning process as a mutual process. Some of the first-year students had clinical experience in healthcare services as healthcare assistants. This placed expectations on the inspiration practice period, and although these students knew the field very well, they were impressed by the amount of practical knowledge they gained during this week. However, being close to the mentor offered opportunities to learn from each other. When the mentors could not answer their questions, they experienced that they searched for knowledge and together agreed about the correct answer for the given situation. The participants experienced that learning was a mutual process, and it did not happen only from mentors to them but also vice versa, as one of the participants said:

Yes, we had a positive dialogue about knowledge… sometimes it was funny to see… I think that it was a positive experience for both of us [to share knowledge], that when we asked questions, they had to search for the answer… and figure it out together… This would not happen with a nurse that has 20 years’ experience that knows the answer: ‘that is it!’… (P1, FG4).

Confidence in mentors’ professional knowledge and teaching and supervision methods

This category was supported by two subcategories: mentors’ theoretical and practical knowledge and skills, and mentors’ ability to apply diversity in didactical and pedagogical methods.

Mentors’ theoretical and practical knowledge

The first subcategory relates to the first-year students’ perceptions of mentors’ professional competence, which can be defined in theoretical knowledge, skills and general competence. The first-year students were positively surprised about their mentors’ amount of theoretical and practical knowledge. This contributed to motivating first-year students to be curious and wanting to learn more. Several first-year students asserted that their expectations for the inspiration practice week were fulfilled because of the supervision they gained from mentors, hence assessing mentors as ‘competent’, meaning ‘knowledgeable and skilled’. One of the participants said the following:

I was quite content with my mentor… She [the mentor] had so much knowledge… it seemed that she worked there [at nursing home] for 10 years… I was motivated by that because I noticed how much they [mentors] have learned during these three years.… (P3, FG6).

Other first-year students reported that they got answers no matter what they asked. They were surprised by the mentors’ theoretical knowledge and how they could provide them with examples of the application of theory in real patient situations. This contributed to an increase in first-year students’ self-confidence. One of the participants described his experience as follows:

Our mentors were very knowledgeable and skilled… They provide us with answers… I was surprised how much knowledge a third-year student could gain through education… As third-year students, they were so well prepared to work and to meet patients in the clinical field.… (P10, FG5).

Other participants were impressed by mentors using professional language during formal and informal conversations and by the clinical gaze they developed. One participant stated the following:

… and they communicate with us by using professional terms… such as… I don’t remember all of them now, but they [mentors] mentioned frontal lobe, and other [laughter]… and yes, ‘she’s got Alzheimer’s [referring to a nursing home resident]… it’s only a name for me… but, you know, Alzheimer’s means that the woman has dementia… (P5, FG7).

The mentors’ practical skills were also praiseworthy among first-year students. They observed and learned from mentors how to use different medical instruments and measure vital signs/National Early Warning Score (NEWS) or the level of haemoglobin or insulin on real patients and then documenting the results. One participant said the following:

I could see that they [the mentors] were knowledgeable and skilled… when they presented and demonstrated for us, they knew what they were doing and talking about… They taught us and demonstrated different measures, and when we asked them, they answered us… yes, they were professional.… (P2, FG7).

A skill that first-year students could easily perceive as a challenge was communication with residents who had a cognitive impairment. However, several first-year students were impressed by the mentors’ communication skills. Many were surprised by the ethical challenges imposed by communication with people with dementia. Others noticed how respectful mentors were when asking the residents for permission to bring into the resident’s room another person who would assist the resident with personal hygiene or toileting. One of the participants expressed this as follows:

He [the mentor] I had was very good at communicating with the residents… he always asked them if we could enter the room to observe or help with the provision of personal hygiene.… (P2, FG8).

Mentors’ ability to apply diversity in didactical and pedagogical methods

The second subcategory was related to first-year students’ perceptions of the mentors’ ability to teach and supervise them and the diversity in didactical and pedagogical methods employed. The participants were content with the mentors’ explanations and demonstrations of all the work tasks a nurse has during a working day at a nursing home. Because the first-year students were not aware of what they should ask about, they particularly liked when their mentors provided them with knowledge without being asked for it or just demonstrated how the medical instruments or personal lift-assist device functioned. For most of them, this was perceived as the most appreciated first-hand knowledge, which mentors ‘just shared’ with them. They were also encouraged to ask questions and eventually provided additional answers if they could. One of the participants explained this as follows:

When we asked the mentors ‘Why are doing in this way and not in another…’, they always had good answers grounded in theory or in their prior clinical experiences… They acted very confident, so we also felt confident in what we were doing.… (P5, FG1).

Most of the participants were content with mentors’ methods of teaching or supervising them and giving feedback. They appreciated when mentors supported and encouraged them to learn things and become independent, but also to try new things and teach them how to do it. They appreciated being told what and how to help the resident prior to entering the resident’s room, not just being told what they had to do while the resident observed and listened, thus making them uncomfortable (i.e., during the provision of personal hygiene for a resident). One participant shared his less positive experience with providing personal hygiene to a female resident:

I had to ask my mentor how I should wash her body, and when I came to her breasts, I became very uncomfortable, but the mentor said to me, ‘Just lift her breasts and wash under and dry gently… it is OK’, and then I did it, but it was a strange experience.… (P3, FG7).

Another participant gladly shared her positive experience of being taught different procedures and routines regarding hygiene routines:

We had an interesting overview of hygiene routines at the ward, and then, we went through infection control equipment, and we had to take on and off, to learn these routines… We also learned how many times, how and when we had to use disinfecting alcohol on our hands and the order of taking on and off all that infection control equipment… a kind of ‘learning by doing’… (P1, FG2).

Another learning method that was much appreciated by first-year students was mentors asking questions during a procedure that engaged first-year students to reflect on knowledge before answering. One participant said the following:

When we got out of the resident’s room, they [mentors] asked us if we would do anything different.… (P3, FG7).

Because of the limited number of nursing homes that could have both first- and third-year students at the same time in the clinical field, a few of the first-year students had to complete their inspiration practice week by being two or three days at school or/and the department’s simulation learning environment and only one or two days in the nursing home. Although these students expressed that they learned a lot from their mentors, their expectations for inspiration practice week were not as positive as they expected to be. Some asserted that they got limited or almost no insights into the nurse’s role and responsibilities in the nursing home. One of the participants revealed her experiences in the department’s simulation learning environment:

Together with a few other students from my group, we were at the school’s simulation environment… They [mentors] had a good plan for us. The first day began with measuring vital signs on each other. and we could do it many times. They created several patient cases where we could measure and document NEWS for each case… Then, we learned to change the sheets on the bed while a ‘patient’ was lying there… I felt that I learned a lot, and I am content with how mentors taught us different procedures; however, I wish I could have been at a nursing home because, personally, I have no clinical experience; it would have been useful to get insights into the nurse’s role and responsibilities at nursing home before we start the clinical period at nursing home.… (P3, FG6).

During the focus group interviews, those first-year students who completed the inspiration practice week at the school’s simulation learning environment revealed some learning and teaching methods employed by their mentors, asserted as being very creative. The mentors could not offer learning activities regarding some procedures that could be done in real life (i.e., changing wound dressing on a resident’s leg ulcer); therefore, they had to think outside the box and create situations that could contribute to learning. One of the participants explained this as follows:

They [mentors] drew a ‘wound’ on their own leg and, by following the procedure, they changed the wound dressing on each other to demonstrate us how to change a leg ulcer dressing. I have to say that I learned a lot, although the wound was ‘fake’… [laughter]. (P2, FG7)

The aim of the present study was to explore first-year nursing students’ perceptions and experiences with peer mentoring as an educational model during their inspiration practice week at nursing homes. The analysis of the empirical data revealed that first-year students were inspired by their mentors, an inspiration that contributed to their learning progression.

As the findings have revealed, as a learning process, peer mentoring facilitates the transfer of learning by mentors designing instructional activities, thus encouraging first-year students to make connections between the theoretical knowledge they gained at school and the simulation learning environment and practical knowledge within new and real patient situations.

The findings from the current study have revealed first-year students’ descriptions of how mentors provided them with explicit instructions on how to apply knowledge or skills, thus engaging them in problem-solving activities that required learning transfer. Through these instructions, the mentors transferred learning over to first-year students, hence enabling their reflective thinking within the context of a nursing home. Moreover, acting as role models, being available and allocating time to be together with first-year students, the mentors were perceived as knowledgeable and skilled, features that contributed to enhancing first-year students’ motivation to search for new and more knowledge and, thus, to achieve learning outcomes. These features can be understood as person-related factors, which Wahlgren and Aarkrog [ 37 ] described as one of the factors facilitating learning transfer. Moreover, a person-related transfer factor was positively related to those participants who had previous clinical experience. As the findings have revealed, if the mentors could not answer the questions, the experienced participants, based on their previous clinical experience, suggested solutions; thus, learning was transferred the other way around, from the first-year students to mentors, with learning perceived as a mutual process [ 48 ].

In the present study, the first-year students showed receptiveness to acquiring knowledge and were concerned with making the most of the inspiration practice week. Their interest in learning was strengthened by mentors’ knowledge and abilities in providing instructions. This finding is similar to and supports the findings from previous studies demonstrating that peer mentoring contributes to students’ engagement and increases their cognitive skills, self-confidence, autonomy, clinical skills and reasoning [ 22 , 49 , 50 ].

The mentors’ specific knowledge about nurses’ roles and responsibilities in nursing homes, different procedures and communication challenges with people with cognitive impairment enhanced trust and the credibility of mentors’ preparedness for inspiration practice week. This led to first-year students’ trust in mentors’ ability to transfer learning. The participants’ curiosity and desire to gain insights into real-life patient situations have enabled their willingness to engage in learning activities. In the current study, the mentors adopted an active role when teaching and supervising first-year students. As the participants described, the mentors gladly shared their knowledge, demonstrated how to perform procedures and had informal and formal discussions about how first-year students could implement theory into practice. Similar to previous studies, which have demonstrated that learning with an equal peer facilitates making friends and developing relationships [ 25 ], hence reducing nursing student anxiety in the clinical setting [ 29 ] and promoting learning, the findings from the current study have revealed that the participants leaned on their mentors and felt safe and could trust their mentors. Although a few felt uncomfortable being exposed to new challenges (i.e., providing personal hygiene or helping residents with toileting), most of the participants stated that the mentors’ feedback given both during and postprocedure performance contributed to increasing their self-confidence when performing measures of vital signs or other procedures. These features resonate with Wahlgren and Aarkrogs’ [ 37 ] teacher-related transfer factor which emphasises the mentor’s ability to organise learning situations by including demonstrations, providing examples from theory and practice and reflecting on possible applications in real-life patient situations.

As suggested above, although person- and teacher-related transfer factors facilitated transfer learning, the situation-related factor raised some challenges. Despite the results from one study [ 51 ] demonstrating that nursing homes as a clinical placement will not add something new to students’ skills and competencies required for their future practice, other studies [ 35 , 52 ] have demonstrated that, in general, learning in a clinical context can affect nursing students’ learning outcomes and satisfaction, as well as influence their choice of future career. Although simulation may prepare students for clinical learning environments, there is no comparison to the learning that comes from nursing patients in a real clinical context and from a simulation learning environment at school [ 53 ].

The findings from the current study revealed that not all the students were content with the learning context during their inspiration practice week. Some first-year students, together with their mentors, used the department’s simulation learning environment and even classrooms as a learning context for two or three days or even for the entire week. In this situation, it is reasonable to think that situation-related transfer factors [ 37 ] posed some challenges, and they were not related only to mentors’ pedagogical methods, but also to the programme’s readiness to inspiration practice week and the leadership of the related factors of the nursing home (i.e., not being able to provide enough placements). If the first-year students and their mentors had the necessary theoretical knowledge but could not apply it in a real-life patient situation, the person-related transfer factors could also be challenged. Although none of the participants expressed that using the department’s simulation learning environment as a learning environment was worthless, some hinted at their disappointment. The lack of situational transfer factors seemed to negatively affect the participants’ motivation to gain knowledge. However, as the participants asserted, their mentors’ creativity contributed to creating potential patient situations similar to those in real life. They also encouraged first-year students to simulate different patient conditions and perform different procedures, thus creating opportunities for first-year students to apply theoretical knowledge and improve their skills. This supports the idea that, despite a lack of situational transfer factors, the transfer of learning was supported by mentors’ teacher-related transfer factors rather than situational transfer factors.

Finally, being a first-year student supervised by knowledgeable and skilled third-year students can contribute to first-year students mirroring themselves and their knowledge with their peers. Thus, first-year students can become more aware of themselves as professionals and develop an understanding of the nurse’s role and responsibilities in the nursing home. Consistent with results from previous studies, the results of the present study suggest that peer mentoring facilitates the development of self-understanding in students [ 25 , 26 , 32 , 36 ], which is essential for first-year students to gain a positive attitude towards nursing older people. The findings from the present study have suggested the use of peer mentoring in nursing education with structured training and supervision. Moreover, as the findings have indicated, peer mentoring facilitates learning transfer from mentors to mentees and provides valuable leadership experience for third-year students as mentors. In addition, mentoring may enhance a first-year student’s opportunity to be mentored and provide mentoring in the future.

Implications for nursing education and clinical practice

Peer mentoring, as a teaching and learning method, can be applied to enhance nursing curricula and clinical practice in several ways. Firstly, incorporating successful peer mentoring strategies into the curriculum can foster a collaborative and supportive learning environment among nursing students. The perceived closeness between mentors and first-year students suggests that fostering strong mentor– first year student relationships can serve as a driver for effective learning in the context of nursing homes. This closeness may create an environment that facilitates open communication, trust, and a sense of support, which are essential elements in the field of nursing. Additionally, the confidence instilled in first year students regarding their mentors’ professional knowledge and teaching and supervision methods can directly impact the students’ understanding of nurses’ roles and responsibilities in nursing homes. In clinical practice, the findings from the study can be used to promote mentorship programs that facilitate knowledge transfer and skill development among nurses and among senior and novice students during their clinical periods. Lastly, the study highlights first-year students’ overall positive experiences with peer mentoring program. This positive experience can help change students’ attitudes towards nursing older people, making it an interesting aspect of their future careers.

Strengths and limitations

The present study has several limitations that must be considered when interpreting the findings. First, although many students were invited to participate, the study was limited by a relatively small sample size restricted to students from Oslo Metropolitan University, hence limiting the findings’ national and international transferability. However, one strength may be that the findings and issues raised are relevant for both national and international nursing education programmes that apply the peer mentoring teaching and learning model in clinical placements. Another limitation may be the sample size and data saturation. As a concept, data saturation in qualitative research has been subject to several discussions arising from a variety of conceptual understandings [ 54 ]. Although the sample size posed some limitations, the richness in the participants’ descriptions was a strength, thus contributing to enhancing the information power [ 55 ]. Another limitation may be related to the researchers not being able to conduct member checks to improve the credibility of the data. For practical reasons, it was impossible to gather the same sample of students to validate their statements. However, during the focus group interviews, the participants were asked to provide detailed answers and were given the necessary time to reflect and express their experiences, thus confirming and or disagreeing with each other’s perceptions. Furthermore, potential research biases should be acknowledged given that the data collection and analysis were conducted by all researchers who were nurse educators employed at the same university as the students, hence entailing a prior understanding of the research context. However, the researchers were not involved in the students’ inspiration practice period, which may have limited the research bias regarding data collection. Another limitation may be its specific theoretical framework [ 37 ]. We are aware that other researchers, by using another theoretical framework, would probably discuss the findings accordingly and, hence, interpret the findings differently.

To the best of the researchers’ knowledge, this is the first study exploring first-year nursing students’ experiences with one week of inspiration practice at a nursing home by employing peer mentoring as a teaching and learning method. The findings revealed that first-year students were inspired by their senior peers to keep learning and moving forward. By being close to their mentors and having confidence in their professional knowledge and teaching and supervision methods’, learning was easily transferred from the third-year students to first-year students. Moreover, person-related, teaching-related and situation-related factors were perceived as drivers that positively influenced students’ learning in nursing homes.

The findings have indicated that first-year students had both positive and less positive experiences with attending a one-week inspiration practice at nursing homes. The challenges with inspiration practice were related to situation-related learning transfer factors, such as clinical field not providing enough placements; therefore, the third-year students had to improvise and be creative. However, despite some challenges, mentorship during the one-week inspiration practice offered significant advantages to both mentors and mentees. To fully harness these advantages, we recommend that first-year educational programmes implement person-centred care for older people into the educational curriculum. This should include a one-week compulsory inspiration practice placement in settings exclusive to older people, such as nursing homes. Moreover, peer mentoring as a teaching and learning method, with themes especially designed to focus on nursing and caring for and with older people, offers first-year students insights into nurses’ roles and responsibilities at nursing homes. We believe that such a programme can prevent ‘reality shock’, reduce dropout rates, enhance academic achievements and cultivate personal and professional qualities in students at all levels of their education programmes. More research is needed to explore how peer mentoring is experienced by students enrolled at different levels of Bachelor of Nursing Education and may contribute to their preparation to care for older people in nursing homes.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Participant (followed by a number indicating the number of participants in the focus group)

Focus Group (followed by a number indicating the number of the focus group)

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We would like to thank all the students who participated in the focus group interviews, thus contributing to data collection. We further thank the Department of Nursing and Health Promotion at Oslo Metropolitan University and the University Library for giving their approval and for supporting the publication fee of this article.

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D.L. contributed to study conception, data collection, analysis and wrote the main manuscript text; H.K., K.L., T.N.F., K.K., & E.H. contributed to data collection and analysis. All authors reviewed the manuscript.

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Lillekroken, D., Kvalvaag, H.M., Lindeflaten, K. et al. Educating the nurses of tomorrow: exploring first-year nursing students’ reflections on a one-week senior peer-mentor supervised inspiration practice in nursing homes. BMC Nurs 23 , 132 (2024). https://doi.org/10.1186/s12912-024-01768-5

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Assessment of women’s needs, wishes and preferences regarding interprofessional guidance on nutrition in pregnancy – a qualitative study

  • Merle Ebinghaus 1 ,
  • Caroline Johanna Agricola 1 ,
  • Janne Schmittinger 1 ,
  • Nataliya Makarova 1 &
  • Birgit-Christiane Zyriax 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  154 ( 2024 ) Cite this article

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A healthy nutrition in pregnancy supports maternal health and fetal development, decreasing the risk for adverse pregnancy outcomes. Guidance by prenatal care professionals can increase women’s awareness regarding the importance of nutrition in pregnancy and thereby contribute to a reduced risk for adverse pregnancy outcomes. The aim of this study was to assess the needs, wishes and preferences of pregnant women regarding the interprofessional guidance on nutrition in pregnancy.

Using a qualitative approach and a purposive maximum variation sampling strategy, 25 pregnant women were recruited to participate in six semi-structured, guideline-oriented online focus groups. In addition, two semi-structured, guideline-oriented interviews, with a midwife and an obstetrician, were conducted. The focus groups and interviews were audio-recorded and transcribed. Transcripts were analysed using a systematic deductive-inductive approach to qualitative content analysis according to Kuckartz.

Focus group participants covered diverse perspectives in terms of their age, different models of prenatal care as well as dietary forms from omnivorous to vegan. The majority of women perceived the guidance on nutrition during pregnancy as insufficient. Involved healthcare professionals, namely midwives and obstetricians, should provide more consistent information, especially to avoid uncertainties exacerbated by the internet and social media. There is a need for individual nutrition information regarding dietary supplements and the specifics of different dietary forms during pregnancy, such as a vegan diet. The majority of participants supported the integration of a free-of-charge professional nutrition counselling in prenatal care. Interviews with experts identified time pressure and the complexity of nutrition as a topic as the main obstacles in consultation settings. Both midwife and obstetrician emphasised the need for improved professional education on nutrition in pregnancy in their respective studies.

Professional guidance for pregnant women on nutrition and uncertainties going along with certain forms of diet during pregnancy could alleviate the burden and overwhelming amount of web-based information. Additionally, information adapted to the needs, wishes and preferences of pregnant women would improve prenatal care through a more personalised approach. The quality of nutrition guidance in pregnancy should be improved by the implementation of this topic in the education of involved healthcare professionals.

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The course of a woman’s pregnancy significantly affects the health of mother and child short- and long-term [ 1 ]. This warrants a focus on promoting a healthy lifestyle in pregnant women and makes health literacy, nutrition and lifestyle choices important factors in pregnancy. The understanding of health information and the interaction with healthcare professionals are associated with beneficial health behaviours as well as an increase in the health status in pregnancy, making a close engagement between prenatal healthcare professionals and pregnant women essential in promoting the health of mother and child [ 1 , 2 , 3 ]. In Germany, pregnant women are predominantly attended by obstetricians and are entitled to midwifery care from conception until their child’s introduction to solid foods. As part of prenatal care, the German maternity guidelines state nutrition as a topic that pregnant women should specifically be educated on [ 4 ]. So far, only few studies have investigated women’s perspectives on nutrition information in pregnancy. While there are studies that examined midwives’ role in providing nutrition advice [ 5 ], and pregnant women’s opinions on the integration of nutrition counselling in prenatal care [ 6 ], there is little corresponding research from Germany. The assessment of experiences and perspectives of pregnant women in German prenatal care is important however, considering the distinctive German healthcare system. Implementing the wishes of those who are the recipients of prenatal care can therefore contribute to quality assurance and effectiveness of that system. Moreover, communicating the importance of nutrition in pregnancy and considering women’s individual needs can be an essential step towards a reduced risk of adverse pregnancy outcomes (APO). Nutrition has been established as a major determinant of maternal and child health and a poor maternal nutritional status is associated with APOs such as preterm birth (PTB), low birth weight (LBW), gestational diabetes mellitus (GDM) and hypertensive disorders [ 1 , 7 , 8 ]. Additionally, dietary patterns and food quality are associated with birth weight and can impact a woman’s risk to give birth to a baby either large for gestational age (LGA) or small for gestational age (SGA), which is correlated with increased child mortality and morbidity [ 9 ]. To ensure optimal growth and development of the fetus as well as to support the mother’s physiological changes throughout pregnancy, a healthy and balanced nutrition is essential and entails the ideal amount of energy, macro- and micronutrients [ 10 ]. While the fundamentals of a healthy nutrition remain the same in pregnancy as for the general population, some nutrient requirements such as folic acid, iodine and iron are increased [ 11 , 12 ]. Research shows that nutrition intervention can reduce the risk of developing preeclampsia and GDM during pregnancy [ 11 , 13 ]. This entails a high intake of vegetables, whole grain products, legumes, nuts and fish, while avoiding simple sugars, processed foods, trans and saturated fats [ 11 , 13 ]. Preeclampsia and GDM are, among other complications, also associated with pregnancy obesity [ 9 , 14 ]. The prevalence of obesity in pregnancy has increased worldwide, which is apparent in Germany as well, where one study among many international studies showed adverse clinical outcomes for mother and child due to maternal obesity [ 14 , 15 , 16 ]. Apart from weight gain, many pregnant women are also concerned with a multitude of nutrition-related challenges such as food aversions, maternity sickness and heartburn [ 10 ]. Food cravings are also often reported in pregnancy and commonly increase the consumption of starchy and sweet foods as well as sugary beverages, as one Canadian study found [ 10 ]. The same study from Canada reported women’s general adherence to pregnancy-specific recommendations on food taboos to avoid the ingestion of harmful substances and the risk of infection by toxoplasmosis or listeriosis [ 10 ]. However, the authors of the study also report that women did not increase their intake of foods that are rich in nutrients [ 10 ]. The possible link of food cravings to weight gain [ 17 ] as well as the adverse impact of nutrient deficiencies in pregnancy support the need for a high-quality, evidence-based and adequate counselling on nutrition as part of prenatal care in order to improve pregnancy outcomes [ 18 ]. There has been an increase worldwide as well as in Germany of women following a vegetarian or vegan diet [ 19 ]. While a purely plant-based diet is not recommended in pregnancy [ 19 ], the increasing prevalence in the general population warrants an adequate education on the part of prenatal healthcare professionals as well as counselling pregnant women regarding regular screenings for nutrient deficiencies and recommending the appropriate dietary supplements [ 11 ]. Nonetheless, all pregnant women benefit from adequate and individual nutrition counselling, irrespective of their specific form of diet [ 6 , 20 , 21 ]. Nutrition as an integral part of everyday life makes it a remarkable tool in the utilisation for an immediate impact on the status of one’s own health, becoming especially relevant in pregnancy. As a topic that is specifically addressed in the German maternity guidelines, the interprofessional guidance on nutrition in prenatal care remains to be evaluated in consideration of pregnant women’s needs, wishes and preferences. Consequently, the aim of this study was to assess these needs, wishes and preferences through focus group discussions with pregnant women. In addition, we aimed to identify their sources for information and consultation on these topics and to compare the perceived importance of nutrition related topics in consultation settings to the perspectives of the involved healthcare professions.

Study design and participants

This study followed a qualitative approach, aiming at the exploration of individual needs, wishes and preferences through focus group discussions and interviews. The use of focus groups with pregnant women was applied to establish important aspects of their prenatal care and assess their wishes, needs and preferences to inform a demand-orientated approach in prenatal care. Focus groups were supplemented by one-on-one interviews with healthcare experts to contextualise women’s statements within the healthcare provider’s professional experiences. The study was based at the University Medical Center Hamburg-Eppendorf (UKE), Germany. It was approved by the Local Psychological Ethics Committee of the UKE (LPEK-0507) and registered at Open Science Framework (OSF) on 12.09.2022 (DOI: https://doi.org/10.17605/OSF.IO/YP7BR ). Six semi-structured, virtually held focus groups [ 22 ] with pregnant women throughout all phases of pregnancy were conducted by M.E. during the months of September and October of 2022, via the online-platform Zoom. A virtual, semi-structured one-on-one interview [ 22 ] was conducted by M.E. at the request of one pregnant participant, who did not feel comfortable in a focus group setting. Additionally, professional healthcare providers were interviewed over the phone by M.E., in semi-structured one-on-one interviews [ 22 ], in November of 2022 and in January of 2023, including a midwife and an obstetrician. Both focus groups and interviews were conducted by female research associate M.E., who, at the time of the study, held a Bachelor of Science and had previous experience in qualitative research through participation in the conduction of focus groups and content analysis in a separate research project. Field notes were made immediately after each focus group and interview. Focus group guidelines are shown in Supplement S1 and Interview guidelines in Supplement S2. Prior to study commencement, the guidelines were audited by multiple researchers experienced in qualitative research, ensuring a clear structure and comprehensibility. Participants for this study were recruited using various methods, with the aim of obtaining a heterogeneous study population through purposive selection, to increase the diversity of perspectives and receive a wide range of insights. To achieve these maximum variation goals, we recruited participants through multiple channels, consisting of social media and distribution of flyers. Women at any stage of pregnancy, who experienced their pregnancy within the German healthcare system, who were able to join a focus group online, speak German and to give informed consent, were included. Pregnant women, who worked as midwives or obstetricians themselves, were excluded. Following the focus groups, one representative of each profession was recruited for expert interviews. The term “expert” in this context was defined as a healthcare professional with the appropriate professional education completed in Germany and at least ten years of experience working in their respective field within the German healthcare system. Prior to study commencement there was no established relationship with participants, other than contact via Email for organisational aspects and further information on the conduct of the study. The participants were aware of the researcher’s (M.E.) place of work (study center) and received an introduction into the background and reasons for conducting the study (details on the introduction in Supplement S1 and S2) as well as the researcher’s credentials and professional background. This information was given at the beginning of each focus group and interview. Focus groups and interviews were audio recorded after informed consent. Data was collected until no new ideas emerged and saturation was apparent. Focus groups lasted between 40 and 60 min, the interviews for 30 (obstetrician) and 50 min (midwife), respectively. The audio files of each focus group and interview were subsequently transcribed verbatim, using the online tool “otranscribe”.

Data management and analysis

The management and analysis of the obtained data was performed using the 2022 version of MAXQDA. All socio-demographic data, focus group and interview recordings were stored independently from personal contact information and intentionally not interlinked.

The collected data was analysed using a concept-driven combined with a data-driven approach, reflecting the systematic approach to qualitative content analysis for a deductive-inductive analysis by Kuckartz [ 23 ]. The applied framework method was described by Gale et al. [ 24 ] and entails the organisation of codes into categories. Based on the focus group guideline and the first impression after reading and summarising all transcripts, the main categories were deductively developed, reflecting the overall themes covered by the discussions. All transcripts were then coded with an inductive approach, using the emerging ideas directly from within the data to extend the main category system with more subcategories until they appeared saturated. The resulting category system was revised by multiple researchers with experience in qualitative research. After initial coding of the data by one researcher, a second researcher, with extensive experience in qualitative research, independently applied the developed category system for one focus group transcript. Aiming for agreement of coding and inter-coder consistency, existing disagreements were discussed between the researchers until consensus was reached. The final category system for the focus groups was subsequently applied to the interview transcripts. We performed translation from German to English as closely to the original as possible.

Sample characteristics

Six focus groups and one interview were conducted with pregnant women, as well as two expert interviews with healthcare professionals. A total of n  = 25 pregnant women participated in the study. Women were between the ages of 23 and 38 years, with a mean age of 30.9 (SD: 3.4). The week of pregnancy ranged from 8 to 40 weeks. All participants had a high school diploma (Abitur) and n  = 13 completed college education. The participating women had chosen three different models of care for their pregnancy, either receiving prenatal care exclusively from their obstetrician ( n  = 10), in an alternating model between midwife and obstetrician ( n  = 11) or in a midwifery-led model of care ( n  = 4). Regarding their form of nutrition, participants followed a variety of diets. More than half ( n  = 14) stated that they are omnivores, n  = 2 women indicated a pescetarian and flexitarian diet, respectively, while n  = 5 women were vegetarians and n  = 2 followed a vegan diet. Supplement S3 summarises the socio-demographics of the focus group participants. The second part of this study consisted of two expert interviews with healthcare professionals, a midwife and an obstetrician. The interview participants completed their professional education in Germany and had multiple years of experience in their field.

Category system

The development of the category system followed a deductive-inductive approach [ 23 ]. The main categories are “source of information”, “topics”, “timing of consultation”, “communication between healthcare experts and pregnant women”, “offered services”, and “professional education of experts”. The final category system is shown in Supplement S4.

Guidance on nutrition during pregnancy

Source of information, focus groups.

Women reported three main sources of information on nutrition during pregnancy. Healthcare professionals, the internet and social media, while the third source for these women were personal contacts, giving advice on nutrition in pregnancy, albeit sometimes unsolicited. Healthcare professionals who advised the women on nutrition during pregnancy were their obstetricians and midwives. Some women recounted a more comprehensive nutrition counselling by their midwives than their obstetricians, often as a result of more time in prenatal visits. Many women reported they had not received any guidance or education neither by their midwife nor by their obstetrician, which they would have wished for in retrospect. For some women this led to the feeling of not being able to rely on their healthcare professional to address the topic.

“I don’t remember any significant information or education given by my obstetrician regarding that. And looking back, I would have appreciated it.” (30 years, 1st child).

Interestingly, one woman stated that she does not necessarily believe healthcare professionals in pregnancy to be the most reliable source for nutrition information and found that a medical training is no guarantee for accurate information on nutrition in pregnancy.

“The problem that I see, when it comes to nutrition, is that specifically medical professionals are not necessarily more trained than someone who deals with it a lot or otherwise works scientifically. So, unfortunately, in my experience, a medical background is not a guarantee for reliable information when it comes to nutrition.” (28 years, 2nd child).

Some participants pointed out that the alternating model in prenatal care between midwife and obstetrician could prevent a lack of guidance, as they were not certain, they would have received such an extensive counselling if they had solely been in obstetrical care and not midwifery care as well.

“If I imagine now that I wouldn’t have had any midwifery care and only the obstetricians, I don’t know if they would have told me about it. Or, I would have wished for it from the obstetrical side as well.” (35 years, 1st child).

Many women saw an issue with the consistency of information they received from different healthcare professions. Women recounted inter- and intraprofessionally inconsistent information on the topic of nutrition, adding to the uncertainty they already experienced around this topic. Consequently, many women stated they needed to find their own way, recognising that they are responsible for their decisions. Many wished however for a more consistent picture and a general consensus between the involved professions.

“So when you hear such contradictory opinions from two professionals, to know, well, which is true? I always feel like in the end, it’s my decision. I have to inform myself for myself about how far I want to go and accept the information that I want.” (23 years, 1st child). “I would have wished for a more consistent picture. Everyone told me something different about nutrition.” (35 years, 1st child).

Regarding other sources than healthcare professionals for nutrition information, a considerable amount of time in focus group discussions was occupied by the topic of social media and the internet in general. Most women stated they used the internet as a research platform, often seeking information on which foods they were allowed to eat during pregnancy. Many women explained the need for internet research with the insufficient or lack of counselling by their prenatal healthcare professionals, some stating they did not feel adequately informed.

“Regarding nutrition, I actually received very little information and had to tediously do the research myself.” (26 years, 1st child).

This became especially apparent regarding a lacking education on GDM, with one woman recounting how she felt when her obstetrician suspected she might be affected.

“So, I ended up googling what would happen if [GDM] turned out to be true and everything. That really wasn’t good because I didn’t feel like I was well-informed.” (30 years, 1st child).

The pervasive nature of the internet introduced a number of concerns for pregnant women, including the multitude of different opinions presented on, for example, social media channels. Some women also pointed out the additional effort to distinguish between online sources trying to sell a certain product, often dietary supplements, and sites without any financial agenda. Many women concluded the necessity to evaluate for themselves which information is useful and individually fitting depending on their situation and personal needs, describing the amount of information as overwhelming and difficult to navigate, especially in their first pregnancy. Some participants also pointed out positive aspects of the internet as a source for nutrition information, serving a quick reinsurance when in doubt about certain food taboos and finding individual solutions.

“When it comes to nutrition, I find it extremely difficult to filter, who is trying to sell a product. Because it’s especially extreme in this pregnancy bubble, the amount of dietary supplements being sold. And what are actually reliable sources without any advertising motives.” (28 years, 2nd child).

In response to what kind of support would be helpful in navigating the internet and social media as a source for information on nutrition, some women pointed to government official websites or apps, meaning evidence based and approved by responsible German ministries. Facilitating the search for reliable answers, specifically on food taboos, women voiced the wish for free-of-charge apps and official websites.

“An official app or an official website would certainly create more trust.” (33 years, 1st child).

Women also wished for written information from their healthcare professionals on specific topics such as GDM, to avoid feeling caught off guard or scared later on and knowing how to use nutrition as a tool to prevent GDM. Another wish was expressed regarding a catalogue on beneficial foods during pregnancy or a list of dietary supplements that could be helpful, together with an explanation on each supplement.

“I would have wished for something either from my obstetrician or my midwife, like lists with nutrition pyramids or generally, what are the superfoods to eat during pregnancy, what should I eat or focus on? If I had only received some kind of informational booklet about what to eat during pregnancy or what is recommended.” (34 years, 1st child).

Lastly, women reported personal contacts as a source of information on nutrition and stated they possess a basic knowledge through their families and friends who have experienced pregnancy. Sometimes however this led to confusion when their advice did not coincide with information from other sources.

“Especially because you always have the mothers in the background or the grandmas, saying, oh, we ate everything, we didn’t know about all that stuff. You have both extremes. The friend who freaks out, saying how could you? Then I feel like, non-pregnant people also like to get involved. And on the other side, the moms, or aunts, grandmas.” (32 years, 2nd child).

Women were concerned with many different topics regarding their nutrition during pregnancy. As already apparent throughout the theme of women’s sources, an important aspect of this were foods that are labeled as a taboo during pregnancy, often in relation to a risk of infection.

“What is much more important is all this infection stuff right at the beginning. And there, I would have wished for something a little more differentiated. A bit more detailed, having more faith in our intelligence. I can remember more than two things (laughs). It’s such a generalisation.” (35 years, 1st child).

Other topics included women’s diets and special nutrient requirements during pregnancy. Participants also addressed nutrition-related health matters and the health of their unborn infant. Many women talked about trying to maintain a healthy nutrition during pregnancy and about what that entails.

“Especially in pregnancy, you want to somehow get the most out of it for yourself and the baby, making sure to have all the necessary vitamins and minerals and not forget anything, that everything is included in your nutrition.” (26 years, 1st child).

Pregnant women who received a more extensive education on nutrition reported a positive impact on their ability to evaluate what a healthy nutrition actually means.

“I think nutrition is something that concerns all of us pregnant women and we want to eat healthily. But what does healthy actually mean and what is / how can you determine this? I really liked that. I think it was great that [the midwives] implemented this.” (35 years, 1st child).

An important issue for many women was the continuation of their previous specific form of diet, such as vegan, vegetarian or omnivorous diet, and the impact this has in their pregnancy. Many women voiced their expectation and wish to be asked by their prenatal healthcare professionals about their specific diet and were disappointed or confused, when neither their midwife nor their obstetrician inquired any further. This was especially addressed by women who followed a vegetarian or vegan diet, or who had special restrictions, such as a gluten free diet. These women wished for a more individual consultation by their midwife or obstetrician regarding particular requirements these diets entail.

“I was also surprised that during my first appointment with the obstetrician, he didn’t ask about my diet. And I found that very strange. He just said something about being careful with meat and cheese. But at the time I thought, well, that doesn’t really apply to me, but I just let him talk.” (32 years, 1st child).

Often in relation to a vegetarian or vegan diet but also voiced by many other participants was the topic of nutrient requirements specific for pregnancy. While many were educated on the importance of folic acid at the beginning of their pregnancy, women voiced a specific need to be informed on more nutrients and in more detail.

“I would have wished for a list of what I can take, and it should be optional. Maybe during another appointment with my obstetrician or maybe as part of the prenatal care with the midwife. Does it make sense for me? Should I take it? So, maybe a bit more individualised.” (32 years, 2nd child).

During focus group discussions, some women reported pregnancy-related issues such as maternity sickness, heartburn or insatiable appetite. A great concern for many was also GDM. For many participants, a suspected GDM was reason for them to inquire more about the impact of nutrition. In this context, they expressed the need to be educated earlier in their pregnancy on the preventive effects of nutrition by their prenatal healthcare professionals.

“I read a lot about [GDM], but there was little information from [the obstetrician] directly. So, I would have wished for more, earlier clarification on the topic.” (34 years, 1st child).

The interviews with the midwife and the obstetrician reflected the main topics related to nutrition and pregnancy, which had previously been outlined in the focus groups by the pregnant participants. Both the midwife and the obstetrician placed special focus on the risk of infection through certain foods and the harmfulness of alcohol, smoking and drugs.

“And specifically with regard to toxoplasmosis, listeriosis, women are informed that they should not eat any raw milk products, any raw meat products, and so on.” (Obstetrician).

The midwife and obstetrician both noted that pregnancy seems to be a great motivator for women to eat healthier and give their child the best possible starting conditions. They also stated that vegetarian and vegan diets give reason to consult on nutrition in more detail with the respective women.

“This taking of responsibility for the child is also reflected in women’s nutrition and they don’t want to do anything wrong.” (Midwife).

Regarding dietary supplements, the obstetrician talked about folic acid and iodine as a recommendation and any other supplements as a possibility. Interestingly, the midwife pointed out that folic acid is justifiably very important to obstetricians but in her experience, they do not convey a sufficient explanation on this to the women.

“Folic acid is very important to obstetricians. But instead of explaining that it is difficult to reach the folic acid levels that we need during this special time through nutrition, which women often don’t know. The background information is not communicated.” (Midwife).

Maternity sickness was briefly mentioned by both midwife and obstetrician in context of the fear many women have that they might not be eating enough to sufficiently provide the unborn child with nutrients.

“Many women in their first pregnancy are concerned that their child may not be getting enough nutrients. They always fear that the child is missing something. And then you can show them the child and say that the child is growing just fine and it will take what it needs.” (Obstetrician).

Timing of consultation

Regarding the timing of nutrition education during pregnancy, many women emphasised how overwhelmed they felt early in their pregnancy by the amount of information they received. Nonetheless, they saw the need for a consultation on the topic of nutrition very early on. Many women would like nutrition to be addressed by their midwife and obstetrician on multiple occasions during their prenatal appointments, as questions might change or arise overtime and the initial feeling of being overwhelmed fades.

“Some questions only come with time. I think it should maybe be addressed again and again, also actively brought up by midwives or obstetricians maybe. Revisited again as time goes on.” (33 years, 2nd child).

Recurrence of the nutrition topic was a frequent point made by women who suffered from maternity sickness early in their pregnancy and could not cope with nutrition counselling at that time.

“I also experienced during this pregnancy that I was just feeling sick for a long time and had to throw up constantly. And I can imagine that if it’s talked about during that period, it would go in one ear and out the other. Therefore, it wouldn’t be a bad idea to repeat it again later.” (32 years, 2nd child).

Some women therefore proposed an early education on the risk of infection in the context of toxoplasmosis and listeriosis and a second consultation on nutrition and GDM in the first weeks of the second trimester, when women felt more settled in their pregnancy.

“I believe a good time for a second consultation would be around the 12th week. I also think at that point, the initial excitement and anxiety that many women feel during the first two to three appointments in the practice would have subsided a bit. And I also believe that would be early enough to educate on gestational diabetes.” (33 years, 1st child).

The dilemma of wanting to be informed but at the same time feeling overwhelmed by the amount of information women are exposed to at the beginning of their pregnancy was also acknowledged by the interviewed midwife. In her experience, nutrition as a topic has a very negative association for many women due to maternity sickness. Similar to what was described in focus groups, she saw the second trimester as the best time to offer nutrition consultation, explaining this with the women’s increasing sense of their pregnancy and awareness of carrying a child.

“At the beginning of pregnancy, women are often confused about nutrition. Because they feel nauseous for up to nine, ten, eleven, twelve weeks and the topic of eating is pushed very far away. After that there is a switch. Then there is the feeling of being pregnant and feeling the baby move. But up until that point, women are preoccupied with many other things to adjust to the changes in their hormone levels. Therefore, discussing nutrition or reducing sugar intake and other things at this point - she can’t focus on that.” (Midwife).

The need for written information in addition to a verbal consultation was reflected by the interviews with midwife and obstetrician, stating written material would facilitate the counselling on nutrition and alleviate the overwhelming amount of information in the beginning.

“So these flyers really make it easier, and things to take with you. Because there is a lot of information at the first appointment, but also important. So we usually say, this is a lot of information, that’s why you get all these flyers and let it sink in first.” (Obstetrician).

Communication between Healthcare experts and pregnant women

An overall theme throughout the focus group discussions that was valued very highly by pregnant women was the importance of communication. Due to pregnancy being a special time in a woman’s life, the interpersonal relationship between women and their prenatal healthcare professionals was considered essential. Many focus group participants wished for a personalised consultation, taking into account their individual tendencies to get easily scared or feeling unsure, or their personal choices regarding their nutrition, and considering the ability of a woman to cope with the amount of information they are presented with on the topic of nutrition. Some women reported they felt left alone and afraid of doing something wrong, which was especially apparent in the context of food taboos. The women concluded that guidance by healthcare professionals is essential in putting risks and fears into perspective.

“You are initially left alone with all these fears and you are afraid of everything. It’s important to take the pressure off a bit and just say, okay, what is reasonable, what is just scaremongering, and what eventually would also become unhealthy.” (35 years, 1st child).

Some women reported they wished they had been given more guidance by their obstetrician to avoid worrying about making mistakes regarding their nutrition. Some focus groups participants even stated, they were somewhat frightened by their obstetrician’s warnings about risks of infections through foods or nutrient deficiencies, especially in vegan diets.

“I can’t even remember my obstetrician saying anything about nutrition. And I was really anxious about the whole topic. I think it’s totally unnecessary to get so worked up about it. And in hindsight, I thought to myself, my obstetrician is my person of trust. If she had given me a little bit of a guide or something from the beginning, then I don’t think I would have gotten so worked up about some things afterwards.” (30 years, 1st child).

The midwife also emphasised the importance of the relationship between her and the pregnant women. In her experience, a good relationship can have a positive effect on the overall course of pregnancy and can help women to cope with fears, especially in regards to nutrition.

“I have the impression that when women are closely bound to their midwife, they go through pregnancy with more ease and confidence, especially regarding nutrition and possible fears, questions, and concerns.” (Midwife).

Referencing the framework conditions that midwives work in, the interviewed midwife noted the amount of time spent consulting women in prenatal visits, and the wish for the topic of nutrition to be specifically addressed in the catalogue of preventive services that midwives can bill for. She stated that topic-related billing options could improve prenatal care, as it would motivate healthcare professionals to incorporate nutrition topics in their care for pregnant women.

“I believe that if there were better conditions for preventive care services, if there were proper billing points for them, then it would also be more focused on. If one were to further break down aspects of billing possibilities and have a topic-specific billing that is also coherent, for example, nutrition counselling or nutrition for dental health, weight counselling, if that were further broken down, then every midwife would have a proper catalogue to work through.” (Midwife).

Time pressure was a big concern for the interviewed obstetrician, which she stated can make the counselling on nutrition difficult. She explained this with the complexity of this topic that also goes along with ingrained habits and the psychology behind trying to change them.

“What makes educating difficult? Well, there’s time pressure, of course. That’s the case in all practices. And of course, if someone is not cognitively able, then it’s also a challenging story and you never know what they will take away from it, except for the ultrasound image (laughs). Nutrition is a specific topic that deals with habits, ingrained behaviour, and also knowledge.” (Obstetrician).

Offered services

In terms of nutrition-related prenatal medical services that women need or appreciate during their pregnancy, two main talking points emerged in the focus group discussions. Firstly, the topic of cost coverage of certain services by their health insurance was addressed and secondly the need for offers of consultation and information proactively provided by healthcare professionals. Especially for folic acid many women voiced their wish for cost coverage of this supplement, at least in the beginning of pregnancy, as it is a standard recommendation but rarely covered by health insurance. Moreover, some women would like for the cost-intensive multivitamin, often recommended by obstetricians, to be covered as well. Many pointed out, that not every woman has the means to cover the cost for supplements herself.

“I also think it’s somewhat of an audacity in the German healthcare system that it’s more or less required with folic acid, the ultimate dietary supplement, and it’s not covered by health insurance. I don’t know why it’s not considered in this context to provide a financial relief for pregnant women.” (23 years, 1st child).

One woman suggested that an education on how to obtain important nutrients via nutrition by healthcare professionals could replace a cost-intensive management with dietary supplements. Building on this theme, many women expressed their wish for a one-time free-of-charge nutrition counselling for pregnancy, especially for women in their first pregnancy.

“I believe there are many pregnant women who can’t afford to take all the vitamins you can take, omega-3 fatty acids, and so on. And of course, it’s possible to manage this through your nutrition, and even manage it more cost-effectively through nutrition. So, there it would be good to receive an education. A pregnancy nutrition counselling service that could be offered once for free during pregnancy or for first-time mothers would be very helpful. Of course, we would have to consider who would pay for it, but it would be very, very valuable.” (33 years, 1st child).

Furthermore, the focus group participants wished for more proactive consultation and information offers by their midwife and obstetrician regarding nutrition in general. They emphasised the need for healthcare professionals to inquire about the woman’s state of knowledge about nutrition in pregnancy, signal a willingness to help, actively address the topic during multiple prenatal visits and prepare a questionnaire to avoid missing any important information the woman might forget to mention herself.

“I think the midwife or obstetrician or both should also ask about the level of knowledge of the pregnant women, whether they have any questions, and whether they can still help. So, the topic should be addressed by them and they should offer help. As a pregnant woman, you may not remember everything during the appointment with the midwife or obstetrician, so that they really ask about everything because it’s really, really important.” (33 years, 1st child).

Women also wished for specific guidance on how to compose meals that are rich in nutrients, as they feel there is an expectation to eat a balanced diet, but no offers for information on how to do so. A wish for more support was also mentioned in the context of maternity sickness and the disappointment at the lack of advice on how to counteract this through nutrition.

“I would have wished for a consultation offer because the nutrient requirements are increased and it would be helpful to have an information offer on how to put together my meals in a smart and nutritious way. Is that information accessible to everyone? Or would it be maybe smart to offer information about that?” (28 years, 2nd child).

In the interviews with midwife and obstetrician some of the topics that were discussed by the pregnant participants recurred while a few new ones emerged as well. The obstetrician touched upon the issue of cost coverage by health insurance.

“Some health insurance companies reimburse certain things, for example they pay for a toxoplasmosis test, which is not a standard benefit in prenatal care. But ultimately, patients have to pay for it themselves, and if it were a standard benefit, it could be offered to everyone. So, this is maybe something else to consider.” (Obstetrician).

The obstetrician also stated, she would appreciate the opportunity and would be open to refer pregnant women to one free-of-charge nutrition counselling, if this were included in health insurance programs, as she recognised that it is otherwise too expensive and as a result not considered by most women.

“Nutrition counselling is of course great, but for most people it’s simply too expensive. But if a health insurance company would include such a program, I would be very open to it. If they were to say, okay, you have the opportunity to go to one nutrition counselling session.” (Obstetrician).

The importance but also time-consuming nature of a nutrition consultation was highlighted by the midwife, who did not have the impression that it is adequately addressed by obstetricians.

“And these are actually very extensive conversations. And this happens within the prenatal care with every woman, and how she reacts to how this conversation [with the obstetrician] went and whether there is still something there, whether there is still a need for discussion.” (Midwife).

Professional education

The prenatal healthcare professionals, interviewed in this study, did not feel adequately prepared by their professional education on the topic of nutrition in pregnancy. They personally had obtained further information through additional training programs or their respective professional associations. The interviewees agreed on the importance of the topic and the need to receive basic nutrition knowledge through their professional education. However, as the obstetrician pointed out regarding her experience during her medical studies, nutrition in pregnancy is a specific topic mostly relevant for those specialising in obstetrics.

“In the end, basic knowledge should of course be there. But there are many people who are not interested in it if they don’t go into obstetrics later on.” (Obstetrician).

The midwife recognised a certain backlog regarding nutrition counselling in pregnancy, while also noting that contents of professional education, be it medical studies or midwifery training, might be different today.

“There was a huge need to catch up on my knowledge, but I didn’t really notice it for a long time. However, during my time as a midwife, I realised that it was not enough, that there were simply topics that I was not familiar with. And I had to catch up and learn more through training and literature.” (Midwife).

With this qualitative study, we sought to assess pregnant women’s needs, wishes and preferences regarding sources for nutrition information and consultation on related topics. This was complemented and contextualised with impressions of involved healthcare experts, in consideration of interprofessional prenatal care. Women wished for a personalised counselling, catering to their individual needs, determined by factors such as their individual knowledge, coping abilities, their lifestyle and specific diet. The results of this study also show women’s need for clarity and intra- as well as interprofessional consistency regarding the information they receive from healthcare professionals. Focus group participants were in some cases offered a comprehensive consultation by their midwives, while obstetricians usually covered basic and general recommendations in terms of food taboos in pregnancy. Compared to women exclusively cared for by obstetricians, women in an alternating care model received a more extensive education in terms of nutrition, due to their midwifery care. However, the lack of personalised advice on nutrition and specific forms of diet, and the inconsistency of information from healthcare professionals resulted in a self-reliant internet research, which in turn exacerbated the already existing uncertainty and anxiety surrounding this topic for pregnant women. The study results identified social media as an integral part for pregnant women’s nutrition information rather than having received a satisfactory guidance on nutrition in pregnancy by healthcare professionals. The impact of the internet and social media in information-seeking on nutrition-related issues has previously been pointed out by multiple studies, amongst others [ 21 , 25 , 26 ] by Aktaç et al. [ 20 ] in pregnant Turkish women and by Bianchi et al. [ 27 ] in pregnant French women, who outline the increasing usage of the internet in answering immediate health-related questions and its contribution to anxiety, due to inconsistent information. This has also been reiterated by a Swedish study, who reported that most women searched the internet for pregnancy-related information, even despite the satisfying information some received from their prenatal healthcare professionals, causing feelings of worry [ 28 ]. A study that recently reviewed leading websites offering guidance on nutrition reported that women access information via the internet that is not in compliance with evidence-based guidelines and concluded a need for updated data on those websites [ 29 ]. Further results of our study indicate that pregnant women and healthcare professionals are concerned with similar topics, show however differences in the weighting of their importance. There is an agreement on the indisputable relevance of food taboos and the risk of infection through certain foods. Especially important to pregnant women was the way healthcare professionals communicate this, and our results show that providing differentiated information and putting potential risks into perspective rather than aggravating fears in respect to nutrition can enhance women’s health literacy and feeling of competence. Pregnant women’s concerns about nutrient supply during pregnancy were shown to be important not only to them but were also recognised by healthcare professionals. However, the results indicate that the topic of dietary supplements is much more worrisome for women than prenatal healthcare professionals realise. This suggests the necessity for healthcare experts to learn more about and implement personalised advice on the significance of different nutrient requirements in women’s individual pregnancies, particularly but not exclusively for those who follow a vegetarian or vegan diet. Advising women on essential and non-essential dietary supplements might alleviate the perceived burden of women who are concerned with the health of their child and worried about the impact of nutritional deficiencies. Research shows that an educational nutrition intervention could improve women’s knowledge of nutrition [ 30 ], while the promotion of nutrition awareness by healthcare professionals has additionally been shown to be more effective and longer lasting when interactive and according to women’s interests [ 31 ]. The benefits of personalised health information have been demonstrated by multiple studies on nutrition counselling and other various outcomes, showing that it can improve the adherence to diet and lifestyle interventions [ 32 , 33 , 34 , 35 ]. In the context of additional costs in pregnancy, the coverage of dietary supplements by health insurances could support women financially as many participants pointed out, especially for those who already struggle financially due to pregnancy-related expenses. A multivitamin preparation containing among other micronutrients folic acid is recommended by many obstetricians to women in pregnancy and preferred over individual dietary supplements, which became apparent during focus group discussions. In Germany, some health insurance companies reimburse costs for individual supplements such as magnesium, iodine, folic acid or iron [ 36 ], however, a multivitamin preparation must be paid by the consumers themselves. The reality is, which this study also demonstrates, that due to convenience and need for reassurance of obtaining all important micronutrients, pregnant women pay for multivitamins instead of selecting individual supplements that might be reimbursed. Additionally, due to dietary supplements being regulated by food laws in Germany, the market and quality control of those products lacks transparency and makes the selection more difficult [ 37 ]. It is important however to keep in mind that the participants of this study had a relatively high educational status, which is associated with higher adherence to supplementation [ 38 ]. The women additionally had the means to cover the expenses themselves, nevertheless mentioned the burden of those costs, especially women who were still in university at the time of the focus groups. While this has not been discussed specifically for Germany, studies from other countries show that free-of-charge folic acid leads to a higher adherence to supplementation and as a result fewer APOs such as spina bifida [ 39 ]. Beyond a cost-coverage of multivitamin preparations for pregnancy, providing women with a comprehensive education on essential nutrients and dietary supplements as well as a consultation on how to include those in everyday nutrition, which was voiced as a wish by many focus group participants, could decrease women’s expenses in supplements and improve motivation to do so, as previously pointed out by Zeng et al. as well [ 39 ]. Furthermore, the results of this study point to the empowerment that women can feel through their healthcare professionals when given information and helpful sources to gain control over their nutrition and lifestyle. However, the results of our study show a lack of professional preparation in respect to the expert’s education on nutrition in pregnancy, leading to privately obtained information by healthcare professionals. Study participants recognised as problematic that this circumstance can lead to very different outcomes regarding the advice pregnant women receive, due to its dependence on the self-education of their respective healthcare professionals, as a medical education is no guarantee for adequate nutrition information [ 5 , 6 , 40 ]. The women interviewed in this study pointed out their self-responsibility to care for their own health, wish however for the tools to do so provided by their healthcare professionals. Our study also suggests that healthcare professionals have the ability to either empower or unsettle the women in their care, which emphasises the importance of communication. The effect their statements have on pregnant women was also recognised by the interviewed midwife who believes that midwifery care can reinforce women’s confidence and ease the fears and concerns regarding, among other topics, nutrition. Interestingly, this aspect of midwifery care has previously also been discussed by Mattern et al., demonstrating that a reassuring care by midwives can increase equanimity and self-confidence in pregnant women [ 41 ]. Taking the time and creating a calming environment has been appreciated by the participants of this study and constitutes somewhat of an advantage midwives have in their approach to prenatal care, where they are usually able to dedicate more time to individual issues such as nutrition [ 41 ] as compared to obstetricians. Research has shown an increase of nutrition awareness in pregnant women, depicting pregnancy as a life event that can trigger motivation to eat healthier and be more interested in nutrition-related information [ 30 , 31 , 42 , 43 ], while interestingly, studies show limited knowledge of pregnant women about specific impacts of nutrition [ 21 , 43 , 44 ]. Finding relevant material and reliable sources can be an overwhelming task for pregnant women, considering the amount of information available, not only from web-based search engines, but also social media and society’s often unsolicited advice for pregnant women [ 30 ]. This can be difficult to filter, especially for women, who are new to this topic, with limited health literacy or nutrition competence. While the relatively high educational status of the study participants might go along with an increased health literacy [ 2 ], introducing a possible bias, the strengths of this study are the perspectives on a variety of different dietary forms, from omnivore to vegan, as well as the age range in the sample, from 23 to 38 year old pregnant women. Additionally, we received insights from women in all possible care models, from prenatal care exclusively by an obstetrician or a midwife to an alternating care model between the two professions. In future research, the results of this qualitative study could be extended with the usage of quantitative tools, such as the Patient Benefit Index (PBI) [ 45 ], assessing individual treatment goals and their subsequent achievement.

This study identified potential for the improvement of German prenatal care in terms of nutrition guidance in pregnancy. This includes the implementation of personalised nutrition consultation in prenatal care, considering women’s individual needs and dietary forms as well as their coping abilities regarding health-related risks through foodborne illnesses and the amount of information they receive at the beginning of pregnancy. The usage of internet sources was shown to exacerbate already existing fears and anxiety in pregnant women, which was proposed to be effectively counteracted by adequate, empathetic and individualised guidance by healthcare professionals. Women in alternating prenatal care models between midwife and obstetrician were found to be more content with their overall nutrition consultation, especially compared to those solely cared for by an obstetrician. Insufficient and inconsistent nutrition information from healthcare professionals could be counteracted by implementing this topic in their professional education. As awareness and knowledge of pregnant women are essential in reducing the risks for APOs associated with poor nutrition, the communication on part of the healthcare professionals should reinforce the importance of nutrition in pregnancy.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on request.

Abbreviations

Adverse pregnancy outcome

Low birth weight

Preterm birth

Gestational diabetes mellitus

Large for gestational age

Small for gestational age

Body mass index

Local psychological ethics committee of the UKE

Open science framework

University Medical Center Hamburg-Eppendorf

Standard deviation

Patient Benefit Index

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Acknowledgements

The authors thank the Scientific Communication Team of the IVDP, in particular Sara Tiedemann and Mario Gehoff, for copy editing.We would like to thank all pregnant women and healthcare experts for their participation in this study.

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ME was involved in study conceptualisation, data collection, data analysis and interpretation as well as drafting the article manuscript. CJA contributed to the conceptualisation of the study, data interpretation, drafting and editing the manuscript. JS contributed to the conceptualisation of the study, recruitment and editing the manuscript. NM contributed to the conceptualisation of the study, data analysis and editing the manuscript. BCZ contributed to the conceptualisation of the study, data interpretation, drafting and editing the manuscript and providing critical and important intellectual content. The authors read and approved the final manuscript.

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The study was approved by the Local Psychological Ethics Committee of the University Medical Center Hamburg-Eppendorf (LPEK-0507) and registered at OSF 12.09.2022 ( https://doi.org/10.17605/OSF.IO/YP7BR ). The interviewer explained the purposes of the research, voluntary participation, confidentiality of records, and that the participants may stop the interview at any time (see Supplement S1 and S2 ). Following participant’s approval to be involved in audio-recorded focus groups and interviews, their informed consent was also obtained. Privacy and confidentiality of all study information was maintained. All methods were conducted in accordance with relevant guidelines and regulations.

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Ebinghaus, M., Agricola, C.J., Schmittinger, J. et al. Assessment of women’s needs, wishes and preferences regarding interprofessional guidance on nutrition in pregnancy – a qualitative study. BMC Pregnancy Childbirth 24 , 154 (2024). https://doi.org/10.1186/s12884-024-06351-z

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  1. Qualitative Research via Focus Groups: Will Going Online Affect the

    Online focus groups are becoming a more popular and accepted method for collecting qualitative data, accounting for more than US$1 billion of the US$10 billion in annual spend on global qualitative market research ( ESOMAR, 2018; Synnot et al., 2014; Wilkerson et al., 2014; Woodyatt et al., 2016 ).

  2. What is a Focus Group

    Focus groups are a type of qualitative research. Observations of the group's dynamic, their answers to focus group questions, and even their body language can guide future research on consumer decisions, products and services, or controversial topics.

  3. Implementation of virtual focus groups for qualitative data collection

    Focus groups are an important part of qualitative research and is a well-established method for collecting data to explore participants' opinions, experiences, and perspectives. 5 The hallmark of focus groups is to produce data and insights from a group interaction that would be less pronounced in an interview setting.

  4. Online focus group: What it is, types, and free examples

    An online focus group is one of the newer online research methods used primarily to conduct business research, consumer research, and other research that needs online qualitative research.

  5. Zooming into Focus Groups: Strategies for Qualitative Research in the

    Qualitative research focuses on exploring individuals' perspectives related to specific research questions, issues, or activities ( 1 ). Frequently, structured interviews or focus groups are tools employed for data collection for qualitative research.

  6. Interviews and focus groups in qualitative research: an update for the

    Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10, 11 The qualitative researcher seeks to answer questions of 'how' and 'why',...

  7. The use of focus group discussion methodology: Insights from two

    Online focus groups boast an aura of dynamism, ... , focus group discussion, as a qualitative research method, is comparatively easier to conduct since all the target participants and the researcher are readily available in one location at the same time. Geographic proximity is an important consideration for researchers with resources ...

  8. Qualitative Research: Introducing focus groups

    Qualitative Research: Introducing focus groups. This paper introduces focus group methodology, gives advice on group composition, running the groups, and analysing the results. Focus groups have advantages for researchers in the field of health and medicine: they do not discriminate against people who cannot read or write and they can encourage ...

  9. UCSF Guides: Qualitative Research Guide: Focus Groups

    Qualitative Research Guide Online and collection-based resources to aid in conducting, finding, using, synthesizing, and teaching qualitative research in the health sciences. What are Focus Groups?

  10. Online Focus Groups

    The traditional, face-to-face focus group method has been a highly effective qualitative research tool (Collis & Hussey, 2013); it makes possible the gathering of detailed information regarding participant perceptions, opinions, beliefs, and attitudes regarding particular phenomena.An established qualitative methodology, using focus groups dates back to the early 1940s (Liamputtong, 2011) and ...

  11. Focus Group Research: An Intentional Strategy for Applied Group Research?

    Focus groups are an established mechanism for data collection across qualitative, mixed method, and quantitative methodologies (Pearson & Vossler, 2016 ). Although employed differently within each research paradigm, the popularity of focus groups is increasing (Carlsen & Glenton, 2011; George, 2013; Kress & Shoffner, 2007; Massey, 2010 ).

  12. "Conducting An Online Focus Group" by Jeanine Stancanelli

    Traditionally, focus groups have been conducted in person using the face-to-face format. However, improvements in technology have resulted in the emergence of the online focus groups. Online focus groups are an extension of traditional focus groups, which have been utilized in qualitative research for decades and, for the most part, the principles are consistent with traditional focus groups ...

  13. Methodological Aspects of Focus Groups in Health Research

    Historically, focus groups were used mainly for market research before the method was adopted for application in qualitative research in the social sciences ( Morgan, 1996 ). The use of focus groups in health care research is even more recent.

  14. VisionsLive

    Our online qualitative research platform is easy to use and accessible with a single click. It supports all devices and operating systems, including smartphones; tablets (Android, iOS) and computers (Mac, PC, Linux), ensuring a seamless experience for users. 24/7 support from our customer success team to make your project perfect

  15. An Overview of Qualitative Research and Focus Group Discussion

    The survey results were compared and combined with the parents' experiences shared during the FGD.Focus Group Discussion (FGD) is a technique for gathering in-depth qualitative data on a ...

  16. Educating the nurses of tomorrow: exploring first-year nursing students

    The study employed a qualitative exploratory and descriptive research design. Data collection took place in October 2022 using focus group interviews. A total of 53 students in their first year of the bachelor's programme at the Oslo Metropolitan University participated in eight focus group interviews.

  17. Qualitative Research via Focus Groups: Will Going Online Affect the

    These results highlight the potential for online focus groups to generate idea diversity at a level that is comparable to in-person focus groups. For practitioners seeking to benefit from guest insights, the findings help to substantiate the value of a lower cost, faster-to-market data collection method.

  18. Assessment of women's needs, wishes and preferences regarding

    The aim of this study was to assess the needs, wishes and preferences of pregnant women regarding the interprofessional guidance on nutrition in pregnancy. Using a qualitative approach and a purposive maximum variation sampling strategy, 25 pregnant women were recruited to participate in six semi-structured, guideline-oriented online focus groups.

  19. A Qualitative Framework for Collecting and Analyzing Data in Focus

    Traditionally, focus group research is "a way of collecting qualitative data, which—essentially—involves engaging a small number of people in an informal group discussion (or discussions), 'focused' around a particular topic or set of issues" ( Wilkinson, 2004, p. 177).

  20. Applied Sciences

    Research staff members recorded, transcribed, and analyzed the focus groups, using a thematic analysis to code and classify the comments. (3) Results: A total of 43 categories of coded statements divided into 12 subthemes and five broad themes were identified and compiled in two core areas of content: clinical care and administrative tasks.