Focus group on qualitative research : experience report

Objective: to report the experience of applying the focus group technique for production of data in qualitative research. Method: four group sessions were held from May to June 2015, with the participation of professionals from the public sector of PHC and from specialized service. Results: the way focus group was developed is described in steps: planning, recruitment, ambience, group sessions, and evaluation. Conclusion: we highlight that the focus group, as a technique to produce data in collective space, can contribute not only to the construction of knowledge in Nursing, but also to the research approach with the assistance practice. Descriptors: Focus Groups; Qualitative Research; Nursing; Methodology; Methodological Research in Nursing. RESUMO Objetivo: relatar a experiência da aplicação da técnica de grupo focal para produção de dados em pesquisa qualitativa. Método: realizaram-se quatro sessões grupais no período de maio a junho de 2015, com a participação de profi ssionais da rede pública de APS e do serviço especializado. Resultados: a forma como o grupo focal foi desenvolvido está descrita nas etapas: planejamento, recrutamento, ambientação, sessões grupais e avaliação. Conclusão: destaca-se que o grupo focal como uma técnica de produção de dados em espaço coletivo pode contribuir não só para construção do conhecimento em Enfermagem, mas também para a aproximação da pesquisa com a prática assistencial. Descritores: Grupos Focais; Pesquisa Qualitativa; Enfermagem; Metodologia; Pesquisa Metodológica em Enfermagem. RESUMEN Objetivo: narrar la experiencia de aplicación de la técnica de grupo focal en la producción de datos para estudios cualitativos. Método: se llevaron a cabo cuatro sesiones grupales en el período de mayo a junio de 2015, con la participación de profesionales de la red pública de la Atención Primaria en Salud y de servicios especializados. Resultados: la forma en la que se organizó el grupo focal sigue las siguientes etapas: planifi cación, reclutamiento, ambiente, sesiones grupales y evaluación. Conclusión: el grupo focal es una técnica de producción de datos en espacio colectivo que pude contribuir no solo con la construcción de conocimiento en Enfermería, sino también con el acercamiento del estudio a la práctica del cuidado. Descriptores: Grupos Focales; Estudio Cualitativo; Enfermería; Metodología; Estudio Metodológico en Enfermería. Focus group on qualitative research: experience report Grupo focal na pesquisa qualitativa: relato de experiência El grupo focal en el estudio cualitativo: narración de la experiencia EXPERIENCE REPORT Daniela Dal Forno Kinalski E-mail: daniela.kinalski@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
The qualitative research extrapolated the field of social sciences, being also helpful in health sciences (1) .This research approach encourages understanding, description and analysis of the reality through the dynamic of social relations.It addresses the universe of meanings, motives, aspirations, beliefs, values, attitudes, perceptions, opinions, interpretations as to how people live, build themselves and their artifacts, feel and think (2) .
In the field of health, Nursing was a pioneer in this approach and maintains its contribution in an upward trend, both quantitatively and qualitatively, in the production of knowledge.This production allows the understanding of the human being in its complexity and depth, promotes the approach between teaching and practice, and develops health assistance through experiences and social relations (1,(3)(4) .It requires from the researcher an immersion in the field of study, with the respective participants, besides dealing with their intersubjectivity.Regardless of the data collection technique, the researcher must be aware of the movements of the participants in the research context, in addition to following a methodological rigor (1) .
It is effective even in studies that aim to investigate the organization of health services and public policies.Several data production techniques are used in qualitative research, including the focus group (FG), which is consistent in studies that have the intent to plan health interventions and discussions of reality (5) .
The FG is applied as a technique by the researcher who aims to collect information on a specific topic through participatory discussion among the participants, gathered in one place and during certain period of time (5) .The FG values the interaction between the participants and the researcher, being held from the discussions focused on specific and directive topics.This provides the exchange of experiences, concepts and opinions among the participants.It promotes discussions and prepare group tactics to solve problems and transform realities, focusing on learning and exchange of experiences on the issue under study, increasing the role of the participants as they dialogue and build collectively the results of the research (5) .
The FG has won recognition as a technique of production of data, by the application in various research areas (6) .In the area of Nursing, we can observe that the FGs are present.However, scientific publications discuss its use in the context of their studies, with a small investment on nursing research that address essentially the technical planning of FG.We felt the need to disclose this technique as an ally in investigative practices (7) .
Thus, this article aims to report the experience of using the FG technique for data production in qualitative research that intends to plan an intervention in health care practice.The relevance consists in creating strategies that assist in evaluation processes and in the discussions of health care quality.This study was approved by the Research Ethics Committee of the institution.

THEORETICAL FRAMEWORK
Enrique Pichon Rivière, Swiss psychiatrist, had as epistemological pillars the psychoanalysis and social psychology and developed a mode of group intervention: operative (8) .This technique was proposed from a dialectical view of reality.Its constructs are based on the idea of movement and continuous transformation of people, of their bonds and of the way they operate in reality.It puts the participant as the center of the learning process and as the protagonist in the production of his health and in the construction of knowledge (9) .
Operative groups are characterized as a non-directive technique, to transform a group situation in a field of active research.The group is defined as "a restricted group of people, who are linked by constants of space and time and articulated by their mutual internal representation, it is proposed, in explicit or implicit form, to a task that is its purpose" (10) .
The task in the Pichonian technique is defined as the path that will be taken to achieve the goal set by the group.It is the moment when the participants explain their opinions and establish a relationship with each other in the group.The task involves the resources that the participants have to interact since the verticality of the participant, with his life story, his experiences, which in turn refer to the horizontality of the group, i.e., to the sharing of these interactions.The task has two dimensions: explicit, related to the reason for the formation of the group and its objectives; and implicit, the elaboration of anxieties caused by the mobilization of changes, such as feelings and emotions, which can prevent the achievement of the task (10) .
Another important point is the group dynamic, marked by four roles: the leader, the saboteur, the scapegoat, and the spokesman.The leader acts as a facilitator and assists the group in carrying out the task, while the saboteur acts in movement contrary to the changes.The scapegoat is the saboteur of the task, who receives the negative aspects of the group.The spokesman is responsible for announcing or denouncing what happens in the group.For a group to act operatively, there needs to be a rotation of these roles among the participants, to provide the fulfillment of the task and avoid the obstruction of learning (10) .
This collective learning process occurs through an intense movement of structuring, destructuring and restructuring, represented by the figure of an inverted cone, which illustrates the scheme of the whole task, passing by the search for something new, desire for change, fear of getting in touch with something new, feelings of anxiety and resistance.It expresses what is explicit and implicit in the group, their manifestos and latent content.Such a movement is not linear, therefore called dialectic spiral (10) .
Thus, in an operative group, everybody contributes to the task, because they are involved with their personal experience, a way to relate and constitute themselves.As the Pichonian referential focuses on learning, transformation, and on the dialectic of human and group processes, the technique of operative groups becomes a valuable tool in the operationalization of scientific research for construction of knowledge in the health area (9) .
Thus, this research, based on the Pichonian assumptions of operative group, articulates with the explicit task of discussing with health professionals about the health care conditions of children and adolescents living with HIV; and with the implicit task to handle their opinions and feelings about the social construct of this theme and the limits and possibilities of their daily life assistance.The use of this referential is justified by providing in-depth discussion and group logic, besides clarifying aspects of this reality, which may be useful in the search for the health care quality of this population.

USE OF THE FOCUS GROUP TECHNIQUE IN RESEARCH FOR PLANNING OF INTERVENTIONS
The research aimed to discuss the construction of the Health Care Network (RAS) of the children and adolescents living with HIV, in the city of Santa Maria, Rio Grande do Sul, Brazil.That is because the recommendation of the public health policy is for specialized services, which mostly assist this population, to act along with the services of Primary Health Care (PHC), possible through the implementation of a RAS.To this end, the structuring of municipal politics is necessary to implement a transfer system, definition of the activities of responsibility of each service and the permanent education of the professionals.They need to know the children and adolescents living with HIV in their area of influence and develop welcoming actions and strengthening of bonds.
We used three fields as the setting of the study: 1) the PHC public network of the city (18 Basic Health Units and 13 Family Health Strategies); 2) specialized services for children and adolescents living with HIV, located in the pediatric outpatient clinic of Santa Maria University Hospital (HUSM), which provides monitoring of 47 children and 45 teenagers living with HIV; and 3) Casa Treze de Maio, which has as main objective the incorporation of a task of the public power regarding health care.
The participants were professionals of these services that met the inclusion criteria of the study: to be an active professional in the pediatric outpatient clinic of the HUSM, PHC, or Casa Treze de Maio.And as exclusion criteria: to be a hired professional who did not belong to the effective board of the city or those who were on sick leave or leave of absence during the period of data production.
In this research, we held four group sessions, with schedule agreed among the participants, from May to June 2015.The development of the FG is described in the steps: planning, recruitment, ambience, group sessions, and evaluation.

Planning
The planning of the FG has an impact on the data collected and, consequently, on the achievement of effective results (7) .To do so, is necessary to plan how to meet the compositional criteria, tools and operationalization of the group sessions.Below is the organizational chart of the FG (Figure 1).
The planning of the FG, in this research, predicted a number of up to 15 participants who fulfilled the criteria listed; with the coordination composed of one moderator (master, author of the research) and two observers (PhD students of the research group), to be prepared by means of thematic and methodological study group and collective guidelines, considering their previous experiences.We planned three sessions of 50 minutes each, in a room provided by the Nursing Department of the Federal University of Santa Maria, with dates and time agreed during the recruitment with the potential participants.The tools for the operationalization of the group sessions included: ambiance in the local of study for the recruitment of participants; theme guide, focused on three main objectives, each being the main focus of a session; evaluation guide, with pilot test applied in the environment of the research group.

Ambiance
The three fields listed were visited by the researcher to verify the possibility of conducting the study in these locations.It was noticed that the study was accepted, both by the professionals and coordinators of services and municipal policies.
As the second step, the researcher returned to the fields of the research to talk to the coordinators of the services about which would be the best strategy for the development and selection of participants.The conclusion was that the best strategy would be to hold a formal invitation to all fields of research, for identification of the number of interested professionals, as well as the identification of the best place, day and time for the first group session.

Recruitment
After these visits to the fields, the disclosure of the research to the possible participants began.The researcher visited all fields of research to give the printed invitation to the services, and thus have an estimate about how many professionals would be interested in participating.Arriving at the local, the researcher would introduce herself and ask to speak to the responsible for the service.She would then explain the purpose of the research and the possibility of a representative, doctor and/or nurse to participate.Then, she would talk to these professionals and ask about their interest in participating; if the answer was yes, she would write their name and phone number down on a list, so that she could get in touch on the week of the first meeting, to revise the key information and obtain their confirmation.We highlight that this invitation contained address, date and time; and that the warning, on the week of the meeting for confirmation, was done over the phone.This step was extremely important for her and for the research because it was in that moment that the first relation between participant and researcher happened; also, the presence of the participants in the focus groups is directly related to the convocation (7) .
By visiting all the fields of research,the researcher made a list with 15 names of professionals, who confirmed their interest in participating, and, thus, the sample was established in accordance with the studies on the focus group technique.They show that a range from 6 to 15 participants is generally recommended.Traditionally, 8 to 10 participants constitute an ideal group.There are also smaller groups from five to seven participants.The size of the group will depend, also, on the objectives of the research.Thus, if the objective is to have multiple points of view, is enriching to opt for a larger group, opposed to thematic depth, in which a smaller group should be selected (7) .
In recruitment, indication of local and time preference for the group sessions were requested from those who showed interest and willingness to participate in the research.The choice of location has fundamental importance in the adhesion of the participants, therefore, it is necessary to establish an environment conducive to interactions (7) .The local most people indicated was the Nucleus of Permanent Education of Santa Maria (NEPES) at 7 p.m., after workday.NEPES is characterized as a service, under the responsibility of the municipal government, which works directly with issues related to the permanent education of the professionals who perform their labor activities with the Secretariat; and linked to the relationship between teaching/service of Higher Education Institutions and Technical Schools with the public service network of the city.
The local chosen has a proper structure, is located in the central part of the city, facilitating the access to the participants.It is a warm, comfortable environment, with privacy, lighting and appropriate temperature.The sessions were held in a conference room, where the seats were arranged in a circular form, in which the participants, moderator and observers were part of the same visual field, with space for organizing coffee breaks and collective discussions.

Theme guide
This guide was a road map for the operationalization of the meeting.Its organization is closely related to the purpose of the study and to the research.In it, there is a scheme of the key moments of each session, which guided the discussion, promoting a more productive investigation (7) .In this study, four theme guides were organized, each one related to the objective of the session.Its importance refers to the good progress of the research, as well as to the aid for the moderator and observers.

Group sessions
The group sessions were operationalized according to the key moments: opening of the session; introduction of the participants among themselves; explanation about the dynamic of the participatory discussion; establishment of the setting; debate; synthesis; and closure of the session (7) (Chart 1).
The recruitment indicated 15 participants; however, during the group sessions, new members participated.In the first session, six participants who had not confirmed justified the interest in their introduction at the local previously scheduled, thus we had 21 participants.In the second session, two other participants justified to have been invited by members of the research group.It was a total of 23 professionals who participated in the meetings, supported by the prerogative of flexibility, pointed out by the literature that recommended from 6 to 15 participants, allowing expansion with justification and agreement with the group (7) .
We respected the homogeneity of the participants of the group, according to their experiences on the health care of the population studied, important to the verticality precept of the group; and with the representation of at least one doctor and one nurse from each point of assistance.
The coordination team was composed by the moderator, responsible for the research and two observers.The moderator is a facilitator of the debate, someone who has a significant role for the proper conduction of the meeting from a dialectical perspective (6) .It entailed preparation, organization and instrumentalization at all stages to mediate the explicit dimension of the task, resuming when necessary that the group had a goal in common.
In addition to presenting favorable attitudes to the group interaction to ensure the task in its implicit dimension.The moderator in this reasearch facilitated the dynamism and the circularity of the group dynamic, detecting situations in which it was necessary to encourage the rotation of roles among the participants to enhance the objectivity of the task amid the subjectivity inherent to each participant of the group, in order to sustain the perspective of group production.
The observers, in this research, were participative, becoming part of the group, doing more than watching and listening, being of paramount importance for the success of the technique.Their role was to monitor and register the expressions of the participants (verbal and non-verbal -implicit dimension of the task) and assist in the conduct of the meetings, in addition to controlling the time and the recording equipment (6) .In this research, the observers were two nurses, PhD students and members of the research group.
The sessions were 2 hours long, following the modules recommended by the literature to provide the structuring movement (that which has been developed in the health care of children and adolescents living with HIV), destructuring (opening, group reflection, and construction of possibilities for this daily life assistance), and restructuring (proposal of health care flow in the city).With this, there can be a moment of group heating, essential for the articulation of ideas for the debate, apart from the moment of synthesis and closing (10) .
It should be noted that, as the first session exceeded 50 minutes, the moderator made a deal with the group, according to the literature indication (7) .Thus, the agreement was that the group production would have 2 hours.The sessions were recorded on audio with the aid of two recorders arranged strategically for sound capture.
The conduction of the debates followed a semi-structured method, which used a theme guide previously outlined (shown in the section "Debate" in Box 1), to enhance the participatory discussion.
We also had a free debate among the participants and, consequently, with the production of questions among them, essential to ensure the group horizontality.From the second group session, in addition to these grants, the theme guides were organized based on the discussions of the previous sessions.
Evaluation In this research, we used the evaluation guide, applied at the end of the last session, to identify how it was the conduction of the FG according to the participants.This instrument was composed of questions about the local and time, operationalization (objectives, guide themes, conduction of Chart 1 -Key moments of the group sessions for the research on the construction of a Primary Health Care Network for children and adolescents living with HIV in the city of Santa Maria, Rio Grande do Sul, Brazil, 2015 Synthesis of the previous session and explanation of the purpose of the new one.We stress that, in the second session, it was necessary to start by resuming the combinations and information provided in the first one, due to the participation of new members, which at that moment also signed the informed consent form.

Introduction of the participants among themselves
The dynamic was conducted in pairs, in which the participants introduced the colleague alongside.
There was no need to resume the introduction, since the participants who integrated the group in the second session were managers, therefore they knew the other participants and were known by them.Everyone remained with badges identifying their names, and the colors indicated the different services.

Explanation about the dynamic of the participatory discussion
Information about the development of the session and theme guides

Establishment of the setting
In the first session, aspects related to logistics and dynamic of the sessions were agreed, such as punctuality, closing time, parallel conversations, use of electronic equipment.We highlighted the commitment of the participants and coordination team with the confidentiality of the research.Finally, the signature of the informed consent form.
In the other sessions, this agreement was incorporated when necessary.the participatory discussion, and synthesis), role of the moderator and of the observers.The possibilities of answer were in a Likert scale, and the analysis of the results pointed out the suitability of the FG.

FINAL CONSIDERATIONS
In this research, the choice of the focus group technique was fundamental for the emergence of points of view and meanings and, consequently, for the success of the discussions.The experience with the FG technique allowed us to realize the importance of a careful planning for the development of the sessions.The continuation of a methodological rigor of operation promoted relations among the participants and the discussion of a common theme of knowledge and interest.The researcher needs to have appropriate knowledge of the technique, to be immersed in the goal of the research, in the theme of the study, and to know the characteristics of the participants, to, consequently, obtain a greater reliability of the data.
The establishment of a group interaction was critical to the intervention, the participatory discussion of the constitution of RAS to children and adolescents living with HIV and the collective construction of the health care flow of this population in the city.The FG allowed the participants of the research to discuss this theme for the first time, in addition to providing a relationship of trust among them.
The FG allowed the construction of the health care flow of children and adolescents living with HIV in the city.However, this study had limitations such as the difficulty that many participants had in controlling themselves not to interfere and provide value judgements in the discussions, as well as the dominance and deviations of the participants.
We highlight that the FG is an appropriate strategy for research that aim to understand group experiences and transformation of reality.For the nursing scientific research, this study contributes to the disclosure of the technique, still new, but promising, besides contributing to the planning and execution of research in the field of nursing and public health that aim to plan interventions in the health care practice.

Figure 1 -
Figure 1 -Organizational chart of the focus group planning