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research-article2014

QHRXXX10.1177/1049732314549602Qualitative Health ResearchTuttas

Advancing Qualitative Methods

Lessons Learned Using Web Conference Technology for Online Focus Group Interviews

Qualitative Health Research 2015, Vol. 25(1) 122­–133 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314549602 qhr.sagepub.com

Carol A. Tuttas1

Abstract Researchers use Internet technology for data collection in qualitative studies. In the literature there are published accounts of synchronous (real-time) and more commonly, asynchronous (not-real-time) focus group data collection methods supported by Internet technology in the form of email correspondence, LISTSERVs, discussion boards, and chat rooms. Real-time audiovisual Web conference technology offers qualitative researchers a promising alternative means to carry out focus groups. In this methodological article I describe how I used Web conference technology to host online focus groups for a qualitative study about job integration experiences of travel nurses geographically dispersed across the United States. I describe lessons learned from the use of this innovative method for qualitative data collection, including a brief overview about the use of dictation software for transcription. This new knowledge is useful to researchers considering Web conference technology to carry out focus group data collection in qualitative research. Keywords data collection and management; focus groups; group interaction; interviews, electronic; research, online; technology, use in research Rapid advancement in and availability of Internet technology continue to broaden the options for participant recruitment and data collection methodology in health care research. Currently, it is feasible to reach and include study participants almost anywhere in the world. The utility of Internet-assisted methods for qualitative research data collection is documented in the literature (Matthews & Cramer, 2008; O’Connor & Madge, 2003). The Internet is an effective means to reach key populations whose participation might otherwise be precluded by time, distance, and even social barriers (Murray, 1997; Turney & Pocknee, 2005). Focus groups (FGs) are a popular means to collect qualitative data in health care research (McLafferty, 2004). The transition toward virtual FGs began in the marketing industry with the use of asynchronous nonaudiovisual Internet techniques (Murray, 1997; Stewart & Williams, 2005). Nonetheless, some reluctance persists to accept online methods as an appropriate alternative to personally attended, face-to-face FGs. For example, the president of a research firm in Connecticut contended that the concept of Internet FGs is not sound. He argued that these methods are not sufficient to capture essential elements such as the role of the moderator, the ability to note nonverbal responses, and group atmosphere and

dynamics (Greenbaum, 2008). Personally attended faceto-face FGs are embraced by social scientists, but the notion of a virtual venue has been slower to gain popularity (Turney & Pocknee, 2005). Internet-assisted methods described in the literature for hosting online FGs are predominantly asynchronous, which means they do not occur in real time. These methods include discussion boards, LISTSERV mailing lists, and closed email discussions. Attempts to achieve synchronous online FGs though the use of chat room environments are also documented. In one of the earliest documented accounts describing the use of computermediated communication to collect qualitative data, Murray (1997) described private email discussions as the venue for asynchronous FGs. At that time, the researcher speculated that Web-based audiovisual (AV) conference technology was not advanced enough for such use and that online FGs would remain almost exclusively textbased for the foreseeable future. Fifteen years later, the 1

CGFNS International, Inc., Philadelphia, Pennsylvania, USA

Corresponding Author: Carol A. Tuttas, CGFNS International, Inc., 3600 Market St. Philadelphia, PA 19104, USA. Email: [email protected]

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Tuttas literature review for the study referred to in this article yielded no published guidance relative to collecting data using real-time, AV-recorded FGs carried out in a Web conference meeting space. Asynchronous methods such as discussion boards and email LISTSERVs offer FG participants the advantage of a perceived identity shield, mitigating social inhibitions and facilitating willingness to openly discuss sensitive topics compared with in-person FGs (Turney & Pocknee, 2005). Researchers use synchronous Internet-assisted FGs such as real-time chat room software with some success, but there are skill-related limitations such as participants’ typing speeds and the need to “think, type, which is to look at the screen, read the text and maintain a logical thread of answering” (O’Connor & Madge, 2003, p. 140). Asynchronous Internet environments (Turney & Pocknee, 2005) and synchronous Internet chat environments (Stover & Goodman, 2012) might lift inhibitions among FG participants, facilitating a freer-flowing discussion. To compare FGs implemented via computermediated communication (CMC) with conventional face-to-face methodology, Reid and Reid (2005) carried out 16 small FG groups (n = 3) using a chat conference program. Although the number of words produced by the interactions occurring in the traditional FG method exceeded that of CMC, the CMC FGs produced a greater volume of ideas and solutions. These findings led the researchers to determine that CMC methods might be more appropriate in some studies. Despite some researchers’ assertions that Internetassisted methods offer an effective means to capture the essential elements of an FG, others maintain that such methods are too distant from the traditional notion of a face-to-face, personally attended FG in that the moderator has no active role, and the sense of participant engagement and immediacy of responses is lacking or absent (Matthews & Cramer, 2008; O’Connor & Madge, 2003). When immediacy of response is not required, participants have time to ponder and discuss the moderator’s questions outside of the FG and can write and edit their responses before posting, thereby forfeiting the potential to capture spontaneity. Literary guidance to inform researchers about the use of Web conference technology for synchronous “face-toface” online FGs and the selection of a best-fit Web conference service for a given study currently lags behind the proliferation and advancement of virtual venues. The purpose of this methodological article is to explain the lessons learned from the use of Web conference technology in a qualitative study in which synchronous, AV-recorded, face-to-face FGs were carried out with travel nurses geographically dispersed across the United States (Tuttas, 2014). A brief discussion about the use of dictation software for the transcription of FG recordings is also included.

The article contributes to a limited but growing body of knowledge and guidance nested within the scope of technology-assisted qualitative data collection methods.

Why Web Conference FGs? Similar to Internet chat rooms, Web conference technology offers the advantage of real-time communication among multiple users across various geographical locations where Internet service is available. Other advantages of Web conference technology include the capacity for participants and the moderator to see each other via full-motion webcam images, and hear each other using microphones and speakers. These features support an FG environment that more closely resembles a traditional face-to-face FG wherein participants can interact across more dimensions than in a chat room or discussion board environment. Web conference technology supports immediacy and spontaneity in responses, facilitates an active moderator role, and enables the researcher to gain a deeper perspective about the degree and quality of interaction, engagement, and nonverbal activity among participants both during the FG and later, when analyzing the AV recording. Numerous examples in the literature draw attention to the effectiveness of Internet technology for carrying out FGs (Gaiser, 1997; Kenny, 2005; Stewart & Williams, 2005; Stover & Goodman, 2012; Williams & Reid, 2012). However, despite these important contributions to the state of the science in technology-assisted FGs, the literature review for this study yielded no published studies in which synchronous AV-recorded FGs were carried out in the social space of a Web conference. In this article, a recent study about travel nurses is referenced to exemplify the method of hosting FGs using Web conference technology. Travel nurses are experienced, mobile RNs contracted via the agency of health care staffing firms to work temporary job assignments, bridging staffing insufficiencies at hospitals across the United States. By virtue of their chosen work arrangement, these nurses are newcomers to jobs three to four times per year. Travel nurses are not widely studied despite their essential role in enabling hospitals to achieve and maintain appropriate nurse staffing. The near absence of published research about travel nurses warrants a qualitative approach to understand their perceived job integration experiences in a work arrangement that deems them newcomers to jobs on a recurring basis. One way to augment knowledge about a topic that has not been previously studied is to collect data using FGs. This method offers several advantages. First is the interaction between and among participants, which adds a valuable dimension to the data collection that is absent from other methods (Kitzinger, 1995). Second, group

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dynamics factor into the quality of the data as participant interactions and responses are called out in a stimulating yet nonthreatening setting (Burns & Grove, 2009; Kitzinger, 1995; Krueger & Casey, 2000; McDaniel & Bach, 1994). Finally, knowledge generated from FG data analysis can elucidate contextual meaning from the results of quantitative analyses (McDaniel & Bach). Hosting face-to-face FGs with travel nurses in person is not feasible because they are situated in various geographic regions and relocate asynchronously. Web conference technology was selected as the method for data collection to capitalize on important features of FG methodology such as immediacy of response, direct moderator involvement, and group interaction with the capacity to observe group dynamics. I had prior experience using Web conference technology to offer interactive educational webinars. The use of Web conference technology as a platform for FGs is an innovative data collection method that offers promise for studying phenomena among populations of interest such as travel nurses, who are geographically dispersed.

Study Description The purpose of this methodological article is to describe how Web conference technology was used to collect FG data for qualitative research. A brief description of a recent study in which the technology was used is presented as an example to furnish a contextual backdrop. The study in its entirety is published separately (Tuttas, 2014).

Design I designed a mixed-methods study to gain understanding about travel nurses’ integration experiences at new job assignments. For the quantitative portion of the general parent study I collected data via a Web-based survey (N = 107). For qualitative data collection, I used Web conference technology for moderating and recording four FGs, each attended by 2 to 5 participants (N = 15), a subset of the general-study sample. Using Krippendorff’s (2004) technique for qualitative content analysis, I analyzed the qualitative data that were collected via the Web conference FGs.

Procedures Selection of the platform. I established eight criteria for selection of the Web conference service used in this study. First, the technology must support meetings attended by up to 10 participants. Second, the service must support real-time audio and full-motion video imaging. Third, the service must support AV recording of the

FGs; both the audio and webcam images must play back from the saved recordings. Fourth, access to recordings must be restricted to the research team. Fifth, no more than moderate technical competency must be required of participants. Sixth, the research team should carry the bulk of the technological activity necessary for participants to join the meeting. Seventh, participants must not be required to purchase and install software. Finally, only invited parties can gain access to enter the meeting space. After establishing the selection criteria, I evaluated several AV Internet-technology options for FG data collection. To select the Internet platform used for this study, I based my points of assessment on the technology available at the time. Strengths and weaknesses of the Web conference services that I evaluated are detailed in Table 1. The Adobe Connect Web conference service was ultimately selected to host FGs in this study. FG process.  Prior to recruiting participants and initiating data collection I secured approval from the University of Miami Human Subjects Research Office. I sent an email message to each invitee, containing an embedded link to open the electronic consent via a secure, Web-based university survey platform. The consent included a detailed description of the data collection method and disclosure that each FG would be AV recorded. The consent also included a description of the technology that each FG participant would require access to, such as a desktop or laptop computer with Internet connectivity (Ethernet was preferred over wireless for the most stable connectivity), a microphone, speakers, and a Web camera (webcam). I retained a research assistant (RA) to coordinate and moderate the FGs. The RA was a travel nurse studying to earn a master’s degree in nursing. Before data collection began, the RA received education from an experienced qualitative nurse researcher at the university about how to moderate FGs using the interview guide that I prepared. The RA and I engaged in numerous practice sessions using the selected Web conference service. Prior to recruiting study participants, I staged mock FGs by scheduling Web conference sessions using the selected system and inviting colleagues to log in to the virtual meeting space. I also oriented the RA to scheduling and opening a virtual meeting space using the selected Web conference service. Functional features were displayed on the host screen, which were necessary for the moderator to manage the meeting, but were not visible to participants. The RA became well acquainted with the appearance and functionality of the participant and host screens. It was essential for the RA to master this dual skill set so that as the FG moderator she could facilitate ease of participant entry to the virtual meeting space and contributions to their respective FGs. The mock sessions

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Tuttas Table 1.  Technology Selection: Strengths and Limitations. Technology Skype (Microsoft)

ooVoo (ooVoo LLC)

Strengths

Limitations

A voice over Internet protocol (VoIP) service that is widely subscribed to for personal use. Supports voice and video via webcam, messaging, and Web conference service. Requires only low-level technical skills. All participants must subscribe to a Skype 5.0 account minimally (no fee), or to a more advanced, paid subscription. Only the host/researcher is required to subscribe to a paid Skype account. Audio and video instant messaging system. Offers video chat and messaging. Can support up to 12 persons via video chat. Participants do not need to subscribe to ooVoo to join an FG hosted on ooVoo.

Up to 10 participants can join a Skype group video call, but Skype recommends limiting group size to 5, presumably for quality-related reasons. The researcher was aiming to include 6 to 8 FG participants in each session. Skype was not selected for use in this study. Recordings can be accessed by all participants, downloaded, and then uploaded to YouTube with a click of a mouse. This poses a serious threat to human subjects’ protection. ooVoo was not selected. Webcam images do not display when the recording is played back, thereby defeating the intended purpose for FG analysis. GoToMeeting was not selected. Webcam images are displayed during the FG, but only the webcam image of the individual who is speaking at any given time is displayed when the recording is played back, posing a limitation for analytical purposes. This service was initially selected, but then deselected following the pilot study for this research because of a discovery by the researcher of a system issue that posed a potential for breach of privacy. System requires the host to enable participants’ microphones and webcams when they join so that they can activate these functions on their computer. Participants must then activate their microphones and webcams by clicking on icons on the Web conference screen. Requires more technical competence on the participant side than the other systems that were considered.

GoToMeeting (Citrix)

A Web conference service to host online meetings. All of the full-motion webcam images are displayed on all participants’ screens during the meeting.

Cisco WebEx Adobe Connect

This Web conference service was initially selected, having met most criteria, and offering excellent customer support. Easy for participants to join the meeting. Excellent audio and video quality. Researcher must subscribe to a paid premier account to host a conference to accommodate the volume of attendees aimed for per FG in this study. Participants do not need a WebEx account to join an FG. Requires low to medium technological competence. A secure Web conference environment with capacity to support a full FG complement of participants. Webcam images of all participants appear simultaneously during the FG and during playback of the recording. Recordings are accessible only to the research team. Researcher must have access to a paid Adobe Connect account but participants do not require a subscription to join the Web conference. Participants who have not joined an Adobe Connect Web conference in the past are instructed by a system cue to download a free plugin when they log in, which takes 30 seconds or less to accomplish. A real-time chat window is visible on the conference screen and available for use by all during the FG, providing an additional means to communicate if needed, which also saves and displays with the recording. This system was used in the study.

helped the RA to develop proficiency in moderating FGs using the Web conference service. I coordinated a pilot FG to foster the RA’s experience in coordinating and moderating Web conference FGs, and to evaluate logistics including meeting coordination, data management, and use of dictation software for transcription. I contacted 42 travel nurses by telephone, explained the purpose and nature of the pilot FG, and invited them to participate. Nineteen of these nurses agreed to receive an email containing an embedded link

to open the electronic pilot study consent. Nine of those nurses consented and four nurses logged in to participate in the pilot FG. The pilot FG yielded insight and experiences contributing to the lessons learned. For example, some participants experienced technical challenges while joining the Web conference (delayed connectivity, speaker and microphone adjustments needed, inconsistent sound quality). However, they reported that the system worked well once the RA moderator assisted them via telephone

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to access the meeting space and make the necessary functional adjustments. One participant joined using a universal serial bus (USB) device to secure Internet connectivity, resulting in a 15-minute meeting-access delay. We learned that USB devices might not facilitate a robust-enough Internet connection to join a Web conference. Another participant joined using an iPhone, through which the Web conference service supported only audio participation, without a video image. These connectivity issues underlined the need to emphasize and iterate to participants the best-fit means of connecting to a Web conference: laptop or desktop computer with an Ethernet connection or a wireless connection not secured through a USB device. Pilot participants commented favorably about the use of Web conference technology, indicating that it did not intimidate or inhibit them from contributing. I learned from the pilot study that successful use of this data collection method is directly associated with the moderator’s proficiency in using the technology. Participants need to receive clear and specific directions to access the meeting space, and the moderator must have sufficient competence in managing the technology to resolve challenges efficiently. Coordinating FGs. Coordinating and hosting in-person FGs attended by geographically local participants is challenging; however, coordinating FGs with travel nurses presents a set of unique circumstances to navigate. Travel nurses are geographically dispersed across different time zones and their schedules involve shift work spanning various start and end times. They are mobile professionals who relocate three to four times per year. These combined work-arrangement characteristics form an array of FG scheduling hurdles. As consents were signed, the RA coordinated FGs by contacting study enrollees via email, text messages, and phone calls. We developed a spreadsheet to manage scheduling data, including time zone conversions, to assist the RA in navigating participant availability. The RA maintained the spreadsheet, reorganizing and updating it throughout the FG coordination process. The spreadsheet method of coordinating FGs was successful; however, Web-based group scheduling programs such as Doodle (www.doodle.com), ScheduleOnce (www .scheduleonce.com), and others can also ease the challenges of coordinating FGs with attendees situated and mobilizing across time zones. Hosting FGs. When each FG was coordinated, the RA logged on to the Web conference system and generated a uniform resource locator (URL), a unique Internet address in the form of a hyperlink. On the scheduled meeting date/time, participants clicked on the URL to open the

virtual FG meeting space. Initially, the RA used a system feature in which a meeting appointment message containing the URL was delivered to participants electronically days or weeks prior to the scheduled meeting, enabling them to plan ahead. However, after sending this email to several participants it became apparent that these messages were often being misinterpreted as an invitation to click on the URL link as soon as the email arrived. Moving forward, Web conference meeting-access emails were not distributed to participants until the day of the meeting, approximately 60 minutes prior to the start time, which successfully mitigated the potential for confusion. On the morning of each scheduled FG the RA as moderator distributed a voicemail message and a text message to the participants. The message reminded them to stand by for the meeting-access email containing the URL, which would be distributed one hour prior to the scheduled FG start time. The email contained instructions for participants to click on the URL 15 minutes prior to the scheduled FG start time. The 15-minute lead time allowed the RA to ensure that participants logged on successfully, and to troubleshoot any technical issues, facilitating an on-time start. We learned that this practice of opening the meeting space early and encouraging participants to log on ahead of the scheduled FG start time was effective to increase the likelihood of starting and ending on time, thereby demonstrating respect for participants’ time. The RA opened the meeting space 20 minutes prior to each scheduled FG start time. When a participant clicked on the URL to enter the meeting space, a dialog box appeared on the RA’s screen to identify who was attempting to enter. This system feature empowered the RA to ensure that only invited parties were granted access to the meeting space. With mouse clicks, the RA allowed participants to enter the meeting space. She enabled the functionality of their webcam and microphone icons by clicking on the respective host dashboard icons. By doing this, the RA enabled participants to activate their own webcam and microphone by clicking on the icons located at the top of their participant screen. If a participant’s microphone or webcam was not subsequently activated, the RA provided guidance either by telephone or by using the chat box feature at the bottom of the meeting display. She guided the participant to locate and click on the appropriate icons that activated these elements. The system featured a choice of either computer or telephone for audio connectivity. Participants who preferred a telephone connection for audio needed to make that selection by clicking on a button in a dialog box while accessing the meeting space. Nearly all participants chose to secure audio connectivity via the computer, which was the default option. To eliminate audio feedback, participants were asked to deactivate their computer speakers if they chose to use the telephone. If

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Tuttas feedback or environmental noise persisted, participants were also asked to mute their computer or telephone microphones when not speaking so that all participants could hear the FG discussion. Prior to clicking on the AV recorder icon, which appeared only on the host side of the system, the RA reminded participants that per the consent verbiage the FG would be recorded. We learned that when selecting a Web conference system it is important to ensure that only the host has capability to record the session. If attendees can also record the session or access the recordings, participant privacy and study integrity are jeopardized. The RA also activated a portable digital recorder for audio backup in the event of a Web conference system recorder or playback failure. The digital audio backup recording prevented the loss of valuable data for the initial 20 minutes of one FG in which the RA noticed, after the FG was in progress, that the recording function was not activated.

General-Study FGs Of the 76 nurses who consented to participate in generalstudy FGs, the RA was able to confirm, coordinate, and schedule 35 nurses across four FGs. The impact of lastminute attrition reduced the final number of participants to 2 to 5 nurses per FG. Web-based qualitative research data collection methods, specifically email venues, can be more vulnerable to attrition than traditional face-toface FGs (Curasi, 2001). The phenomenon was observed in this study, albeit to date there are no examples in the literature to validate it as a trend with the use of Web conference FGs. Because of attrition, two of the FGs did not meet the minimum of 4 participants generally accepted in the literature to constitute an FG (Krueger & Casey, 2000; McDaniel & Bach, 1994). Nonetheless, out of professional respect toward the nurses who fulfilled their commitment to attend, no FG was canceled. A larger number of FG participants is not necessarily better. Finch & Lewis (2003) posited that participants from a professional background tend to contribute more freely in an FG, in which case a smaller group might be preferable to accommodate this feedback. In the virtual milieu, the size of an FG does not necessarily determine the level of participation (Murray, 1997). Recall, Reid and Reid (2005) comprised FGs consisting of just 3 participants each in a comparison of CMC and traditional FG methods, with satisfactory data quality. When the travel nurse study was designed, it was estimated that each FG would last 40 to 50 minutes. This estimation was based on consideration of the originally anticipated FG sizes of 6 to 8 participants and coverage of all questions in the interview guide. Actual FG durations ranged from 30 to 50 minutes, relative to the number of participants in each. Despite some technical interruptions

such as participant microphone and sound quality issues, loss of participant video image visibility, and occasional freezing video frames, the moderator was able to proceed at a reasonably steady pace through all eight questions in the FG guide for both the pilot and general studies. Review of the recorded FGs reflected that the moderator ensured sufficient opportunity for each participant to contribute in all questions.

Transcription Software Most methods of Internet-assisted FGs do not require transcription because transcripts are generated as participants type in their responses to the moderator’s questions; however, when Web conference technology is used, AV recordings must be transcribed for analysis. Dictation software was used to facilitate the first iteration of transcriptions for each AV recording in this study. More detail about how this technology was used is provided in the following section.

Lessons Learned Through the experience of carrying out one pilot FG and four general-study FGs I learned about using Web conference technology to collect qualitative data. This body of knowledge has not appeared in prior literature. It guides researchers who are considering the use of real-time Web conference technology to collect qualitative data.

Testing and Retesting the Technology Before using Web conference technology to host FGs in this research, the RA and I carried out numerous practice sessions to gain familiarity with and develop competency in the use of the final selected service. During the practice sessions I became aware of a tendency for the initially selected Web conference system to sporadically distribute an unsolicited, automated email message to meeting participants shortly after the meeting space was closed. The message advised participants that by clicking on a link embedded in the email they could regain access to the meeting space and view the recorded FG. Allowing FG participants to access the recordings would breach participant privacy and the ethical integrity of the study. Discovery of the unwanted, sporadic emails prompted me to notify a senior engineer at the Web conference service of the anomaly. The engineer developed a workaround consisting of a prescriptive alternative method for closing the Web conference meeting to prevent the unwanted email from being distributed. After testing the method in additional practice Web conferences, I incorporated the workaround procedure to close the pilot FGs. The workaround was effective in preventing distribution

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of the unwanted follow up email to participants of the pilot FG; however, a lingering concern about the potential for a breach of participant privacy led me to select a more secure Web conferencing service (Adobe Connect) for use in the general study. This experience validated the importance of judiciously testing and retesting a Web conference service to determine its soundness for research purposes.

Establishing Effective Lines of Communication Coordinating traditional face-to-face FGs can be a formidable task; however, coordinating Web conference FGs with geographically dispersed travel nurses working various shifts spanning across time zones presents an additional set of challenges. In both situations, lines of communication underpin the success or failure of the effort. During the coordination of FGs, travel nurses sometimes did not respond to the RA’s voicemail messages or emails in a timely manner, if at all; however, they were considerably more responsive when attempts were made to reach them via cell phone text messaging. Travel nurses’ reliance on cell phone technology was more extensive than we had anticipated; hence, text messaging was adopted as the primary mode of communication to follow up with participants during the FG coordination process. Participants indicated that because of their busy lives and work schedules, text message reminders sent from the RA on the morning of their scheduled FGs were especially helpful. We learned that when scheduling FGs with geographically dispersed populations, asking participants to identify their preferred mode of contact might save time and prevent frustration. Finally, researchers might consider using readily available Web-based scheduling programs or meeting coordination software products to mitigate challenges associated with arranging FGs.

Assessing the Technological Capacity of Participants When considering Web conference technology for use in FG data collection, the technological proficiency of the participant population should be assessed or estimated. This technology-assisted data collection method is not appropriate for all study populations. Travel nurses comprise a sector of experienced RNs who regularly adapt to new technologies in changing health care settings; at each new job assignment they encounter and adapt to unfamiliar brands of electronic clinical equipment and electronic medical record systems. Moreover, they are accustomed to corresponding and doing business with their respective staffing agencies using email and Internet portal technology. Social media and voice over Internet (VoIP) technology like Skype are commonly used by

these nurses to communicate with friends and family as they travel. All things considered, I estimated that a medium level of technological proficiency was required of participants, vis-à-vis the degree of proficiency that these nurses applied in their daily professional and personal lives. The study consent included a description of the Internet technology to be used for the FGs and the hardware required to participate. The RA informed the participants of how to access the meeting space; nonetheless, some nurses attempted to access using alternative technology, resulting in a suboptimal connection. Thus, we learned that it is important to reiterate instructions so that participants succeed in accessing the meeting space at full capacity. I estimated that the majority of travel nurses owned or had access to a laptop or desktop computer with Internet connectivity and webcam. However, when the RA coordinated the pilot and general FGs, she encountered several situations in which nurses who consented and were willing to participate did not have access to this technology. Instead, these nurses relied mainly on smaller electronic devices like cell phones and tablets. In hindsight, this preference is understandable, because the technological capacity of these devices has expanded remarkably over recent years and they are compact for mobile lifestyles. When the data were collected for this study, these devices did not have the capacity to access full Web conference functionality. Several travel nurses tried to join FGs using a tablet, with limited success. Others tried using a smart phone, which limited their access to audio mode only. These occurrences exposed a study limitation related to the potential for Web conference technology requirements to preclude participation by some invitees who otherwise met study inclusion criteria.

Establishing Rapport During FG coordination several points of contact occurred between the RA and each participant. Initial correspondence typically occurred by phone, followed by several additional points of contact, usually via text messaging. On the day prior to and the morning of each scheduled FG, the RA sent email and text reminders to participants. We learned that these multiple points of contact helped to develop a favorable rapport between participants and the RA, facilitating introductions and social exchanges at the start of each FG to stimulate discussion.

Connectivity: Access to the Virtual Meeting Space The RA sent an email to participants one hour prior to the meeting start time, which contained a URL and instructions

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Tuttas about how to join the FG. The RA encouraged participants via a morning text message reminder to watch for and open the pending FG access email, and to click on the embedded URL to log in 15 minutes before the scheduled start time. The 15-minute lead time allowed participants’ to establish a connection and for technical challenges to be addressed by the RA prior to the scheduled start time. During the pilot study, two nurses attempted to access the virtual meeting space using a tablet, and at least one nurse tried to gain access using a smart phone. These participants determined that their devices would be as technically capable of establishing an audio and visual connection as a laptop or desktop computer. Although none of these nurses were able to secure a webcam image, they participated by audio connection. The tablet audio connection was of substandard quality; the smart phone audio connection was substantially better. To select an audio connection by telephone, the participant was prompted to enter a callback telephone number into a field presented in a dialog box during the login phase; within a few seconds a callback transmitted to that number, activating the participant’s audio connection to the meeting by telephone. This method yielded better sound quality than the computer audio connection. Nonetheless, most participants chose to establish their audio connection via computer, which was the default option. Some FG participants were unable to maintain a video connection or were only able to establish an audio connection. For such cases, in keeping with the study purpose, these participants were not excluded from the FG. The video images were an important component for assessing the level of group engagement and interaction, but the incapacitation of video connectivity was not deemed sufficient to warrant exclusion of participants’ valuable contributions. All participants had the option to stop sharing their webcam images at any time if they so desired, as described in the consent. There were no occurrences in which participants purposely stopped sharing their webcam images during the FGs. A USB laptop stick device used by a pilot participant to secure an Internet connection on her laptop had the capacity to secure a connection, albeit weak, but the connectivity to the Web conference was very slow. The participant was unable to gain entry to the meeting space until 15 minutes into the FG session. Her video image lasted only a short time once she finally accessed the FG. We learned the importance of advising and reminding participants to use a laptop or desktop computer with a solid wireless signal or Ethernet Internet connection.

Sound Quality Management Even with just 2 to 5 participants, the RA realized that for sound-quality purposes it was necessary to ask and

intermittently remind participants to click the microphone icon at the top of their conference display to activate the mute function when not speaking, and to unmute whenever they spoke. This practice served to reduce or eliminate extraneous noise. Participants discretely helped remind each other of this by communicating via the chat dialog window located at the bottom of the screen. Some sporadic technical challenges occurred with individual participants. For example, one participant had an excellent webcam image and could hear all that was spoken, but her microphone did not operate. Another participant had excellent webcam and speaker capability, but each time she unmuted her microphone to speak, a loud, noxious sound transmitted that obliterated all other audio. The moderator improvised by asking these participants to type their contributions into the chat room dialog window at the bottom of the conference display. Both of these participants established their audio connection via the computer. Using the telephone to secure an audio connection in these cases might have improved the sound quality.

FG Attendance Challenges The study design called for 6 to 8 participants per FG; however, because of coordination conflicts and last-minute attrition, just 2 to 5 participants were in attendance at each of the four general-study FGs. Even when the RA confirmed as many as 13 participants within 24 hours prior to an FG, the largest FG consisted of just 5 participants. Although short-notice changes in availability are an unavoidable reality when scheduling geographically dispersed mobile professionals, we also surmised that for some participants, the virtual methodology might have distanced them from a compelling sense of commitment to attend their scheduled meeting. We learned that to secure a group of 6 to 8 Web conference FG participants it is necessary to confirm a much larger number of participants, anticipating 50% or greater attrition. For this study, with the exception of the first FG, the pool of enrolled participants who were willing and available to meet at one time was not large enough to schedule twice the desired number of participants. The smaller FG sizes did not hinder interactive dynamics or the volume and richness of data yielded from each. Finch & Lewis (2003) identified 6 to 8 participants as the generally accepted range for a FG; however, they acknowledged that groups composed of professionals tend to contribute more freely in an FG, so a smaller group might be preferable. Another researcher who used asynchronous email FGs to collect qualitative data maintained that in the virtual milieu the size of a FG does not necessarily determine the level of participation (Murray, 1997). I found no literature to inform of the appropriate number of participants for a Web conference FG.

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I posited that participants might sense more control in a Web conference FG, where they are free to opt at will to remove their video image from the group’s view, mute their microphone, or decide after the FG starts to withdraw completely from the study with a click of a button, without having to walk out of a personally attended meeting. Assessment of the population of interest is necessary when considering whether or not Web conference FGs are appropriate for data collection in a given qualitative study.

Observations of Interactions and Group Dynamics Although the information about recording the FGs had been previously disclosed and permission secured when participants signed the informed consent, the moderator verbally reconfirmed everyone’s permission to record the session prior to clicking the record button and posing the first question. When the AV recordings were reviewed for analysis, it was evident in all five FGs that the participants regarded the moderator and one another with professional respect. Participants yielded to one another so that no more than one person spoke at one time, facilitating better audio quality and opportunities for all participants to contribute their views. The moderator maintained an active role by asking the questions, monitoring and clarifying responses, and ensuring that each participant was offered an opportunity to respond to each FG-guide question. Despite the occurrence of some distractors such as children in the background and intermittent microphone feedback, participants remained fully engaged, maintaining attentiveness to what others were saying. The webcam recordings displayed only the head and shoulders of each participant, thereby limiting the potential for full capture of nonverbal communication; however, facial expressions, posture, and general body movement were discernable. It is possible that the awareness of being visible via webcam might have influenced participants to maintain attentiveness to what was being said by others. The moderator did not need to motivate participants to speak freely. All participants in each FG demonstrated willingness to contribute, often building on what others said or asking each other additional related questions on the topic. All participants in each FG demonstrated respect for the moderator by requesting clearance to speak and being prepared to respond when called on by the moderator. The moderator monitored which participants had not responded to each question and addressed those persons to ask if they wished to contribute. Participants interacted with nods of agreement, intermittent laughter, and by addressing one another verbally to build on previously expressed views.

Data Quality Verbal and nonverbal utterances, postures, facial expressions, voice tones, and other behavioral nuances depicted in the AV recordings revealed and preserved the context of participants’ contributions, cultivating richness in the meaning of the data. For example, the comment “I’ve been in places where you only have one day to orient. I mean, they’re so short they need you on the floor” was received and acknowledged by other participants with evidence of full intuitive understanding as observed through head nodding, facial expressions, and verbal and nonverbal utterances. The interaction and authentic sense of agreement observed among participants signified a level of understanding that only a fellow travel nurse could share. One participant’s description of techniques that she employed to integrate with a new team included the following: “I wouldn’t do what the core staff does if it was against my nursing work ethic, but there are some little things that I do do to fit in because that’s how you fit in,” which others received with collegial laughter, signifying that they could relate and perhaps incorporated similar techniques into their own integration practices. The four general-study FGs generated 265 thematic contextual meaning units, which are segments of verbatim text, for analysis. Through the iterative examination and analytical inferencing, four subthemes and one overarching theme emerged.

Technology-Assisted Transcription Researchers have acknowledged the centrality of verbatim transcription as a critical element of qualitative research to capture the interactive exchange between the study moderator and participants. Hennink and Weber (2013) studied the transcription error rate and types of errors associated with the engagement of court reporters and transcriptionists to produce verbatim transcripts for qualitative research. Researchers seek more efficient methods to accomplish this pivotal, yet detail-oriented and time-consuming task associated with qualitative research. Internet-assisted methods of FG data collection are described in the literature, whereby textual data are generated immediately via discussion boards, LISTSERVs, and chat rooms, bypassing the need for manual transcription; however, the AV-recording data generated from the FGs necessitated transcription. I purchased and used dictation software called Dragon Dictate 3.0.1 (Nuance Communications, Inc., 2012) to aid in the initial transcription of each FG recording. The system required a compatible USB microphone, which I purchased separately. The microphone was highly sensitive to any sounds; therefore, the transcription environment had to be almost absent of background noise.

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Tuttas Prior to use, it was necessary for me to establish voice recognition by the software, and to learn how to use the product by completing a tutorial. The software was helpful for transcribing the first draft of each FG recording; however, the process was somewhat awkward for several reasons. The system did not recognize fillers like uhm, uh, like, or health care jargon, and certain contexts that commonly occurred within the FG dialogue. It was necessary to load such utterances, words, and phrases into the program’s vocabulary so that they would be recognized and not “corrected” by the system. Transcribing the AV recordings was not a smooth, uninterrupted process; this factored into my dictation software learning curve and influenced my perception of the software’s utility for this purpose. Using two computer monitor screens, I listened to a segment of the FG recording with a headset and then spoke what I heard into the USB microphone, a process referred to as “parroting.” I learned that the best quality dictation output is yielded when the speaker uses a methodically paced rate of enunciated speech. Speaking too fast or without articulating clearly enough prevents the software from accurately capturing the words. The FG recordings consisted of natural speech by numerous persons, typically spoken at a faster pace than what the dictation system could accurately transcribe if parroted at that speed. It was necessary for me to toggle between the recording playback and the dictation platform because I often needed to “catch up” by replaying a segment of the recording that was difficult to comprehend. Therefore, it was not possible to achieve a smooth and continuous listen/speak rhythm. Finally, as a novice user of the software I lacked speed and proficiency, which created an element of frustration at times because the intent of purchasing the software was to reduce transcription time. With continued use of the software to improve competency, it holds promise as a useful tool for transcribing FG recordings.

Discussion Web conference technology offers a promising and evolving synchronous data collection method that more closely resembles the milieu of personally attended FGs than other currently available Internet-assisted methods. Lessons learned from the use of Web conference technology in this study yielded suggestions and recommendations for researchers considering this method for collecting qualitative data from samples of geographically dispersed populations.

Pilot Participant Feedback When asked for their feedback pertaining to the Web conference method used to host FGs, the pilot participants

emphasized how greatly they appreciated the opportunity to share their experiences and views in a real-time, electronic, “face-to-face” scientific milieu. One participant suggested that health care staffing firms could benefit by hosting Web conference FGs with travel nurses to seek their feedback about what their unique professional and occupational needs are and what factors impact their ability to perform their jobs. Another participant suggested that a few additional participants per FG might enhance the depth of the discussion. All pilot participants indicated that the Web conference FG, which lasted 40 minutes, was appropriate in length. With the exception of the attempt to use a USB Internet connection device and the attempt to use a tablet device, no participants reported difficulty in accessing the virtual meeting space using the URL embedded in the invitation email. The service that was finally selected, although more secure, was somewhat more complex to navigate compared with the initial software choice; however, the broader learning curve existed mainly on the host side of the system, which was more feasible to manage than challenges on the participant side would have been.

Recommendations and Suggestions Determine appropriateness.  When considering the use of Web conference technology to host FGs it is prudent to perform an early assessment of the appropriateness of this method relative to the study topic and population of interest. For example, participants must have access to the Internet and to the type of hardware necessary to participate. They also need to have a moderate level of technological comfort and competency, enabling them to follow instructions to log on and participate in a virtual environment. Not all participant populations or topics of interest are amenable to FG discussions via this venue (Stover & Goodman, 2012). Incompatibility between the method and the capacity of the population of interest could preclude otherwise eligible invitees from participating, a limitation that could impact study results. The researcher needs to establish criteria for selection of the best-fit Web conference service and make comparisons accordingly to determine which service appropriately matches the study requirements. In Table 1 I offer guidance in this regard. Sufficient preparation.  Once a Web conference system is selected, and prior to implementing FGs, it is essential for the moderator to acquire sufficient knowledge and proficiency pertaining to how the system operates from both host and participant roles because the Web site displays differently on each side. Repeated practice sessions equip the moderator with knowledge necessary to troubleshoot and intervene on behalf of participants if technical issues

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arise. It is advisable for researchers considering the use of Web conference technology to host numerous practice sessions and incorporate a pilot study into the design. Size of FGs.  The literature generally suggests 6 to 12 as the common appropriate range of participants per FG. In this study the population of interest was composed of experienced professional travel nurses who contributed freely in the virtual FG environment; thus, smaller groups were advantageous to accommodate this feedback. Participant engagement and interaction among group members are described in the literature as essential elements of FGs (Kenny, 2005). Gaiser (1997) described a well-functioning FG as “self- managed,” meaning that group interaction is characterized by a degree of spontaneity. In harmony with the literature, despite FG sizes that were smaller than anticipated for this study, participants contributed richly and freely, requiring only enough prompting to inform them of what the researcher sought to learn from them. There was no hint of inhibition, lack of engagement, or want of interaction, and the real-time environment preserved the quality of immediacy in response time (Matthews & Cramer, 2008; O’Connor & Madge, 2003). There was no evidence that the modest FG sizes impeded the quality of the data; however, no prior research using Web conference technology to host FGs could be located in the literature for comparison. The FGs in this study yielded sufficient data to answer the research questions. Saturation was realized in the absence of unique data emerging from the final FG. Benefits of webcam technology.  Full-motion video creates a resemblance to in-person FGs that is not achievable using methods of Internet-assisted FGs described in the literature at the time of this writing. The webcam images produced in this study portrayed participants who maintained engagement, attentiveness, professional respect, and interest in what their colleagues were saying. This behavior was observed despite several potentially distracting audio technical issues that occurred during each FG. Participants interacted naturally by agreeing with, differing from, and building on the comments of their colleagues. They proactively attempted to assist one another to solve minor technical issues if they arose. AV capacity with full-motion webcam video images also met another essential FG criterion by enabling the moderator to maintain an authentic, visible presence and an active role for the duration of each session (Greenbaum, 2008; Matthews & Cramer, 2008; O’Connor & Madge, 2003). Combined procedures.  A plan that incorporates a secondary means for participants to join an FG might mitigate the loss of willing invitees who do not have the hardware or Internet connectivity to join a full-AV FG. For

example, if an invitee is willing to participate but cannot join the Web conference with full-AV capacity, rather than lose this valuable data, that participant could use the Web conference telephone number to join by audio only. It might also be worthwhile to consider opening a discussion board for a day or two following each FG, to provide participants with a secure electronic dialogue space where they can type in afterthoughts pertaining to the FG topic of discussion.

Limitations Despite the appeal and innovative characteristics of Web conference technology for FG data collection, there are limitations unique to the method. Some persons meeting study eligibility criteria might be precluded from participating because they lack access to the technology necessary to participate. Similarly, some might be precluded from participating because they lack the necessary skill or proficiency to navigate the technology. Webcam images displayed only the head and shoulders of each participant, preventing the analysis of full-body motions and positions. Popular small electronic devices (i.e., cell phones and tablets) did not support full functionality of Web conference technology in this study. Finally, not all populations or topics of interest are a suitable match for the use of Web conference FGs. The appropriateness of a topic or population of interest must be carefully assessed before deciding to use this method.

Conclusion In this article, new knowledge is presented about the use of Web conference technology as a secure, Internetassisted method to achieve synchronous qualitative data collection for research. This method, when used for appropriate populations of interest and subject sensitivity levels, offers a suitable venue for FGs that supports the free flow of rich data with high levels of participant engagement and interaction. Web conference technology provides a means to host FGs for geographically dispersed populations in a synchronous virtual environment that more closely resembles traditional FG settings than other Internet-assisted methods described in the literature at the time of this writing. Despite limitations associated with the use of Web conference technology, the evaluation of its effectiveness for qualitative data collection in this study aligned with prior research supporting the use of both asynchronous Internet-assisted methods (Kenny, 2005; Murray, 1997; Turney & Pocknee, 2005; Williams & Reid, 2012) and synchronous Internet-assisted methods (Stovner & Goodman, 2012) for data collection in qualitative research.

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Tuttas New knowledge emerged from lessons learned while using Web conference technology for data collection in a qualitative study about travel nurses. The technology provided a more authentic online FG environment and experience than other synchronous Web-based methodologies reported in the literature. Future research using a Web conference service to collect qualitative research data will contribute to this developing body of knowledge, in tandem with the perpetual expansion of Internet technology capabilities. Acknowledgments I acknowledge Helena Johnson for her enthusiasm and diligence in coordinating and moderating all of the FGs for this study. I also respectfully acknowledges the travel nurses who so generously contributed their time and views as participants in the research.

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

Funding The author received no financial support for the research, authorship, and/or publication of this article

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Author Biography Carol A. Tuttas, PhD, RN, is the director for enterprise services at CGFNS International, Inc., Philadelphia, Pennsylvania, USA.

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