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About the Center > Needs Assessment > Nominal Group Discussions > The Nominal Group Process

The Nominal Group Process

The nominal group discussion follows these steps:

  1. Group orientation
  2. Questions and silent generation of ideas
  3. Round-robin sharing of ideas
  4. Discussion and elimination of duplicate ideas
  5. Individual silent selection and rating of priorities
  6. Conclusion of discussion

(Note: Examples are based on the context of assessing the needs of asthma patients.)

Group orientation

  1. As group members arrive, greet them and make them feel welcome. Engage in warm, casual conversation and offer refreshments. Let people know where the restrooms are, and make informal introductions as more participants arrive.
  2. When all the group members have arrived, invite everyone to sit around the conference table.
  3. Make sure each participant reads, signs and turns in an Informed Consent form. If a participant is younger than 18 yeas old (a minor), both they and their parent must sign the consent form.
  4. Introduce the facilitator (principal investigator) and any observers. There should be at least one other observer who takes supplementary notes.
  5. Give a brief re-cap of what the project is and the purpose of the study.
    • Example: "As you know, we are developing a computer-based support tool to help people with asthma cope with their illness and improve their quality of life. Before we do that, we need to understand what the issues and frustrations are. We want you to help us understand what it's like to live with asthma, and to help us create a list of needs, which we will then prioritize. The information you give us tonight will form the basis for an in-depth survey to prioritize the needs of asthma patients."
  6. It is good to have the task written in advance on a flip chart and placed somewhere clearly visible throughout the meeting. This will help remind the group of what they need to focus on throughout the discussion. It could be as simple as a few keywords.
    • Example: Identify any: Fears, Frustrations, Uncertainties, Difficulties.
  7. Ask if they have any questions or concerns. Answer those briefly but adequately.
  8. Have members take turns to introduce themselves – their age, when they were diagnosed with the illness and the severity. This is a good time to verify (if you haven't already done this) who has been hospitalized, been to an ER, or experienced other specific critical events due to their illness. Depending how much their experiences vary, you may need to tailor your questions later to their experience.
  9. Explain what is expected of them and the process of the discussion group. Tell them how long it will take.
    • Example: "I will ask you a series of questions, and you will write down whatever ideas you have. Write down anything that comes to mind. Be as specific as possible. There will be about five main questions, and we'll probably take about 20 minutes to answer all of them. I want you to not talk to each other during this time. Later, round-robin, we will share our items one at a time till all the ideas have been mentioned. Then we'll talk about them, and vote on which ones are most important, or which frustrations you most want to get rid of."
  10. Answer any questions they might have about the process.
  11. Make sure everyone has paper and a pen.
  12. Remind them they can ask clarifying questions at any time if they are unclear as to what is being asked or what is expected of them.

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Questions and silent generation of ideas

  1. Use the Critical Incident Technique to help members of the group think back to key events regarding their illness that stand out in their minds. Help them to remember as many details as possible about the experience. This will encourage them to be more specific in the items they list.
  2. Focus your questions around the fears, frustrations, uncertainties and difficulties of the illness. This will draw out their core needs.
  3. Ask questions that cover the various stages of the illness. For each stage, help them remember the incident vividly by asking them to remember details. As they begin to reconstruct the critical incident in their minds, ask them to list their fears, frustrations, uncertainties and difficulties on paper.

    Sample questions:
    • Equilibrium
      • Remembering Details: Think about what it's like to be a person with asthma. Think about how it affects your everyday life.
      • Identifying Needs: Write down any fears, frustrations, uncertainties and difficulties you face as someone with asthma. Spend the next two minutes listing anything that comes to mind. Also, what information do you wish you had about your condition? Write those down too.
      • (Sometimes it is helpful to interject some brief dialog between questions. Now would be a good time. See point 5 below.)
    • Onset
      • Remembering Details: Think about a really bad asthma attack you had recently. Think about what happened from the very beginning.
      • Identifying Needs: What was your biggest worry? What uncertainties or fears did it create? What frustrated you?
    • Decision to seek care
      • [Emergency Room]
        • Remembering Details: Think about a recent flare-up where you had to go to the emergency room. Try to remember how far you were away from the ER, what it looked like when you drove up and when you entered. Think about what happened when you walked in the door.
        • Identifying Needs: What were some of the difficulties you encountered? List anything that really made you fearful or upset. What things about the ER experience made you feel frustrated or helpless? Spend about three minutes writing down anything that comes to mind.
      • [Hospital]
        • Remembering Details: Think about one time you had to go to the hospital to have your asthma treated. Try to remember what brought on the attack and how your asthma was affecting you when you arrived at the hospital. Think about the admission process, about getting to the hospital room and getting into the bed.
        • Identifying Needs: What were your worst fears? What difficulties did you encounter on the way there or when you got to the hospital? What made you feel angry or frustrated or helpless? Take two or three minutes to list down anything that comes to mind.
      • [Clinic]
        • Remembering Details: Think about a particularly frustrating visit to the clinic. Think about who all you interacted with at the clinic. Think about what happened in the reception area and then later in the doctor's office.
        • Identifying Needs: What were some of the difficulties you encountered that you wished could be changed? What information did you wish you had? What made you fearful, uncertain or frustrated? List those down.
    • Recovery period
      • Remembering Details: Now I want each of you to think about a long or particularly difficult recovery of your own that you've experienced in the past year. Think about how you felt emotionally and physically.
      • Identifying Needs: Write down the things that made you worry a lot. What did you wish had been done differently in terms of your medication or rehabilitation? List anything at all. What information did you wish you had? What hassles or difficulties did you encounter? Spend the next two or three minutes listing anything that comes to mind.
  4. As you move from one set of questions to the next, allow two to three minutes for them to list their thoughts, and then move on. While they are writing, feel free to reiterate important parts of the question, to emphasize what you want them to list.
  5. Sometimes it is a good idea to break out of the silent writing process once, early in this process, to engage the group in dialog by asking a "share-your-experience" question. Dialog helps the group loosen up, since the silent writing process can sometimes feel like a written exam. Dialog will also helps them think about reality and steer away from generic answers and platitudes. Dialog should be introduced between sets of questions, for instance between Equilibrium and Onset questions. You could, for example, ask the group to stop writing for a moment and just dialog. Ask: "Think about an asthma attack. Help me understand what it's like from the very beginning… what it feels like. How about if we start with you, _______." As each person talks, everyone, including the facilitator should listen and not take notes. This is an informal warm-up to the more specific questions asked later. The observer, however, should note anything that is insightful that can be considered by the researchers when designing the survey. After each has shared their experience, ask them to return to silent writing of their thoughts by asking them another critical incident question.
  6. Towards the end of the silent generation process, you could enter into dialog again by asking one or two people in the group to share a specific experience. Again, this can be a refreshing break in the silent writing process, and can help the group re-focus on real experiences instead of generalities. For example, ask the group to stop writing for a while, and pose the question: "Think about one of the longest recovery periods you've had in the past year." Invite one or two to share their experience with the group. Ask questions to draw out details if necessary. After one or two have spoken, thank them, and then return to the written response process. Ask the next critical incident question and instruct them to resume writing down their thoughts without any discussion.
  7. Repeat this process of questions, brief dialog (when needed) and silent generation of ideas, until all the questions have been asked.

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Round-robin sharing of ideas

  1. When all the questions have been asked and each participant has finished writing their thoughts, ask them to look at their entire list.
  2. Request that they take turns around the circle to read one item from their list (in no particular order or ranking.)
  3. The facilitator should write on the flip chart each item mentioned. Write legibly so that the group can read them from where they are sitting.
  4. The facilitator can ask for clarification and rephrase the items as s/he writes them on the charts in order to be succinct. The essence of what was originally said, however, must be intact. Check with the participant to make sure you have accurately represented what s/he said.
  5. As they begin to run out of items on their list, reassure them that this is perfectly OK, and that you will check back with them occasionally in case they have any other ideas.
  6. Keep going around the circle sharing one item each until no one has any more items to share.
  7. As one more way of getting the group to think about a problem differently, ask one more question that they can answer aloud, in turn. For example, you can ask: "If there's one piece of advice you would give to other asthma patients, what would it be?" Asking them to give advice does not focus on their own needs, but will reveal what they think will meet someone else's need. This can lead to some fresh ideas. It is also a good way to wind up the discussion.

The round-robin method allows each member equal participation in sharing ideas. No one person can dominate the sharing process. It is fine if someone occasionally talks out of turn, in response to what someone else has said. However, if there are too many interruptions, request those additional thoughts be noted down on paper and shared when it's their turn.

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Discussion and elimination of duplicate ideas

  1. After everyone has completed sharing their list with the group, ask them to look at the entire list on the flip chart sheets taped to the wall. Ask if there is anything else they want to add. Interacting with other people's ideas often prompts new items that were not thought of before.
  2. Allow them to ask questions so everyone is clear about the items listed.
  3. When there are no more revisions to the list, the facilitator should read each item aloud and number each item clearly. It is important to read each item out loud while doing this, for clarity.
  4. Ask the group to help identify and eliminate duplications as you number the items. Any duplicate items should be ascribed the same number. Before combining the duplications always ask first: "What do you think? Does anyone object to combining these?" This empowers the group to be the experts and to make judgement calls.
  5. Do not confuse duplications with categories.
  6. A duplication is the same item worded differently and these should be combined. For example: "I can't run. I don't have full use of my lungs," and, "I can't sing. I don't have the air for it," are duplicates regarding reduced lung capacity and limited activity. Some items share a category but are separate issues. These should not be combined. For example: "I can't hunt in the woods anymore. I would be too far away from medical help if I had an asthma attack," falls into the category of limited activity like the two earlier examples. However it is a different issue, about access to medical help, and should not be combined with the other two items.

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Individual silent selection and rating of priorities

  1. As each item is number and read aloud, have each participant silently write down on their paper the items they feel are most important to resolve, either for themselves or anyone with asthma. (Note: If the overall list has 31-40 items, they should choose seven items. If there are 41-50 items, choose eight. If 51-60 items, choose nine. If there are more than 60 items, choose ten.)
  2. They should write down the number of the item and a phrase or keyword that indicates what each item is. They should not discuss their choices with the others.
  3. Once you have numbered and read through the whole list, and each participant has made their selection of most important items, tell them to count up how many items they have noted. If they have more or less than the given limit, instruct them to narrow or expand their selection till they have the total required.
  4. Then, have them to look at their short list and prioritize their selection, rating the most important with the highest number, the second most important with the next lower number, and so on. Again, they should not discuss their choices with anyone. Some instructions that can be given: "Look over your list of eight most important items. Pick the most important one. Give it a score of 8. Now look at the rest. Pick the next most important. Give it a score of 7," (and so on.)
  5. After everyone in the group has numerically prioritized their items, request that they come up to the flip charts and write their priority numbers next to the corresponding items on the large sheets.

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Conclusion of discussion

  1. When everyone has identified their ranked priorities on the flip charts, summarize some of the patterns of prioritization you see on the charts. Point out the items that you observe as being high priorities to resolve, and which ones are lower. Note any other interesting observations.
  2. Genuinely thank everyone for taking the time to be involved in the discussion and for their effort in producing the list of items on the flip chart. Reiterate that their list of priorities will be foundational for the design of the needs assessment survey to follow, and for beginning the design of the CHESS module.
  3. The group can be dismissed at this point. Make sure everyone has signed their informed consent forms before they leave.
  4. Save the flip charts to be typed up and analyzed by the survey design team.
  5. Shred any paper with writing that was left on the table by the participants in order to protect their anonymity.

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