Clinical Simulation in Nursing (2021) 55, 37-42

Short communication

Using Social Media and Snowball Sampling as an

Alternative Recruitment Strategy for Research ✩
Kim Leighton, PhD, RN, CHSE, CHSOS, ANEF, FSSH, FAAN a ,∗,
Suzan Kardong-Edgren, PhD, RN, ANEF, CHSE, FSSH, FAAN b,
Tonya Schneidereith, PhD, CRNP, PPCNP-BC, CPNP-AC, CNE, CHSE-A, ANEF,
FAAN c, Colette Foisy-Doll, MSN, RN, CHSE, ANEF d
a
Itqan Clinical Simulation and Innovation Center, Hamad Medical Corporation, Doha, Qatar
b
MGH Institute of Health Professions, Boston, MA, USA
c
University of Maryland School of Nursing, Baltimore, MD, USA
d
MacEwan University Faculty of Nursing, Edmonton, AB Canada

Keywords Abstract The COVID-19 pandemic demanded rapid change in health care education, moving many stu-
snowball sampling; dents to online learning. It is important to examine how this shift affected both student perceptions
social media; of learning and achievement of learning outcomes. Snowball sampling strategy was used to reach and
LinkedIn; recruit nursing students, who had shifted to online learning during the pandemic, to participate in a
Twitter; research study survey. This paper outlines the process of snowball sampling using social media, explores
survey response rate; the relationship between social media posts and survey completion, describes the strategy’s challenges
simulation; and benefits, and provides recommendations to those who may consider using this novel sampling
methodology.
undergraduate nursing;
screen-based Cite this article:
simulation; Leighton, K., Kardong-Edgren, S., Schneidereith, T., & Foisy-Doll, C. (2021, Month). Using Social Me-
clinical dia and Snowball Sampling as an Alternative Recruitment Strategy for Research. Clinical Simulation in
Nursing, 55, 37-42. https://doi.org/10.1016/j.ecns.2021.03.006.
© 2021 International Nursing Association for Clinical Simulation and Learning. Published by
Elsevier Inc. All rights reserved.

Introduction
The COVID-19 pandemic demanded a swift change to
all facets of healthcare education, including the deliv-
ery of didactic material, simulation, traditional clinical,
and psychomotor and non-technical skills training. These
✩ This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
∗ Corresponding author. kleighton@hamad.qa (K. Leighton).
1876-1399/© 2021 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2021.03.006
changes were often made with few resources, including the
time and support necessary to teach in alternative environ-
ments. Outcomes related to these altered teaching strate-
gies needed to be studied so that educators could determine
which of their new teaching methods should be retained
for future use and which should be discarded. Data were
needed to drive these decisions; however, the pandemic
quarantine challenged the ability of many researchers to
reach their target populations. This paper outlines how
snowball sampling was used to complete a research study
Clinical Simulation in Nursing 38

on distance learning and describes the benefits and chal- Sampling Strategy
lenges of using this social media sampling method.
Reaching the target population was challenging as most
students were learning from home. A novel approach to
Background subject recruitment was used, incorporating snowball sam-
pling into social media. This snowball sampling method
On March 11, 2020, the World Health Organization and study was approved by the university’s Research Ethics
(WHO) announced the global health crisis of COVID-19 Board. Snowball sampling is a recognized and viable
and declared it a method of recruiting study participants not easily acces-
worldwide pandemic sible or known to the researcher (Marcus et al., 2017;
Key Points (WHO, 2020). Many ed-
• Social media was an
Naderifar, Goli, & Ghaljaie, 2017; Reagan et al., 2019;
ucators were forced to Wohl et al., 2017). Briefly, it is a common sampling
effective and efficient move courses and expe- method in qualitative research where the researcher does
way to recruit study riential learning activities not directly recruit participants but contacts others who
participants. entirely online. Guidance
• Snowball sampling is
then connect them to research participants (Marcus et al.,
came rapidly from or- 2017; Parker, Scott, & Geddes, 2019). As the researchers
a viable method of re- ganizations such as the could not access students in a classroom, or within a col-
cruiting study partici- American Association lege or similar location, they were unable to easily identify
pants. for Colleges of Nursing
• Social
their potential participants to recruit and needed to rely on
media sites (AACN, March 2020) and social media to find the participants through snowball sam-
provide analytic the Canadian Association pling.
data that can help of Schools of Nursing Researchers used snowball nonprobability convenience
researchers track en- (CASN, Mar 2020); how- sampling by initially connecting with professionals or
gagement with their ever, the logistics of groups on social media platforms (e.g., LinkedIn and
posts. moving online were re- Facebook student nurse groups) that most closely aligned
ported to be challenging. with the target population. First steps involved identify-
For simulation educators, there was a tremendous shar- ing social media sites that catered to nursing students,
ing of resources. Simulation leaders met regularly online to nursing educators, and simulationists. Twenty-eight sites
converse about how to keep learners safe and healthy. Ven- from LinkedIn and Facebook were identified (13 student
dors freely distributed scenarios and associated documenta- sites; 15 educator/simulationist sites). Of 13 student site
tion. Although the internet abounded with examples of the owners contacted, only one posted the study recruitment
collaborative nature of these efforts, the impact on learn- information. The researchers then requested permission
ing outcomes was unclear. Additionally, it was important to to post on the fifteen educator and simulationist sites,
determine the students’ perceptions of how well their expe- with seven site owners posting recruitment information via
riential learning needs were met through the screen-based blogs, LinkedIn, Twitter, Instagram, and websites. The re-
simulation (SBS) environment, defined as taking place on searchers also emailed colleagues to post recruitment in-
a computer screen where a keyboard, mouse, or other in- formation on their personal, school, or business social me-
put device is used by a learner to interact with graphi- dia sites. Additionally, each researcher posted to their per-
cal images and text. Feedback and assessment are possible sonal social media sites (Facebook, Twitter, LinkedIn) to
because actions and decisions can be tracked. The SBS ask readers to forward the research opportunity to students
environment does not necessarily require an instructor’s in an effort to reach more potential participants. While
presence (Lioce et al., 2020). impossible to know how many people were reached, or
if they were reached by another student, faculty, or ran-
dom chance, these combined accounts had over 28,000
Educational Research during COVID-19 members or followers. Postings included wording designed
to prompt nursing students to share the study information
The research team set out to assess how well undergraduate with peers, such as:
nursing students’ learning needs were met through use of . . . ‘share a research opportunity with pre-licensure
the SBS environment, compared to the traditional clinical nursing students worldwide’. . . ‘we are using a snowball
(TC) environment and face-to-face simulation (F2FS). This sampling strategy through social media sites to reach [nurs-
study used an updated version (CLECS 2.0) of the Clin- ing students]’. . . ‘We know these are challenging times
ical Learning Environment Comparison Survey (CLECS; and we appreciate any assistance that you can offer to help
Leighton, 2015) that added a SBS environment response us reach students’. . . ‘help connect us to nursing students
section. Revision and psychometric analysis of the CLECS and graduates’. . . ‘send nursing students to the link’. . .
2.0 fall outside the scope of this manuscript. ‘retweet for nursing students.’

pp 37–42 • Clinical Simulation in Nursing • Volume 55

Clinical Simulation in Nursing 39

Table 1 Data Collection at Start & End of Study

First 15 Days Number Last 15 Days Number Total Number (100%) During Data
(Percentage) (Percentage) Collection Period

Survey Responses 126 (61%) 48 (23%) 208 (100%)

∗
174 usable surveys for data analysis
LinkedIn (LI) Posts 8 posts (26%) 8 posts (26%) 31 posts (100%)
4697 views (49%) 704 views (7%) 9561 views
66 shares (88%) 0 shares (0%) 75 shares
66 reactions (34%) 13 reactions (7%) 196 reactions
12 comments (57%) 0 comments (0%) 21 comments
Twitter (T) Posts 4 tweets (17%) 5 tweets (21%) 23 tweets (100%)
2144 impressions (33%) 2094 impressions (32%) 6540 impressions
76 engagements (35%) 78 engagements (35%) 220 engagements
14 retweets (36%) 12 retweets (31%) 39 retweets
0 replies (0%) 1 reply (50%) 2 replies
12 likes (32%) 13 likes (34%) 38 likes
21 URL clicks (81%) 4 URL clicks (15%) 26 URL clicks
20 detail expands (24%) 34 detail expands (40%) 84 detail expands
LI: Reactions = expressions that make it easier to participate and communicate (e.g., Like, Celebrate; LinkedIn reactions, 2020).
T: Impressions = “number of times users saw the Tweet on Twitter”; Engagements = “total number of times a user has interacted with a Tweet” (Twitter
Analytics, 2020).

When recruiting via snowball sampling, it is crucial
to keep the snowball ‘rolling.’ Each researcher commit-
ted to reposting, retweeting, and sharing their own and
others’ posts on a planned bi or tri weekly basis over
the recruitment phase of the study. This was done us-
ing hashtags (#) to promote content categorization and
At Signs (@) to maximize reposting and facilitate com-
munication (Hunt, 2015), in efforts to reach the right
population. Data collection began April 26th and ended
June 30, 2020. Researchers tracked dates of LinkedIn data
(postings, views, shares, reactions, comments) and Twitter
data (tweets, impressions, engagements, retweets, replies,
likes, URL clicks, and detail expands); one researcher
collated overall data. Additionally, survey responses were
tracked and aligned to postings.
Findings
Overall, 208 people accessed the survey via Qualtrics
(Provo, UT) link, with 174 usable responses. Data col-
lection was brisk during the first and last 15 days of the
study (Table 1), with 84% of the total responses occurring
in these two periods. Respondents were from 9 countries,
with participants from 8 countries responding in the first
15 days.
The researchers’ LinkedIn posts numbered the same
during both periods (8); however, the total views decreased
over each period. Researchers tracked viewers, employ-
ers, and locations of those who viewed or responded to
posts using LinkedIn analytics function. Comparable data
was unavailable for Twitter. LinkedIn post viewers hailed
from seven countries and represented academic, clinical,
companies/vendors, government entities, and organizations
(Table 2). Facebook posts were not analyzed due to a lack
of analytics collection by the platform.
Discussion
Data were analyzed for two points in time–the first 15
days (April 26-May 12, 2020) and the last 15 days of data
collection (June 16-30, 2020). These data were analyzed
against the total response data for the study. Eighty-four
percent of the CLECS 2.0 survey responses were tendered
at the beginning and end of data collection. Researchers’
social media posts were evenly distributed at both assess-
ment points.
On LinkedIn, views and responses were high, with the
majority of shares occurring during the first 15 days result-
ing in almost half of the total views. Shares in LinkedIn
decreased toward the end of the study. Twitter retweets and
engagement metrics were almost equally distributed at the
start and end of data collection, except for a decrease in
URL clicks and an increase in detail expands. These find-
ings correlated with decreased survey responses over the
last 15 days, as the URL clicks led to survey information
posted on a website. Detail expands may have increased
as viewers checked to see if new information was posted
(Table 1).
Demographics of those who viewed posts in LinkedIn
were analyzed. As the researchers have academic, clini-
cal, company/vendor, governmental, and organizational ties
in their employment history, it is not surprising that the
posts attracted views from those sectors. Responses show
the potential power of a snowball strategy to reach those

pp 37–42 • Clinical Simulation in Nursing • Volume 55

Clinical Simulation in Nursing 40

Table 2 Demographics of LinkedIn Viewers

General Type of Business Type of Organization Title of Viewers∗

Academic Colleges Arts Professional

Community Colleges Career Counselor
Technical Colleges Community Development Specialist
Universities Education Administrator
Fellow
Human Resources Specialist
IT Consultant
IT Support Specialist
Laboratory Scientist
Operations Specialist
Program Manager, Research
School Teacher
Student
University Professor
Clinical Ambulance Service Customer Service Specialist
Health Systems Dietician
Home Health Care Medical Assistant
Hospitals Nurse
Companies & Vendors Construction Business Owner
Design Business Strategist
Publishing Consultant
Simulation Contract Worker
Telecommunications Executive Director
Workforce Solutions Founder
Logistics Specialist
Mechanic & Maintenance Tradesperson
Product Development Engineer
Product Manager
Salesperson, Medical
Technology Manager
Government Armed Forces Corporate Trainer
National Health
Organizations Medical
Nursing
Simulation
Surgical
Location of Respondents United States (22 states, District of Columbia), Canada,
Australia, Belgium, Turkey, India, United Kingdom
∗ Titles are defined by LI; not all responses were aligned with a title.

who might not otherwise learn about a study. However, it
is impossible to know which respondents were attracted
to the study by which platform and whether they learned
about the study from a peer, educator, or random oppor-
tunity. Future research into this sampling strategy should
include questions to help determine how respondents were
reached.
There are benefits and challenges associated with snow-
ball sampling. While researchers can access a sample that
is unknown or difficult to reach, the downside is an inabil-
ity to determine sampling error and make generalizations
that findings are representative of the studied population
(Sharma, 2017). However, this strategy may help recruit
more participants. A recent multisite study (manuscript un-
der revision) using the CLECS required 9 Institutional Re-
view Board (IRB) approvals and 9 months of data col-
lection with a resulting sample of 159. This is an 8%
lower response rate, took 7 months longer, and required
8 additional IRB approvals than this comparable study us-
ing snowball sampling. This strategy overcame the need to
have site coordinators, thereby reducing staff/faculty time
as well as potential deviation from the study protocol. De-
creasing study time and personnel involvement may lead
to cost savings. Researcher relationships with study par-
ticipants is a known potential bias when conducting re-
search on site; therefore, snowball sampling through so-
cial media widens the sample to those unknown to the
researchers.

pp 37–42 • Clinical Simulation in Nursing • Volume 55

Clinical Simulation in Nursing
Snowball sampling through social media may introduce
sampling bias toward characteristics of those who have an
active online presence. Eighty-one percent of the US popu-
lation have smartphones, increasing access to the Internet,
but people earning under $30,000 annually (Silver, 2019)
and living in rural locations (Wheeler, 2020) have less ac-
cess. Worldwide, almost half the population does not have
Internet (UNESCO, 2019). Nursing students can fall into
these categories, thereby potentially limiting representation
in the sample. The researchers were also challenged by
lack of response from social media sites catering to nursing
students as this led to use of social media sites designed
for faculty.
Recommendations
In hindsight, the researchers could have learned more about
how social media works before starting the snowball sam-
pling strategy. For example, researchers were inexperi-
enced with Twitter and would have benefitted from a better
understanding of how hashtags are used. Analytics support-
ing LinkedIn and Twitter provided detailed feedback on en-
gagement with posts; however, there were different types
of data, making direct comparisons challenging. Recom-
mendations include using site analytics of successful posts
early-on to create future content or designs.
Maintaining enthusiasm and creating interest in each
post was challenging. Researchers posted recruitment in-
formation, then retweeted/reposted each other, in addi-
tion to reposting others’ comments or posts on our study.
Each time, the researchers included hashtags and At Signs
geared toward the student nurse. Analytics showed that
the contacts were similar amongst the researchers and may
have resulted in viewer fatigue. Our team suggests dispers-
ing messages throughout the two platforms at irregular in-
tervals, rather than all at once. The data showed sustained
interest on the Twitter platform; research into platform ef-
fectiveness is warranted. There are products available (e.g.,
Hootsuite) to facilitate a planned, strategic approach to
posting.
Conclusion
This exploration of data collected using snowball sam-
pling via social media demonstrated that this method is
an effective and efficient way to recruit study participants.
When compared to the authors’ previous experience, snow-
ball sampling made possible an increased sample size and
decreased time to completion, as well as elimination of
burdensome IRB applications. Recommendations include
a deeper dive into the workings of social media and avail-
able analytics before embarking on a study using social
media sites for snowball sampling.
41
Conflicts of interest
None.
References
American Association of Colleges of Nursing (AACN). (2020). Con-
siderations for COVID-19 preparedness and response in U.S. schools
of nursing. Retrieved 4 Oct 2020 from https://www.aacnnursing.org/
News- Information/COVID- 19/AACN- Recommendations.
Canadian Association of Schools of Nursing (CASN). (2020).
Nursing education during the COVID-19 pandemic. Retrieved
4 Oct 2020 from https:// www.casn.ca/ wp-content/ uploads/ 2020/ 03/
COVID- 19- POSITION- STATEMENT.pdf.
Hunt, C. (2015). Understanding and using # tags and @ tags. So-
cial Media Today. Retrieved 4 Oct 2020 from https://www.
socialmediatoday.com/ social-networks/ courtney-hunt/ 2015-07-06/
understanding- and- using- tags- and- tags.
Leighton, K. (2015). Development of the clinical learning environment
comparison survey. Clinical Simulation in Nursing, 11(1), 44-51. https:
// doi.org/ 10.1016/ j.ecns.2014.11.002.
LinkedIn reactions (2020). Use LinkedIn reactions Retrieved 4
Oct 2020 from https:// www.linkedin.com/ help/ linkedin/ answer/ 101466/
use- linkedin- reactions?lang=en.
Lioce, L. (Ed.), Lopreiato, J. (Founding Ed.), Downing, D., Change, T.P.,
Robertson, J.M., Anderson, M., Diaz, D.A., & Spain, A.E. (Assoc Eds.)
and the Terminology and Concepts Working Group (2020). Health-
care Simulation Dictionary Second Edition. Rockville, MD: Agency
for Healthcare Research and Quality. AHRQ Publication No. 20-0019.
doi:10.23970/simulationv2.
Marcus, B., Weigelt, O., Hergert, J., Gurt, J., & Gelléri, P. (2017). The use
of snowball sampling for multi source organizational research: Some
cause for concern. Personnel Psychology, 70(3), 635-673. https://doi.
org/ 10.1111/ peps.12169.
Naderifar, M., Goli, H., & Ghaljaie, F. (2017). Snowball sampling: A
purposeful method of sampling in qualitative research. Strides in De-
velopment of Medical Education, 14(3), Article 367670. https://doi.org/
10.5812/sdme.67670.
Parker, C., Scott, S., & Geddes, A. (2019). Snowball sampling. Sage
research methods foundations. London, UK: Sage Publications. https:
// doi.org/ 10.4135/ 9781526421036831710.
Reagan, L., Nowlin, S. Y., Birdsall, S. B., Gabbay, J., Vorderstrasse, A.,
Johnson, C., & Melkus, G. D’E. (2019). Integrative review of recruit-
ment of research participants through Facebook. Nursing Research,
68(6), 423-432. https:// doi.org/ 10.1097/ NNR.0000000000000385.
Sharma, G. (2017). Pros and cons of different sampling techniques. In-
ternational Journal of Applied Research, 3(7), 749-752 No doi.
Silver, L. (2019). Smartphone ownership is growing rapidly around the
world, but not always equally. Pew Research Center: Global Attitudes
& Trends. Retrieved 4 Oct 2020 from https://www.pewresearch.
org/ global/ 2019/ 02/ 05/ smartphone- ownership- is- growing- rapidly-
around- the- world- but- not- always- equally/.
Twitter Analytics (2020). Tweet activity. Retrieved 4 Oct 2020 from https:
//analytics.twitter.com.
United Nations Educational, Scientific and Cultural Organization (UN-
ESCO). (2019). New report on global broadband access underscores
urgent need to reach the half of the world is still unconnected.
UNESCO. Retrieved 16 Oct 2020 from https:// en.unesco.org/ news/
new- report- global- broadband- access- underscores- urgent- need- reach-
half- world- still- unconnected.
Wheeler, T. (2020). 5 steps to get the internet to all Amer-
icans. Brookings: Center for Technology Innovation. Re-
trieved 16 Oct 2020 from https:// www.brookings.edu/ research/
5- steps- to- get- the- internet- to- all- americans/.
pp 37–42 • Clinical Simulation in Nursing • Volume 55
Clinical Simulation in Nursing
Wohl, A. R., Ludwig-Barron, N., Dierst-Davies, R., Kulkarni, S., Ben-
detson, J., Jordan, W., & Perez, M. (2017). Project engage: Snow-
ball sampling and direct recruitment to identify and link hard-to-reach
HIV-infected persons who are out of care. Journal of Acquired Im-
mune Deficiency Syndromes, 75(2), 190-197. https:// doi.org/ 10.1097/
QAI000000000000312.
42
World Health Organization (WHO) (2020). WHO characterizes COVID-
10 as a pandemic Retrieved 4 Oct 2020 from https://www.who.
int/ emergencies/ diseases/ novel- coronavirus- 2019/events- as- they-
happen.
pp 37–42 • Clinical Simulation in Nursing • Volume 55