The process and indicators of resilience among nursing students in clinical practicum in Taiwan: A qualitative study.

Background: Resilience is essential for managing stress and maintaining equilibrium. During the clinical practicum, nursing students may experience tremendous physical and mental stress, and these negative experiences are considered a source of resilience for students. However, no universal definition of resilience among nursing students exists in the literature, occasioning the need to define the processes and indicators of resilience. Purpose: This study aims to explore the resilience process and indicators among nursing students in clinical practicum in Taiwan. Participants: Fifteen fifth-year junior college nursing students in Northeastern Taiwan who had completed the clinical practicum were interviewed, including 12 females and three males. All participants were aged 20.3 ± 0.61 years and all participants had clinical practicum experiences over four months. Methods: A qualitative descriptive study, using purposive and snowball sampling methods, was conducted to collect the experience of the nursing students in their internship. Data were collected using a semi-structured guide and deep interviews, and analyzed through the content analysis method by Waltz, Strickland, & Lenz (2010). Results: Based on the participants' practical experiences during their clinical practicum, three main themes and nine indicators were identified. The resilience of nursing students is considered a process. The main themes are (1) uncontrolled clinical practical stress, (2) Maintain learning-life balance, (3) Positive attitude toward nursing. Conclusions: Resilience is a critical factor to stabilize nursing students and enable them to recover from adversity. Both positive and negative experiences significantly impacted the students' attitudes and confidence levels during the clinical practicum. The findings will provide faculty to adapt their teaching method to various situations of nursing students.

Stress and Coping Strategies of Online Nursing Practicum Courses for Taiwanese Nursing Students during the COVID-19 Pandemic: A Qualitative Study.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has resulted in significant changes in nursing education. Maintaining social distance could slow down the spread of COVID-19, and it was necessary, but it significantly reduced students' hands-on clinical practice experience in healthcare settings. Traditional classroom teaching in schools has transitioned to distance or online learning methods, which significantly reduced students' hands-on clinical practice experience in healthcare settings. Although distance education had been implemented for a long time, there are many problems and challenges to be resolved. The experiences and needs of nursing students in remote clinical training urgently require further understanding. PURPOSE: To understand the stress and coping strategies of online nursing practicum courses for Taiwanese nursing students during the COVID-19 pandemic. METHODS: A qualitative research approach with purposive sampling was supplemented by snowball sampling. Semi-structured interviews were conducted, and the data were collected following the eight-step process outlined by Waltz, Strickland, and Lenz (2010). The participants were 12 nursing students on a two-year nursing RN-to-BSN program at a university in Eastern Taiwan, consisting of 11 females and 1 male student. FINDINGS: The stress and coping behaviors of nursing students consist of four main themes, each with three subthemes, including "urgent changes", "the gaps between online courses and practical operations", "mixed feelings of joy and anxiety" and "unexpected gains". CONCLUSIONS: The pandemic has impacted nursing students' learning and living. Engaging in online nursing practicum brought about significant stress; nevertheless, students employed various coping strategies to navigate through this challenging period. The findings of this study would also help nursing educators understand the learning gaps in clinical practicum among students.

Development and Psychometric Testing of the Clinical Reasoning Scale Among Nursing Students Enrolled in Three Types of Programs in Taiwan.

BACKGROUND: There is no instrument currently available to assess the essential nursing competency of clinical reasoning (CR). PURPOSE: The purpose of this study was to develop and test the psychometric properties of CR assessment instrument appropriate for use with nursing students across different types of programs. METHODS: H. M. Huang et al.'s (2018) Framework of Competencies of Clinical Reasoning for Nursing Students was used to guide this study. Two rounds of Delphi study and confirmatory factor analysis (CFA) were conducted to test content and construct validity. Internal consistency was tested for reliability. RESULTS: The four-domain, 16-item Likert-scale Clinical Reasoning Scale (CRS) was developed. One thousand five hundred four nursing students currently enrolled in three different types of nursing programs completed the CRS. The content validity index was .85-1.0, the CFA indicated goodness of fit, and the Cronbach's α score range was .78-.89. CONCLUSION: The CRS is a valid and reliable tool for assessing CR in nursing students in different types of nursing program.

The effectiveness of designing and evaluating i-STAR applications in pediatric nursing courses.

To apply the App to the curriculum could improve students' motivation and concentration, and also strengthen the effectiveness of professional knowledge of nursing students. OBJECTIVES: To construct and evaluate the effectiveness of smartphone applications (i-STAR) in pediatric nursing courses. METHODS: Quasi-experimental study and two-group repeated-measure design were used to evaluate the effectiveness of smartphone applications (i-STAR) in pediatric nursing courses. The "i" means "interactive", students had to log into App and finish four steps, including "Situation(S), Task(T), Action(A), and Reflection(R). A total of 163 nursing students in the third grade of associate's degree in nursing (ADN) participated in the study. The experimental group consisted of 77 participants, whereas the control group consisted of 86 participants. The instruments included the clinical reasoning readiness scale (CRRS), self-directed learning instrument (SDLI), and learning satisfaction of students. The 1st phase was the development, construction, and testing of the "i-STAR App", including hyperbilirubinemia, pneumonia, and urinary tract infection (UTI). In the 2nd phase, students operated and applied the App in the classroom. The 3rd phase was to evaluate the effectiveness of the "i-STAR App" in the course. RESULTS: The average scores of CRRS and SDLI were not significantly different between the two groups in the T0 andT1 (p > .05). The experimental group of CRRS and SDLI were better than the control group in T0-T1, T1-T2, and T0-T2 (p < .001). The experimental group showed better CRRS and SDLI scores than the control group in T0-T1, and T0-T2 with Repeated measures ANOVA. Also, the experimental group showed prolonged learning effectiveness. The experimental group (41.22 ± 6.08) was more satisfied than the control group (37.29 ± 7.40) (p < .05), although their academic performance was about the same (p > .05). CONCLUSION: "i-STAR App" could enhance students' interest in pediatric nursing courses, strengthen nursing students' clinical reasoning and self-directed learning ability.

Effectiveness of e-STORY App in clinical reasoning competency and self-directed learning among students in associate nursing program: A quasi experimental study.

AIM: The purpose of this study was to promote students' clinical reasoning (CR) and self-directed learning (SDL). The specific aims were: (1) to examine effectiveness of the e-STORY App in promoting nursing students' CR and SDL; and (2) to explore the relationships between levels of learning motivation and suitability of the e-STORY App. BACKGROUND: CR and SDL are core competencies for nursing students. However, new graduates tend to be in adequately prepared in these competencies. Humanoid diagram uses diagrams to guide students in gaining a comprehensive view of the patient issues, which may promote attainment of these competencies. The Z generation students favor learning through smart devices for the feature of no time and spatial limitations. The e-STORY App was developed to overcome the setbacks of creating hard-copy drawings to promote learning effectiveness. DESIGN: This quasi-experimental study used two-group repeated measure design with a convenience sample. METHODS: A total of 77 students from two sections of the "Seminar for Clinical Case Studies" course participated in the study (experimental group: 39 students; control group: 38 students). Data were collected before, one week after and four weeks after the teaching intervention. The instruments used were demographic information sheet, Huang et al.'s (in press) Clinical reasoning scale and Cheng et al. (2010) Self-directed learning instrument. RESULTS: There were no significant differences in the CR and SDL scores between the experimental and control groups one week after the intervention (p＞.05). Analyses of the delay effects four weeks after the intervention found significantly higher CR scores in the experimental group than the control group (p < .05). However, there were no significant differences in the SDL scores between groups (p＞.05). Analysis of the findings from the experimental group found that students with moderate and low learning motivation showed significantly higher CR scores on the posttest and follow-up test (p < .05). CONCLUSIONS: Application of the e-STORY App as a supplementary teaching strategy promoted nursing students' CR ability, especially in students with moderate or low learning motivation. It is recommended to use the App in students with moderate or low learning motivation to promote learning effectiveness.

Effectiveness of a Mobile Technology-Supported Self-Reflective Course in Communication Behaviors for Outpatient Nurses.

Background Communication is a core competency for outpatient nurses. This study investigated the effectiveness of a mobile technology-supported self-reflective (MTS) course in communication behaviors among outpatient nurses. Method This quasi-experimental study used a convenience sample of 78 outpatient nurses (experimental group = 39; control group = 39). The experimental group completed the MTS communication course. Communication behaviors were evaluated before, 1 week after, and 1 month after the course. Results There was no significant difference in communication behaviors between the groups before the intervention. One week after the intervention, communication behavior scores significantly increased in both groups without significant between-group differences (p > .05). One month after the intervention, the experimental group showed significantly higher communication behavior scores (p < .05). Both groups demonstrated high learning satisfaction. Conclusion The MTS communication course was successful in promoting effective outpatient nurse-patient communication. Health care facilities may want to incorporate the MTS course into their orientation program. [J Contin Educ Nurs. 2022;53(6):279-288.].

The Lived Experiences of Stigmatization in the Process of HIV Status Disclosure among People Living with HIV in Taiwan.

People living with HIV (PLWH) face social stigma which makes disclosure of HIV status difficult. The purpose of this descriptive qualitative study was to understand the lived experiences of stigmatization in the process of disease disclosure among PLWH in Taiwan. Analysis of the semi-structured interviews from 19 PLWH in Taiwan revealed two phases and six themes. Phase one "experiences before disclosure" involved three themes: "Struggles under the pressure of concealing the HIV Status", "Torn between fear of unemployment/isolation and desire to protect closed ones", and "Being forced to disclose the HIV status." Phase two "experiences after disclosure" included three themes: "Receiving special considerations and requirements from school or work", "Receiving differential treatments in life and when seeking medical care", and "Stress relief and restart." Healthcare professionals need to assess stigmatization in PLWH and develop individualized approaches to assist with the disease disclosure process.

[Interpersonal Communication Competence and Conflict Handling Styles of Nurses in Intensive Care Units].

BACKGROUND: Nurses in intensive care units (ICUs) must be capable of employing appropriate conflict handling styles in order to communicate with medical teams, patients, and patient family members effectively. There is a current lack of research on the interpersonal communication competence and conflict handling styles of ICU nursing staffs in Taiwan. PURPOSE: This study aimed to: (1) explore the interpersonal communication competence and conflict handling styles of ICU nurses and related factors and (2) examine the relationship between the interpersonal communication competence and conflict handling styles of ICU nurses. METHODS: A cross-sectional correlational research approach was adopted and convenience sampling was used to recruit 351 ICU nurses from three hospitals in southern Taiwan. Data were collected using a demographic questionnaire, interpersonal communication competence scale, and conflict handling styles scale. RESULTS: (1) ICU nurses demonstrated a moderate or higher level of overall interpersonal communication competence, with "integrating" identified as the most commonly used conflict handling style. (2) Higher educational attainment and job position were both associated with better interpersonal communication competence. (3) The adoption of "compromising" and "avoiding" styles was significantly affected by age; the adoption of "obliging", "compromising", "avoiding", and "integrating" styles was significantly affected by education level; the adoption of "obliging", "compromising", and "integrating" styles was significantly affected by job position; and the adoption of "dominating", "compromising", and "integrating" styles was significantly affected by seniority. (4) Interpersonal communication competence correlated significantly and positively with the adoption of "dominating", "obliging", "compromising", and "integrating" styles. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Future study of the views of ICU nurses toward their own styles in handling interpersonal conflicts is needed. Furthermore, holding training courses annually to orient ICU nurses with the advantages and disadvantages of interpersonal conflict handling styles is recommended.

[Application of Flipped Classroom Teaching Strategy in Nursing Education].

The ultimate purpose of education is to provide students with the skills and motivation necessary for lifelong learning. Students with lifelong learning abilities are better able to continue improving their professional core competencies, especially in terms of problem solving and clinical reasoning. Prior to enhancing lifelong learning abilities, students must learn self-directed learning. Studies have shown that flipped classroom learning has the potential to improve self-directed learning. Flipped classroom teaching requires prerecorded lectures, strengthened teacher-student interaction, and assisting students to learn in-depth. The authors developed a four-phase dynamic case-based learning (4D CBL) innovative teaching strategy and then assimilated this strategy into flipped classroom teaching. This innovative teaching strategy may be used in various academic nursing programs to reinforce self-directed learning and clinical reasoning abilities. After introducing the concepts of flipped classroom teaching and 4-D CBL, how to merge 4D CBL with the flipped classroom model and the effectiveness of this innovative teaching strategy are demonstrated. Nurse educators may use the flipped classroom teaching strategy with 4D CBL in their future practice.

Rationale underpinning postgraduate student nurses' choice of research methods used for their masters' theses.

Many nurses in Taiwan use quantitative research for their master's thesis. However, qualitative research explores humankind in depth providing a more holistic approach relating to nursing. The purpose of this study was to explore the rationale postgraduate students used to choose the research methods for their masters' theses in Taiwan. A descriptive qualitative research design was used. Data were collected through semi-structured interviews of sixteen nursing students studying a master's from seven different Universities in Taiwan in 2016. Data were analyzed using thematic analysis. Finding revealed three themes (1) Students' personal and professional backgrounds; (2) Myths about quantitative research; (3) Misperceptions about qualitative research. Nurse educators could use these findings as a reference to design post-graduate nursing courses. It is essential to provide a balanced educative experience between delivering qualitative and quantitative modules to enhance respect of research method, knowledge and skills. Further, this could facilitate students' choice in research methods when designing their master's theses.

Development and Psychometric Testing of the Suicidal Recovery Ability Scale (SRAS) for Assessing Individuals Who Have Attempted Suicide.

Assessing the recovery ability of individuals who have attempted suicide is crucial for psychiatric health nurses. The purpose of this study was to develop and test a psychometric Suicidal Recovery Ability Scale (SRAS). Confirmatory factor analysis (CFA) indicated that three subscales with 15 items best fit the data. The global SRAS score showed significant negative correlation with the Beck Hopelessness Scale (BHS) score. The Cronbach's α and test-retest reliability scores for the global SRAS and the subscales all exceeded 0.70. Nurses can use the SRAS to assess the recovery ability of individuals who have attempted suicide and provide proper care to help them.

[The Relationship Between Fatigue and Uncertainty in Patients With Liver Cirrhosis].

BACKGROUND: Cirrhosis is a chronic, progressive, and currently incurable disease. Cirrhotic patients often experience uncertainty due to poor control of symptoms and disease recurrence. Although fatigue is a common symptom in patients with liver cirrhosis, this symptom is often ignored by healthcare professionals due to the lack of efficacious treatment options. Improper management of fatigue may trigger greater uncertainty and affect adaptation success. PURPOSE: To explore the relationship between fatigue and uncertainty and the factors that respectively relate to these two concepts in liver cirrhosis patients. METHODS: A cross-sectional, correlational design and convenience sampling were used to recruit 76 liver cirrhotic inpatients from one hospital. Three structured questionnaires, including the Personal Demographic Questionnaire, Brief Fatigue Inventory-Taiwan Form, and Mishel's Uncertainty in Illness Scale, were used for data collection. RESULTS: (1) The participants suffered from fatigue at a moderate or higher level, with an average score of 5.39 ± 2.34, which affected their daily activities and greatly impacted their recreational activities. Factors that were found to be associated with fatigue included disease severity, albumin level, total bilirubin level, ascites, and the degree to which fatigue affected the performance of daily activities. (2) Uncertainty was found to be at a moderate or higher level, with an average score of 71.81 ± 10.67. Level of fatigue, the degree to which fatigue affected the performance of daily activities, disease severity, and albumin level were found to relate significantly to level of uncertainty. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Fatigue and uncertainty are prevalent and distressing experiences for patients with liver cirrhosis. A comprehensive assessment and broad-based approach to nursing interventions are necessary in order to alleviate fatigue and uncertainty effectively.

Establishing the competences of clinical reasoning for nursing students in Taiwan: From the nurse educators' perspectives.

BACKGROUND: Clinical reasoning is an essential core competence for nurses. Maintaining quality of care and safety of patients results from cultivation of student's clinical reasoning competency. However, the concept of clinical reasoning in nursing students is complex and its meaning and process needs further clarification. OBJECTIVES: The objectives were to explore the meaning of clinical reasoning competency in Taiwanese nursing students and to operationalize the concept in order to structure a framework illustrating the process of clinical reasoning. SETTING AND PARTICIPANTS: Thirteen seasoned nursing experts who had more than ten years of experience in nursing education or clinical practice participated in the interviews. The interviews were conducted in settings that the participants perceived as convenient, quiet and free of disturbance. METHODS: Semi-structured interviews were conducted. The interviews were audio-recorded and field notes were taken. The data were analyzed using Waltz et al.'s (2010) method of content analysis. RESULTS: The data revealed four domains and 11 competency indicators. The four domains include: awareness of clinical cues, confirmation of clinical problems, determination and implementation of actions, and evaluation and self-reflection. Each domain comprises of 2-4 indicators of clinical reasoning competency. In addition, this study established a framework for cultivation of clinical reasoning competency in nursing students. CONCLUSION: The indicators of clinical reasoning competency in nursing students are interwoven, interactive and interdependent to form a dynamic process. The findings of this study may facilitate evaluation of nursing students' clinical reasoning competency and development of instruments to assess clinical reasoning in nursing students.

Category 3 and 4 Controlled Drugs Users' Perceptions of Participating in Drug-Abuse-Health Prevention Lectures in Taiwan.

This study was designed to explore Category 3 and 4 controlled drug users' perceptions of participating in health-prevention lectures. A phenomenological approach was used. Twelve participants were interviewed after completing the lectures. Findings revealed five themes (1) mixed emotions; (2) self-development; (3) finding the lectures lacked practicality and relevance; (4) highlighting three stages for discontinuing drug-usage; and, (5) suggesting tips for the advancement of lectures. These findings could be used as a map to help health professionals understand drug users' perceptions of attending health prevention lectures and provide insight into how young people might stop using drugs.

Challenges in intergenerational caregiving for frail older people: A multiple case study.

Families in Taiwan are considered central in caring for frail older people. However, rapid social changes are reshaping Taiwanese family values and structures. In this study, we explored the challenges of intergenerational families in caring for frail older people in Taiwan. Using a multiple-case study, 32 participants representing 12 families comprising three or more generations participated in individual, semistructured interviews. A grounded theory technique was used for the data analysis. Four themes emerged in the findings: intergenerational and intragenerational disharmony, restrictions in the physical environment, financial caregiving burdens, and lack of support from the healthcare system. The findings can help raise awareness of filial caregiving obligations of aging family members that have shifted from a parent-child dyad to being shared across multiple generations in Taiwan. Intergenerational caregiving for frail older people has become a challenge for policies aimed at keeping the aging population in the community.

A Study of Interpersonal Intimacy and Meaning of Life Among Elderly Institutionalized Veterans.

BACKGROUND: Most senior veterans who live in veterans' homes in Taiwan are single and have few intimate, interpersonal relationships. Aging is often accompanied by solitude and illness, which causes senior veterans to doubt the meaning of life and to lose confidence in the value of life. PURPOSE: This study investigated the personal characteristics that influence interpersonal intimacy and the meaning of life as well as the relationship between interpersonal intimacy and the meaning of life among senior veterans living in veterans' homes. METHODS: A cross-sectional design was used, and 120 senior male veterans were convenience sampled from three veterans' homes in southern Taiwan. Three structured questionnaires were used in this study: personal characteristics questionnaire, interpersonal intimacy scale, and purpose in life test. RESULTS: (a) Interpersonal intimacy was influenced by source of income or funds, type of residence institution, religious affiliation, and the quality of the participant's relationships with family, friends, and fellow residents. Educational level and self-perceived health status correlated positively with interpersonal intimacy, and period of residence correlated negatively with interpersonal intimacy. (b) Meaning of life was influenced by the quality of relationships with family and friends. Educational level and self-perceived health status correlated significantly and positively with meaning of life, and period of residence correlated negatively with meaning of life. (c) Significant, positive correlations were found among interpersonal intimacy, the four domains of interpersonal intimacy, and meaning of life. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Health professionals involved in the care of senior veterans in institutions may use the results of this study to develop and implement interventions that promote a higher degree of interpersonal intimacy and a higher appreciation of the meaning of life, thus enabling senior veterans to confront old age in a more positive manner.

The Psychological Process of Breast Cancer Patients Receiving Initial Chemotherapy: Rising From the Ashes.

BACKGROUND: In Taiwan, breast cancer is the most common cancer in women. Most breast cancer patients are willing to receive chemotherapy and experience adverse effects and suffering during the process of chemotherapy. OBJECTIVES: The aim of this study was to explore patients' psychological process when receiving initial chemotherapy for breast cancer. METHODS: A qualitative grounded theory approach was used. Data were collected through semistructured interviews of 20 patients who were from 1 district teaching hospital during 2012 to 2013. RESULTS: A substantive theory was generated to describe the psychological process experienced by breast cancer patients in their initial treatment. The core category was "rising from the ashes." Four categories emerged and represented 4 stages of the psychological process experienced by breast cancer patients. They were (1) fear stage: patients are frightened about permanent separation from family, chemotherapy, and the disease getting worse; (2) hardship stage: patients experience physical suffering and mental torment; (3) adjustment stage: patients fight against the disease, find methods for adjustment, and get assistance from supporting systems; (4) relaxation stage: patients were released from both the physical and mental sufferings, and patients accepted the disease-related change in their lives. CONCLUSION: Each stage is closely related to the other stages, and each is likely to occur repeatedly. It is important to help patients achieve the relaxation stage. IMPLICATIONS FOR PRACTICE: The results of this study may enhance nurses' understanding of the psychological process of patients receiving initial chemotherapy for breast cancer, thereby helping nurses to provide appropriate assistance to improve the quality of patient care.

Undergraduate student nurses' lived experiences of anxiety during their first clinical practicum: A phenomenological study.

BACKGROUND: The Fundamental Nursing clinical practicum is an essential module for nursing students. Some feel stress or anxiety about attending this first placement; however, evidence demonstrates that it is rare to explore the feelings of anxiety felt by the nursing students concerning their first clinical practicum. OBJECTIVE: This study was designed to explore student nurses' experiences of anxiety felt regarding their initial clinical practicum while studying for their University degree. DESIGN: A phenomenological approach was used. SETTINGS: A university in Southern Taiwan. PARTICIPANTS: A purposive sampling of fifteen student nurses with anxiety reactions who had completed their first clinical practicum. METHODS: Data were collected using a semi-structured guide and deep interview. Data were analyzed using Colaizzi's seven-step phenomenological method. RESULTS: Three themes surfaced in the findings. The first theme was anxiety around their first clinical practicum, which stirred up anxiety about: self-doubt, worry and fear; difficulty coping with the learning process; worry hampered establishing therapeutic relationships with patients; the progress of the patients' illness could not be predicted; and anxiety felt about lecturer-student interactions. The second theme was three phases of anxiety reactions, which included increasing anxiety before clinical practicum; exacerbated anxiety during clinical practicum, and relief of anxiety after clinical practicum. The third theme was coping behaviors. This comprised: self-reflection in preparation for clinical practicum; finding ways to release emotions; distractions from the anxiety; and, also facing their difficulties head-on. CONCLUSION: The findings could help raise the awareness of lecturers and students by understanding student nurses' anxiety experiences and facilitating a healthy preparation for their initial clinical practicum, consequently proactively helping reduce potential anxiety experiences.

Development and psychometric testing of the Suicide Caring Competence Scale (SCCS) for family caregivers in Taiwan.

Suicide caring competence is important for family caregivers to care their relatives with suicidal tendencies. The purpose of this study was to develop and test the psychometric properties of the Suicide Caring Competence Scale (SCCS) for family caregivers in Taiwan. A 20-item SCCS was tested on 165 family caregivers. Confirmatory factor analysis indicated that five subscales with 19 items best fit the data. The Cronbach's α and test-retest reliability of the SCCS was 0.90 and 0.81, respectively. The SCCS demonstrated acceptable construct validity and reliability. Nurses can use the SCCS to assess the suicide caring competence of family caregivers.

[A comparison of convenience sampling and purposive sampling].

Convenience sampling and purposive sampling are two different sampling methods. This article first explains sampling terms such as target population, accessible population, simple random sampling, intended sample, actual sample, and statistical power analysis. These terms are then used to explain the difference between "convenience sampling" and purposive sampling." Convenience sampling is a non-probabilistic sampling technique applicable to qualitative or quantitative studies, although it is most frequently used in quantitative studies. In convenience samples, subjects more readily accessible to the researcher are more likely to be included. Thus, in quantitative studies, opportunity to participate is not equal for all qualified individuals in the target population and study results are not necessarily generalizable to this population. As in all quantitative studies, increasing the sample size increases the statistical power of the convenience sample. In contrast, purposive sampling is typically used in qualitative studies. Researchers who use this technique carefully select subjects based on study purpose with the expectation that each participant will provide unique and rich information of value to the study. As a result, members of the accessible population are not interchangeable and sample size is determined by data saturation not by statistical power analysis.