ProfessionalIssues Melanie Henderson

Michael D. Dahnke

The Ethical Use o f Social Media inNursing Practice

S ocial media have become a significant part of com­munication, especially for the Millennial genera­tion, but for many other generations as well.

People of all ages across the world are using this technol­ogy to obtain news, stay connected to family and friends, and exchange information, which means nurses will be caring for many patients who are connected via social media. Because nurses have a distinct role in help­ing patients receive appropriate care and achieve opti­mal health outcomes, they must find ways to reach patients that allow continued meaningful relationships. Connecting with patients and meeting their needs is crucial to holistic nursing practice, which involves con­tinual evolution in developing knowledge and skills "through caring encounters with patients" (Hines, 2009, p. 3). Proper use of social media may help nurses accomplish this if they can avoid violating patients' right to confidentiality and privacy or compromising the integrity of nurses.

D e fin in g Social M e d iaSocial media are "electronic tools that enhance com­

munication, support collaboration, and enable users across the globe to generate and share content" (Thielst, 2013, p. 1). Different popular types of social media include social network sites, blogs, online chat rooms, video sites, video sharing, podcasts, microblogging, pro­fessional networks, and content-driven communities (National Council of State Boards of Nursing [NCSBN], 2011a; Walaski, 2013). Popular social media sites include Facebook, Twitter, Linkedln, Pinterest, Instagram, and Wikipedia (Walaski, 2013). Social media are collaborative, with continuously changing mecha­nisms and platforms that allow for communication (Spector & Kappel, 2012). Due to multiple formats and wide varieties of social media, nurses or other health care professionals are unable to know every type; how­ever, acquiring basic knowledge of two of the most widely used would not be unreasonable.

Melanie Henderson, BA, RN, SCRN, is Stroke Coordinator, St. Vincent Hospital, Erie, PA; and Student, Master of Science in Nursing Program, Drexel University, Philadelphia, PA.

Michael D. Dahnke, PhD, is Associate Teaching Professor, Department of Health Administration and Division of Graduate Nursing, Drexel University, Philadelphia, PA.

Social N e tw o rk in g Sites, B lo g g in g , an d M ic ro b lo g g in g

Social networking sites "promote building relation­ships among people with similar interests and activities" (Walaski, 2013, p. 41). People use Facebook, for exam­ple, to "stay connected to friends and family, to discover what's going on in the world, and to share and express what matters to them" (Facebook, 2014, para. 18). Many people upload photographs, share personal thoughts or posts, and then "Like" online content posted and uploaded by others. Content of posts generally is broad, but some individuals do post updates on personal health situations. Nearly 60% of Americans over age 18 and 73% of younger Americans ages 12-17 use Facebook (Smith, 2014). In addition, 802 million average daily active users were reported for March 2014, with 1.28 bil­lion monthly active users (Facebook, 2014). Many busi­nesses, including health care providers, have a Facebook page and ask consumers to visit and "Like" their page.

Given the popularity of social networking sites, nurs­es must realize their possible impact on the way health care information is delivered. The American Nurses Association (ANA) (2001) indicated nurses must know current standards of nursing practice and changing issues. Certainly, social media in health care falls within the category of changing issues. Similarly, the International Council of Nurses (2012) warned nurses' use of technology should be "compatible with the safe­ty, dignity, and rights of people" (p. 3). If nurses do not learn how these social networks work and identify sites for patients to access trustworthy information on health topics, patients may become more vulnerable to misin­formation.

Blogs utilize a web-based format for expressing an opinion or offering information; microblogging involves the use of short blogs. Twitter is the most pop­ular microblog. Its text messages or "tweets" have a 140- character limit and are sent via telecommunications (Walaski, 2013). Twitter (2014) reports monthly active users at 255 million; nearly half a billion tweets are sent daily. Twitter's mission is "To give everyone the power to create and share ideas and information instantly, without barriers" (Twitter, 2014, para. 1). In a study of patients' reasons for using social media in a health-relat­ed fashion, Antheunis, Tates, and Nieboer (2013) found the typical patient uses Twitter to "stay updated on the new developments in health care and to increase my knowledge on my disease" (p. 428). However, one of the obstacles of Twitter use in health care is the potential for sharing erroneous information, especially "given the

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sheer number of people disseminating information with virtually no limits” (Walaski, 2013, p. 43). Thus, given their role in helping patients achieve optimum health outcomes, nurses should be knowledgeable enough to refer patients to trustworthy tweets or links for referenc­ing accurate information on health conditions, lifestyle changes for disease prevention, and other applicable health information (ANA, 2001).

Ethical Issues Arising from Social M edia Use

Privacy and C onfidentialityPerhaps the greatest risk in use of social media in

health care is to the patient's privacy and confidentiali­ty. "Privacy relates to patient's expectation and right to be treated with dignity and respect" (NCSBN, 2011b, p. 1). The principle of confidentiality in medical ethics refers to patient information and the limitations on a health care provider sharing that information with oth­ers (Dorland, 2007). Establishing trust between the patient and the nurse is the most basic principle of the nurse-patient relationship. Respecting privacy and con­fidentiality engenders trust between the patient and nurse. If the patient does not trust the nurse, he or she will not reveal important information crucial to receiv­ing care for his or her health condition. Given the ease with which information can be disseminated quickly by one person to countless others, social media present great risk for violation of patient privacy and confiden­tiality. Violations of privacy can erode a trusting rela­tionship, which can decrease quality of care if a patient no longer feels able to disclose to a provider all relevant information or no longer trusts a provider to follow medical advice.

Nurses have posted on blogs, social network sites, and other forums potentially identifying information about patients, including derogatory remarks, photo­graphs, and details about patient care. However, nurses have the duty to protect patient privacy and to "main­tain confidentiality of all patient information” (ANA, 2001, p. 16). Some nurses mistakenly believe omitting a name will protect the patient. However, according to the Safe Harbor Method of De-Identification, 18 identi­fiers must be removed for patient information to be safe (Clark, 2013). In addition to a patient's name, two other key identifiers are "geographic subdivisions smaller than a State" and "all elements of dates" (p. 185). A nurse who posts about caring for an 85-year old female in her city could cause the patient to be identified by content in the post. This action does not protect the patient.

In many instances, patient confidentiality and priva­cy have been violated through the use of social media and nurses have been reported to the boards of nursing (BONs) in their states (NCSBN, 2011a, 2011b; Spector & Kappel, 2012). A survey conducted with BONs in 2010 revealed complaints of nurses who either inadvertently or intentionally breached a patient's privacy, with disci­

pline ranging from minimal action to nursing license suspension (NCSBN, 2011b; Spector & Kappel, 2012). NCSBN (2011a, 2011b) provided a white paper and brochure to guide nurses in the use of social media. Topics in these documents included social media in the workplace, privacy and confidentiality, Health Insurance Portability and Accountability Act, proper uses of social media, and ways to avoid disclosure of confidential information. In addition, many hospitals and health care organizations have created policies that specifically address the use of social media in the work­place; nurses should review and reference these local regulations to avoid violations (NCSBN, 2011a, 2011b; Walaski, 2013).

Nonm aleficenceMost nurses enter the nursing profession because

they want to relieve suffering and treat their patients with caring and compassion. Nurses who post on social media about recent care of any patient are misusing these venues and violating the Code of Ethics (ANA, 2001), even if they believe the patient could not be identified. Even if the patient never is identified, "sub­jecting patients to unnecessary risks is wrong even if no damage is done" (Vaughn, 2010, p. 10). If the patient is identified, the risk of embarrassment and other emo­tional pain is very real. As an additional drawback of social media, anything saved to a server is "there forever and could be retrieved later, even after deletion" (NCSBN, 2011a, p. 8). Clark (2013) also emphasized the digital tracings of Internet or social media entries are a permanent record.

Professional IntegrityIntegrity was described by Lachman (2009) as "hav­

ing and consistently holding firm to moral principles and standards" (p. 60). Social media as a new social influence can impact the integrity of nurses as it relates to patient care. Nurses who learn of questionable post­ings by others must take additional action in accordance with their facility's social media policy. They should not post or blog complaints about employers, patients, or the profession on social media. In addition, nurses should maintain professional boundaries between patients when using these platforms. Connecting with a patient on social media as a "friend," or any other rela­tionship beyond that of provider-patient, risks blurring lines that help to maintain a professional relationship best suited for providing optimal care (NCSBN, 2011a).

Whether due to the questionable postings of others, a nurse's personal temptation to post inappropriately, or threats to professional boundaries, social media will pose challenges to nurses' professional integrity. However, understanding their actions and beliefs will help nurses utilize social media appropriately. As Lasala (2009) asserted, "The nurse who is mindful and obser­vant of the challenges inherent in caring recognizes self­understanding as essential to maintaining personal integrity" (p. 432). To create caring patient encounters and improve the delivery of care, nurses must reflect on

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their personal and professional views of social media and ensure their integrity is not jeopardized in their pro­fessional or personal use, or in the use of others in their workplace or profession.

Appropriate Use of Social Media

Nursing PracticeSocial media have many benefits in assisting nurses

with patient care, such as providing patient educational materials about health conditions and a healthful lifestyle, linking patients to support groups, and improving adherence to the medication regimen (Prasad, 2013; Walaski, 2013). Knowledgeable use of social media can allow nurses to plan care to reflect a patient's uniqueness, allow the patient to contribute to the plan of care, and ensure the plan is deemed accept­able by the individual (ANA, 2001). If nurses are unfa­miliar with the forms of preferred social media or ade­quate sources of education, health promotion, or sup­port groups, they have a responsibility to seek more information from colleagues or refer the patient to other members of the interdisciplinary team to ensure the patient receives appropriate care (ANA, 2001). A patient education committee at the hospital or organization could identify approved sites for nurses to suggest to patients as trusted sources for patient education through social media. Another option is to create a social media committee, an interdisciplinary team of nurses and other professionals, to ensure social media are used eth­ically to impact patient care positively. The team would focus on recommending credible sites, offering educa­tion on social media use to staff, ensuring staff is aware of social media policies, and giving examples of improp­er use of social media. The goal is to ensure patients receive high-quality education to obtain optimal health outcomes.Personal Use

Nurses are free to use social media in their personal lives as a norm for communication (NCSBN, 2011a). However, nurses also must realize they "have both per­sonal and professional identities that are neither entire­ly separate, nor entirely merged, but are integrated" (ANA, 2001, p. 24). Creating both personal and profes­sional Facebook pages, for example, would be wise (Walaski, 2013). Nurses must understand what is posted is likely to be reviewed and used as an evaluation of future performance or potential (Clark, 2013). Clark rec­ommended Facebook accounts be deleted, private and professional profiles be separated, and serious thought employed before posting.

ConclusionSocial media themselves are not the issue in the

debate over their use in health care. Rather, it is the use of the technology that may cause harm. Thus, care must be taken to ensure patients' rights to privacy and confi­

dentiality are protected at all times. In addition, nurses' integrity must not be compromised. Used properly and with thoughtfulness, social media can be valuable tools in reaching today's technologically advanced con­sumers to impact public health, patient education, and the nurse-patient relationship. Pho (as cited in Prasad, 2013) stated, "Social media is where the future is, and most importantly, that's where our patients are going to be" (p. 492). Nurses and other health care professionals must continue to expand their knowledge of social media. Research must contribute to evidence-based practice with use of social media platforms to maximize usefulness in an ethical way to meet patients' needs. At the same time, care must be taken to ensure all patients' needs are met, including those who do not embrace social media. By using social media in an ethical and appropriate manner, nurses may continue to improve individual practice and promote caring interactions with patients. ESH3

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