Social media can be a very effective way of communicating in nursing, but also presents regulatory concerns. Would you think that a simple entry in a local newspaper’s blog could escalate to a complaint to a board of nursing (BON), followed up by an interview with the BON’s investigator? That is precisely what happened in a case described in NCSBN’s “White Paper: A Nurse’s Guide to the Use of Social Media” (NCSBN, 2011e). Social media can be a very effective way of communicating in nursing, but also presents regulatory concerns. This article briefly introduces the phenomenon of social media and introduces three actual scenarios where nurses unintentionally violated appropriate use of social media in healthcare. The scenarios are discussed related to social media, career concerns, and nursing regulation. The nature of complaints against nurses is explored as well as common myths and misunderstandings about using social media platforms. Guidelines and available resources for appropriate use by nurses and to inform organizational level policy are offered.

The Phenomenon of Social Media

Social media has become one with the fabric of society and while it may undergo constant evolution over its lifespan, it will remain part of the world in which we live for the foreseeable future. Social media is instantaneous and powerful, carrying messages that can be profound or profane. It is hardly an overstatement that social media is transforming the way that people communicate. Just a few years ago, it was almost unimaginable that social revolution or political upheaval would be tweeted about by those actually experiencing it for millions around the world to read in real time. In most cases, social media carries messages far more mundane, but in their own way, they are just as powerful because such communication has changed how the world is seen and experienced. Social media has become one with the fabric of society and while it may undergo constant evolution over its lifespan, it will remain part of the world in which we live for the foreseeable future.

Kaplan and Haenlein (2010) define social media as "a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of user-generated content" (p 61).  “User-generated” is the key phrase in that the social networking is defined by the community it generates. Social media is fundamentally collaborative, opening communication between participants through mechanisms and platforms that change continuously.

Social media is a not merely a driving force in everyday life, but one that fits seamlessly into how communication is transmitted. Twitter^® and tweeting, blogging, wikis, Facebook^®, Google+^®, LinkedIn^® and dozens of other terms are all words that have entered the cultural lexicon, but did not exist within social consciousness five years ago. The rate at which such words enter the public arena becomes exponentially more rapid. Social media is a not merely a driving force in everyday life, but one that fits seamlessly into how communication is transmitted. The social networking statistics are staggering; there are more than 900 million active Facebook^® users, a 32.5 percent increase from the same period in 2011 (Hachman, 2012); Twitter^® now has 140 million users accounting for 340 million tweets per day (What is Twitter?, 2012).

What does this all mean for nurses and the nursing profession? Social media can be a highly effective mechanism that allows for the cultivation of professional connections; promotes timely communication with patients and family members; and educates and informs consumers and health care professionals. For example, in 2010 at Jewish Hospital in Louisville, Kentucky, the health care team performed a double hand transplant, which at the time was only the third such surgery in the US. It is a lengthy surgery and involves teams of experts rotating in and out of the surgical suite. During the surgery, senior hand fellows sat outside the surgical suite with a laptop and tweeted updates for the family to read (Yin, 2010).

Nurses who use blogs, social networking sites, video sites, online chat rooms, and forums to communicate both personally and professionally with other nurses can positively use social media in a responsible manner that fosters congenial interface with other professionals. An outlet where nurses can share workplace experiences, particularly those events that are challenging, can be as invaluable as journaling and reflective practice, which have been identified as effective tools in nursing practice (Bulman & Schutz, 2008). Social networking provides means by which nurses can connect with others, such as the discussion board on www.nurseconnect.com, and receive support needed in this high stress and emotionally charged profession.

Participating in social media is not a problem as long as nurses always remain cognizant of their professional obligations. Participating in social media is not a problem as long as nurses always remain cognizant of their professional obligations. Nurses must always be aware of potential consequences of disclosing patient-related information via social media and mindful of employer policies; relevant state and federal laws; and professional standards regarding patient privacy and confidentiality. Patients should expect a nurse to act in their best interests and to respect their dignity. Inadvertent or intentional breaches of patient privacy and confidentiality have potential to cause harm and erode the crucial nurse-patient relationship, as the following actual scenarios clearly illustrate.

Actual Scenarios

Scenario 1: Public Blog

A nurse, who called the physically disabled child she cares for her “little handicapper,” commented on the small town newspaper’s blog about caring for the child, mentioning the child’s age and use of a wheelchair. One of the blog’s readers complained to the BON that the nurse was violating “privacy laws” of the child and his family (NCSBN, 2011e). Even without considering the insensitive and unprofessional language, the BON could have taken disciplinary action for failing to maintain the confidentiality of patient information, though it decided a warning was sufficient¹. Still, the nurse was shaken and learned a valuable lesson about not posting any information about patients on websites.

Scenario 2: Forwarded Inappropriate E-mail

In one case (NCSBN, 2011e), nurses arrived on their unit to find a picture of a patient, in her hospital gown with her backside exposed, in their emails. The staff who received this email did not know the source, so they forwarded it to others who had not received it to find out who might have sent it.  In the course of the morning, this email was the subject of conversation, with some nurses airing their concerns, but others finding it funny. No one reported it to the supervisor. By midday, hospital management became aware of the photo and began investigating because of their concern that the patient’s rights may have been violated. The local media found out and the story was covered so extensively that it made national news. Law enforcement became involved, investigating whether sexual exploitation occurred. Hospital management placed the nurses on administrative leave while they reviewed the facility’s rules that emphasize patient rights, dignity, and protection. Management also reported the incident to the BON, which opened an investigation to determine whether state or federal regulations enforceable by the BON, such as confidentiality of health records, were violated. Eventually the patient was identified and the hospital faced possible legal consequences. Had the nurses acted as professionals and reported the incident, this entire situation could have been avoided.

Scenario 3: Student Nurse on Facebook^®

This student, like many who are naïve about social networks, did not realize that others can access posts even when appropriate privacy settings are in place. In yet another case where there was no original intent to harm (NCSBN, 2011e), a student nurse wanted to remember the 3-year-old pediatric patient she had been caring for who was receiving chemotherapy for leukemia at a children’s hospital. She took his photo, with his room number visible in the background. She then posted his photo on her Facebook^® wall for friends to see, writing about how brave her patient was and how proud she was to be a student nurse. This student, like many who are naïve about social networks, did not realize that others can access posts even when appropriate privacy settings are in place. In this case, someone forwarded the information to a nurse at the children’s hospital who then contacted her supervisor. Since the nursing program had a clear policy about students not breaching confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) violations (U.S. Department of Health & Human Services, 2012), the student was expelled from the program. Further, the nursing program was not allowed to come back to the children’s hospital for pediatric clinical experiences and the hospital faced HIPAA violations.

Social Media, Career Concerns, and Nursing Regulation

While social media can be extremely valuable to nurses and other health care providers, inappropriate use of these tools can be devastating to a nurse’s career, as was seen in the three scenarios above.These three cases illustrate that many of the social media situations involving nurses can begin without malicious intent. These three cases illustrate that many of the social media situations involving nurses can begin without malicious intent. However, events can quickly escalate into serious situations where patient confidentiality and privacy are violated and nursing careers are in jeopardy. Two surveys were sent to BONs in November 2010 and again in March 2012 (NCSBN, 2010; NCSBN, 2012) to examine the extent of nursing regulatory complaints against nurses who misuse social media. Of the 46² executive officers who responded in 2010, 67% reported that they received complaints about nurses misusing social media, and of those, another 67% reported that they disciplined nurses for this infraction. At that time, only 7% of the BONs had specific social networking guidelines in place, though many reported that they can use their general patient privacy protection laws.

By March 2012, not much had changed at BONs (NCSBN, 2012). Of the 30 executive officers who responded to the survey, 63% reported that they received complaints against nurses for inappropriately using social media, and of those, 64% reported that they disciplined nurses for this. BONs reported a wide range of complaints, such as nurses inappropriately posting patient photos or posting patient information on blogs, Facebook^®, or other platforms.  BONs reported a wide range of complaints, such as nurses inappropriately posting patient photos or posting patient information on blogs, Facebook^®, or other platforms. The action taken by BONs ranged from cautionary letters to suspension. By 2012, however, 17% of the BONs reported having specific social networking guidelines in place.

Depending on the state or jurisdiction, some boards have specific laws that address the nurse’s inappropriate use of social media. Other boards (Cronquist & Spector, 2011) may use existing laws and will investigate complaints on the grounds of:

• Unprofessional conduct
• Unethical conduct
• Moral turpitude
• Mismanagement of patient records
• Revealing a privileged communication
• Breach of confidentiality

There can be other consequences as well, such as the violation of state or federal laws that could result in civil or criminal penalties, including fines or even jail time. Some of these laws might include state privacy laws, laws related to confidentiality of health records, or criminal laws related to harassment. Case law could also create tort liability such as invasion of privacy, intentional infliction of emotional distress, or possibly libel.

Consequences of misusing social media platforms can be stiff and oftentimes are unexpected... a nurse could face personal liability and be sued for defamation, invasion of privacy, or harassment. In the second scenario above (Inappropriate Forwarded E-mail), law enforcement agents were alerted because of possible violations of sexual exploitation laws. Further, a nurse could face personal liability and be sued for defamation, invasion of privacy, or harassment.

Nurses may face employment consequences if the conduct violates the employer’s policies. The hospital faced a possible lawsuit because of the patient’s embarrassment. In the second situation, nurses were placed on administrative leave.

The student nurse in the third story was expelled from her nursing program because she posted her patient’s photo on her Facebook^® page. Consequences of misusing social media platforms can be stiff and oftentimes are unexpected. Who would have thought that a blog post, as in the first case, would have brought an investigator to the nurse’s home?

Complaints Against Nurses Who Misuse Social Media

Complaints to the board of nursing against nurses related to social media generally can be placed in the following categories:

• Breach of privacy or confidentiality against patients
  • Egregious cases
  • Cases that are more subtle (similar to the above cases)
• Failure to report others’ violations of privacy against patients
• Lateral violence against colleagues
• Communication against employers
• Boundary violation
• Employer/faculty use of social media against employees/students

This section reviews each of these categories as they apply to the previous scenarios and/or additional examples.

Breach of Patient Privacy or Confidentiality

...breaches of patient privacy or confidentiality are the most egregious errors that nurses can make when posting on social media. First and foremost, breaches of patient privacy or confidentiality are the most egregious errors that nurses can make when posting on social media. It is important to distinguish the concepts of confidentiality and privacy (Cronquist & Spector, 2011). These are related, but decidedly distinct, concepts. Any patient information gained during the course of patient care must be safeguarded by the nurse. This information may only be shared with other members of the health care team for health related purposes. Confidential information must only be shared with the patient’s informed consent, when disclosure is legally required, or when a failure to disclose results in significant harm. In two of the cases presented above (Public Blog and Forwarded Inappropriate E-mail), the nurses shared confidential information about their patients.

Privacy is the patient’s expectation and right to be treated with dignity and respect. The second situation (Inappropriate Forwarded E-mail) clearly illustrates a violation of patient privacy related to a loss of dignity and respect. The nurse-patient relationship is built on trust, and the patient needs to be confident that their most personal information and their basic dignity will be protected by the nurse. If they fear information will be disseminated to others beyond those who need to know, patients will hesitate to disclose information. Any breach of trust, even inadvertent, damages the nurse-patient relationship and the general trustworthiness of the nursing profession.

Federal law reinforces and further defines privacy through HIPAA (U.S. Department of Health & Human Services, 2012). HIPAA regulations are intended to protect patient privacy by defining individually identifiable information and establishing how this information may be used, who may use it, and under what circumstances it can be used. Individually identifiable information includes any information that relates to the past, present, or future physical or mental health of an individual, or provides enough information that leads someone to believe the information could be used to identify an individual.

Nurses may breach confidentiality or privacy in a variety of ways, including with information they post via social media. Breaches of patient confidentiality or privacy are serious and can be intentional or unintentional. Nurses may breach confidentiality or privacy in a variety of ways, including with information they post via social media. All three cases cited above are examples of breaches of privacy and/or confidentiality.

Sometimes the cases are egregious, and the nurse should realize that what he or she is doing is wrong. Egregious examples can be found on the Internet. For example, a 60 year-old patient was brought into an emergency department in California with more than a dozen stab wounds and was nearly decapitated (Hennessy-Fiske, 2010). What did the nurses do? Instead of tending to the patient, they snapped pictures of him and posted them on Facebook^®. The examples in this article, as well as NCSBN's white paper on social media (NCSBN, 2011e), are somewhat more subtle and therefore more likely to happen in everyday situations.

Failure to Report Violations

It is imperative for nurses to report any violation of privacy or confidentiality that others take against patients. This concept was clearly spelled out in the second illustrative case (Inappropriate Forwarded E-mail). The consequences of not reporting the situation described in the scenario are quite typical.

Lateral Violence Against Colleagues

Online posts about co-workers, even if posted from home during non-work hours, may constitute lateral violence. Inappropriate use of social media can adversely affect team-based care (Cronquist & Spector, 2011).  Online posts about co-workers, even if posted from home during non-work hours, may constitute lateral violence. These actions are now receiving greater attention as more is learned about the impact on patient safety and quality clinical outcomes. Lateral violence includes disruptive behaviors of intimidation and bullying (Stanley, Martin, Michel, Welton, & Nemeth, 2007). When these comments are made via the Web, they are often referred to as cyber-bullying. Such activity causes concern for current and future employers and regulators because of the patient-safety ramifications.

Communication Against Employers

The line between speech protected by labor laws and the First Amendment, and whether an employer can impose expectations outside of work, is being determined in the courts. In one example that has been widely cited, a paramedic was fired for complaining about her employer on her Facebook^® page (National Labor Relations Board, 2011). The National Labor Relations Board eventually decided in favor of the employee, stating that the employer’s policy on social networking was overly broad. This case could set a precedent for future disputes between employees and employers.

Boundary Violation

Nurses must always be mindful of boundary violations with patients. Online contact with patients or former patients blurs the distinction between a professional and personal relationship. Professional boundaries are the spaces between the nurse’s power and the patient’s vulnerability. The power of the nurse comes from the professional position, the access to private knowledge about the patient, and the patient’s need for care (NCSBN, 2011a ).

Nurses have the obligation to establish, communicate, and enforce professional boundaries with patients in the online environment. They must use caution when having online social contact with patients or former patients. Online contact with patients or former patients blurs the distinction between a professional and personal relationship. The fact that a patient may initiate contact with the nurse does not permit the nurse to engage in a personal relationship with the patient. NCSBN (2011a) provides a professional boundaries brochure free of charge.

Employer/Faculty Use of Social Media Against Employees/Students

In one study of 454 pharmacy directors, Cain, Scott, and Smith (2011) found that 89% of program directors agreed that it was “fair game” to use social media for making judgments of their candidates’ character, professionalism, and attitude. Further, 52% of those who used social media for making decisions about residencies had encountered e-professionalism issues, including questionable photos and posts revealing unprofessional attitudes. It is reasonable to think that ... [Faculty] must be cognizant of boundary issues with students. nursing employers are also likely to use social media when making hiring decisions (Miller, 2011).

At one recent national nursing student meeting, several students shared with the audience that potential employers were asking for their social media passwords or to be “friended” so that they could bypass privacy settings. Other students at the same meeting reported that their professors were asking to be “friended,” and the students felt uncomfortable refusing because they were in class with those professors.Employer use of social media is another area that is being determined in courts.  Faculty not only have to guide students on proper use of social media, but they themselves must be cognizant of boundary issues with students.

Employer use of social media is another area that is being determined in courts. Currently only Maryland has a law, which will take effect October 1, 2012, that will ban current and prospective employers from demanding access to employees' or job candidates' social networks. Illinois has passed similar legislation and is waiting for the governor to sign the bill (Samuelson, 2012).

Common Myths and Misunderstandings of Social Media

While employers and BONs have dealt with cases where intentional or malicious misuse of social media has occurred, the inappropriate disclosure is unintentional in most instances. Solitary use of the Internet, even while posting to a social media site, can create an illusion of privacy.  A number of factors may contribute to a nurse inadvertently violating patient privacy and confidentiality while using social media.

Solitary use of the Internet, even while posting to a social media site, can create an illusion of privacy. Many nurses have the mistaken belief that the communication or post is private and accessible only to the intended recipient.The nurse may fail to recognize that content, once posted or sent, can be disseminated to others and where this content ends up is no longer under the control of the original sender or poster. In fact, the terms of using a social media site may include an extremely broad waiver of rights to limit use of content.

Another common misconception is the notion that content deleted from a site is no longer accessible or recoverable. Because most individuals think that deleting content “destroys” what was posted, they falsely assume they have eliminated the problem. Unfortunately the moment something is posted, it exists on a server that can always be discoverable in a court of law.

The quick, easy, and efficient technology enabling use of social media reduces not only the time it takes to post, but also the time to consider whether the post is appropriate and what ramifications may come from posting inappropriate content.Nurses often presume it is harmless if private information about patients is disclosed, if the communication is accessed only by the intended recipient. This still constitutes a breach of confidentiality. Likewise it is unacceptable for nurses to discuss or refer to patients even if they are not identified by their actual name, but referred to by a nickname, room number, diagnosis, or condition.This, too, is a breach of confidentiality and demonstrates disrespect for patient privacy.

Confusion also arises between a patient’s right to disclose personal information about himself or herself (or a health care organization’s right to disclose otherwise protected information with a patient’s consent) and the necessity for health care providers to refrain from divulging patient information without a care-related need for the disclosure. Nurses should proceed cautiously in these instances and seek appropriate guidance.

The relative ease of posting and the commonplace nature of sharing information via social media may appear to blur the line between one’s personal and professional lives. It is that very line that nurses must remain most cognizant of not crossing. The quick, easy, and efficient technology enabling use of social media reduces not only the time it takes to post, but also the time to consider whether the post is appropriate and what ramifications may come from posting inappropriate content.

Guidelines for Using Social Media Appropriately

Nursing organizations are beginning to develop social media guidelines so that social media can be used to its fullest potential in communicating with patients. Nursing organizations are beginning to develop social media guidelines so that social media can be used to its fullest potential in communicating with patients. NCSBN’s guidelines (NCSBN, 2011e) can be found online and are summarized as follows:

• Nurses must recognize that they have an ethical and legal obligation to maintain patient privacy and confidentiality at all times.
• Nurses must not transmit, by way of any electronic media, any patient-related information or image that is reasonably anticipated to violate patient rights to confidentiality or privacy or to otherwise degrade or embarrass the patient.
• Nurses must not share, post, or otherwise disseminate any information, including images, about a patient or information gained in the nurse-patient relationship with anyone unless there is a patient care related need to disclose the information or other legal obligation to do so.
• Nurses must not identify patients by name, or post or publish information that may lead to identification of a patient. Limiting access to postings through privacy settings is not sufficient to ensure privacy.
• Nurses must not refer to patients in a disparaging manner, even if they are not identified.
• Nurses must not take photos or videos of patients on personal devices, including mobile devices.
• Nurses must maintain professional boundaries in the use of electronic media.
• Nurses must consult employer policies or an appropriate leader within the organization for guidance regarding work-related postings.
• Nurses must promptly report any identified breach of confidentiality or privacy.
• Nurses must be aware of and comply with employer policies regarding use of employer-owned computers, cameras, and other electronic devices and use of personal devices in the workplace.
• Nurses must not make disparaging remarks about employers or coworkers.

Additional Resources on Social Networking

The response to the availability of easily accessible, free resources about social media has been overwhelmingly enthusiastic. In conjunction with publishing the social media white paper, NCSBN (2011e) introduced the brochure, “A Nurse's Guide to the Use of Social Media,” and the accompanying video, “Social Media Guidelines for Nurses” in December 2011 (NSCBN, 2011b; 2011d). The response to the availability of easily accessible, free resources about social media has been overwhelmingly enthusiastic. The ability to order online and receive materials quickly is being widely embraced by both the nursing community and health care facilities throughout the United States. Organizations and facilities as diverse as correctional institutions, law firms, insurance agencies, and the military, along with traditionally expected consumers such as hospitals, nursing programs, and home health care agencies, have eagerly requested materials for dissemination to the nurses they contract with or employ. Orders for these brochures have also come from regulatory agencies and individuals in Canada, the Philippines, and Europe. Since the initial offering of the brochure and launch of the video in December 2011 through the end of July 2012, more than 250,000 printed brochures have been distributed and the online version of the brochure has been downloaded more than 1,600 times. The video has been viewed on ncsbn.org and YouTube^® more than 20,000 times.

In light of examples brought forth by the use of social networking, other nursing organizations have addressed the issues surrounding this pervasive concern as well. The American Nurses Association (ANA, 2011) published the Principles for Social Networking and the Nurse, which are available to their membership online. ANA has endorsed NCSBN’s social media guidelines, and NCSBN has endorsed ANA’s social media principles (NCSBN, 2011c).

The National Student Nurses Association (NSNA, n.d.) recently published a white paper on social media, Recommendations for Social Media Usage and Maintaining Privacy, Confidentiality and Professionalism. Sigma Theta Tau has published a book on the effective use of social media, devoting a chapter to guidelines for avoiding pitfalls (Fraser, 2011). There is a helpful table in this book that highlights advice about social media, along with inappropriate and appropriate examples. Internationally, the Royal College of Nursing in the United Kingdom has published legal advice on using social media appropriately (Royal College of Nursing, 2009), and Canada has been exploring the issue from a regulatory perspective (Anderson & Puckrin, 2011).

Conclusion: Next Steps

It is time for regulators, educators, and nursing employers to review policies, making sure there are effective social media guidelines in place in their organizations. It is time for regulators, educators, and nursing employers to review policies, making sure there are effective social media guidelines in place in their organizations. Diane Skiba (2011) writes about the need for social media policies in schools of nursing, linking to a funny, but also meaningful video, called “LOL – Hospital Social Media and Lack of Social Media Policy” (Baumann, 2011). Skiba (2011) reviews and analyzes several social media policies and then cites Junco’s (2011) suggestions for the policy development process.

When developing policies related to the use of social media, employers and faculty might begin by reviewing the sound sources cited above. If a committee is formed to develop the institution’s policy, this is a good time to bring students or new graduates into the process as they are often familiar with social media and can provide valuable input.  Information about appropriate use of social media should be presented in nurse orientation sessions and in beginning nursing courses. Below are key points to consider when developing such policies for employers and educators:

• Be proactive. Even though your institution has not experienced a problem with students or nurses inappropriately using social media, policies should be in place.
• Develop the policy as a guideline, respecting social media as a viable communication avenue. Don’t be negative and restrictive.
• Emphasize that appropriate use of social media is essential for maintaining professional and ethical nursing practice.
• Instruct on privacy, confidentiality, and HIPAA laws and how they limit disclosures on social media.
• Avoid citing specific social media platforms because they frequently change.
• Educate about common myths of social media.
• Inform how disparaging remarks against colleagues on social media can adversely affect team-based care.

Education of nurses and students on the importance of being cautious when using social media is essential. As we increase nurses’ understanding of appropriate use of social media, we will see fewer complaints at BONs and more effective use of what can potentially be an invaluable tool in health care.

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Note:
¹ Whether a warning is public discipline or not depends on the laws in that state or jurisdiction. However, it is likely that many states/jurisdictions would not consider it disciplinary action and therefore it wouldn’t be made public.

²There are 60 BONs, which include the 50 states, the District of Columbia, four practical nurse BONs, four territories, and one advanced practice registered nurse (APRN) BON.

Authors

Nancy Spector, PhD, RN
E-mail: nspector@ncsbn.org

Nancy Specter, PhD, RN, graduated from the University of Wisconsin, Madison with her BSN; the University of California San Francisco with her MSN; and Rush College of Nursing in Chicago with her PhD. Before coming to the National Council of the State Boards of Nursing (NCSBN) in 2002, Nancy was a faculty member at Loyola University’s School of Nursing in Chicago. Currently, she is the Director of Regulatory Innovations at the NCSBN. Nancy is the principle investigator on a multi-site transition to practice study, and she is working on a number of other initiatives, including fostering innovations in nursing education, the regulatory implications of social media, and the future of nursing program approval. Dr. Spector presents and publishes nationally and internationally on regulatory issues in nursing education.

Dawn M. Kappel, MA
E-mail: dkappel@ncsbn.org

Dawn M. Kappel, MA, graduated from Northern Illinois University, DeKalb with her BS in journalism and her MA in communications studies with an emphasis in organizational communications and integrated marketing. As the current director of the Marketing & Communications department at the National Council of State Boards of Nursing, she produced two national television campaigns about nursing regulation. She also served as the project director and senior editor for NCSBN’s self-published book, The First 25 Years, and was the project manager for both Nursing Pathways for Patient Safety and Substance Use Disorder in Nursing publications. Kappel has also co-written several articles for JONA’s Healthcare Law, Ethics, and Regulation.

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© 2012 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2012