Social media is now well-embedded in our information gathering and sharing strategies, and it is revolutionising the way we communicate. The use of information and communication technology (ICT) and the Internet continues to grow in all regions of the world. Over 2 billion Internet users globally represent 37% of the world’s population (Internet World Stats, 2011). Hand-in-hand with this increase is the exponential growth of the use of social media, both within the general population and by the health care community. Kaplan & 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). They characterise the many forms of social media into six main types: collaborative projects (e.g., Wikipedia^®); blogs and microblogs (e.g., Twitter^®); content communities (e.g., YouTube^®); social networking sites (e.g., Facebook^®); virtual game worlds (e.g., World of Warcraft^®); and virtual social worlds (e.g., Second Life^®). Social media is now well-embedded in our information gathering and sharing strategies, and it is revolutionising the way we communicate.

Globally, over 20% of Internet time is spent on social network and blog sites (NielsenWire, 2010). At the end of June 2012, Facebook^® had over 950 million monthly active users (Facebook, n.d.). Also in March 2012, Twitter^® had 140 million active users, generating over 340 million tweets daily (Twitter Team, 2012). The power of social media’s outreach and impact was evidenced by recent events in North Africa and the Middle East.  A study out of the University of Washington which analysed more than three million tweets, several gigabytes of YouTube^® content, and thousands of blog posts, found that social media played a central role in shaping political debates in what is now commonly referred to as the “Arab Spring” (O’Donnell, 2011).

...social media is also finding a place in public health communication strategies. Not surprisingly, social media is also finding a place in public health communication strategies. The World Health Organization (WHO) has a Facebook page, a Twitter^® feed, and a significant presence on YouTube^®. WHO is using social media to disseminate public health information, to counter rumours, and to keep the global public informed during disease outbreaks or disasters (Jones, 2011). As an example, WHO used Twitter^® during an influenza A (H1N1) pandemic and had more than 11,700 “followers.”  As the experience of WHO indicates, one fact sheet or an emergency message about an outbreak can be spread through Twitter^® faster than any influenza virus (McNab, 2009).

The Use of Social Media Within Nursing

Social media is gaining popularity among healthcare professions, including nursing. The United Kingdom’s (UK) nursing and midwifery regulator, the Nursing & Midwifery Council, estimates that there are now around 355,000 registered nurses and midwives on Facebook^® in the UK alone. (NMC, 2012). With UK adults representing less than 5% of the global Facebook^® user base, the number of nurses and midwives using Facebook^® worldwide must now run into several millions.

...individuals, healthcare institutions, and educational programs are both embracing social media and recognizing that caution is needed. The wide usage of social media both outside and within the healthcare community has far reaching implications for healthcare and the nursing profession, in terms of increased opportunities to communicate at personal and professional levels and enhanced access to information by both healthcare providers and members of the public. In addition, individuals, healthcare institutions, and educational programs are both embracing social media and recognizing that caution is needed. Professional, ethical, regulatory, and legal issues must be addressed. For nursing, this is evidenced by the growing volume of policy and guidance documents that focus on the use of social media. Examples from several professional organisations (see Table 1) illustrate the worldwide focus on the use of social media in healthcare.

In addition, there have been many published articles providing direction and commentary with respect to the use of social media by health care professionals in such journals as the International Journal of Nursing Regulation (Anderson & Plunkit, 2011, Cronquist and Spector, 2011), New Zealand Journal for Nursing Praxis (Wilson, 2011), Nursing Review (Sweet, 2012), Imprint (Stryker McGinnis, 2011), and Military Medicine (Balog, Warwick, Randall, & Keiling, 2012). Our search of articles in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medline published from 2009 to the present day located over 1200 records with either ‘social networking’ or ‘social media’ in the title.

Participants from countries in the Middle East, Asia, Africa, Europe, and the South Pacific ...engaged in dynamic dialogue on social media... Although the published literature is primarily from the United States (US), Canada, UK, Australia, and New Zealand, the use of social media (and the issues surrounding its use) is not confined to these countries. Users of LinkedIn^®, a professionally-oriented social networking site, are located in more than 200 countries (LinkedIn, n.d.), and Facebook^® is available in 70 languages with over 80% of its users located outside the US and Canada (Facebook Newsroom, n.d.). Participants from countries in the Middle East, Asia, Africa, Europe, and the South Pacific attending the 2011 International Council of Nurses Credentialing and Regulators’ Forum in Taipei, Taiwan engaged in dynamic dialogue on social media, citing many examples related to both the advantages and challenges with respect to its use in nursing and healthcare in their countries. As cited by one participant in this forum,  “At a recent forum hosted by the International Council of Nurses and attended by representatives from 17 countries, it was clear to me that most organizations are wrestling with the expanding influence of this communication tool” (Robinson, 2011, p. 42). Recognition of the impact, in terms of its great potential and its inherent risks, of social media on the global nursing community is growing. The importance of the dialogue on social media at this forum was also highlighted in professional journals and communications from a number of other organisations who participated (Bard, 2012, NMBA, 2011, RCNA, 2011a).

The Impact of Social Media

Recognition of the impact, in terms of its great potential and its inherent risks, of social media on the global nursing community is growing. It is widely-recognised that social media can be a powerful tool for communicating, influencing, and educating. Much, therefore, is to be gained with respect to its use in healthcare and nursing. This section will consider, from an international perspective, the impact of social media on both the public as consumers of healthcare information and nurses.

Impact on Healthcare Consumers

Social media provides consumers of healthcare with tools by which they can share with others their health concerns even as they arise, and receive a very In remote areas of the world, social media delivered via mobile phone may obviate the need for more expensive ICT and may increase access and equity to health care information and services.  immediate response, either from healthcare providers or from others members of the public. Individuals who have similar health concerns can form virtual communities through which they can connect, interact, and share experiences. A national survey in the United States carried out by the Pew Research Center indicates that one in three adults in the US (30%) say they or someone they know has been helped by following medical advice or health information found online (Fox, 2011).

The wide outreach of social media can also provide opportunities for the promotion of programmes and services, increasing awareness in the communities served by nurses (Rutledge, et al, 2011). In remote areas of the world, social media delivered via mobile phone may obviate the need for more expensive ICT and may increase access and equity to health care information and services. To this end, “Closing the Gap” (in access and equity), including through the use of technology, is a theme of International Nurses’ Day for the period 2011-2013.

Impact on Nurses

ICN... provides opportunities for online dialogue by nurses from around the world through discussion forums. For nurses themselves, social media provides opportunities to dialogue with colleagues and to stay abreast of recent health care developments. This may be particularly beneficial for those working in more rural or remote areas and who may feel removed from traditional resources and support. ICN, for example, provides opportunities for online dialogue by nurses from around the world through discussion forums for educators, students, nursing regulators, advanced practice nurse, and nurses engaged in rural and remote practice settings. Examples of dialogue on these international forums include: students discussing opportunities for international placements; educators posing questions about social media guidelines for students; rural and remote nurses dialoguing on transition programs for those entering rural and remote practice; regulators discussing requirements for language fluency; and advanced practice nurses considering career options and research issues. It would be impossible to provide a comprehensive list of all of the many nursing-oriented social media initiatives and innovations. The following examples are provided to illustrate how nurses are taking advantage of, in different ways, opportunities afforded by social media:

• The rich information that results from the use of social media, and the accessibility of that information, makes it a very useful resource for healthcare and/or health and nursing research (Sweet, 2012). Examples of this include the use of Twitter® content in predicting and  tracking disease outbreaks such as influenza (Schmidt, 2012) and the use of data mining techniques to determine the nature of communities from physical activity-related Twitter® content (Yoon, 2011).
• Nursing education programs are using social media to communicate with current, past, and potential students to connect and to share information. An example of this is the use of Facebook® to connect with former nursing students in order to support educational research (Amerson, 2011). Nursing students also use social media to dialogue amongst themselves and with the larger nursing community (McNeil, n.d.).
• Many healthcare, professional, and regulatory organisations are using social media to enhance a two-way dialogue with the public and healthcare professionals. For example, the Canadian Nurses Association, the American Nurses Association, the Royal College of Nurses of Australia, DENOSA in South Africa, the UK’s Royal College of Nursing, and the Cyprus Nurses and Midwives Association all use social media to reach their members and members of the public. In February 2012, a live social media event was held by the Nursing & Midwifery Council, “Talking with patients online: What are the boundaries?” This event reached over 24,000 Twitter® followers, an example of the popularity and the scope of this type of outreach.
• In partnership with three other nursing organisations, and with the support of Sanofi, ICN has been participating in the development of the Connecting Nurses initiative. Connecting Nurses seeks to provide a forum for nurses from around the world to share their ideas, advice, and innovations. Connecting Nurses is now an integral part of ICN’s eHealth Programme which seeks to transform nursing through the visionary application of ICT. There are two programmes within Connecting Nurses: Care Challenge and Information Shareapy. Care Challenge is an annual contest that highlights nursing innovations and helps to put them into practice. This challenge encourages nurses from across the world to upload their ideas, thereby forming a content community. In 2012, 20 entries received awards in one of two categories: “Helping Hand,” which included a financial prize to support the innovation; and “Nurses in the Limelight,” which offered the opportunity of a professionally-produced video to showcase the innovation. For more information, visit the Care Challenge web site at: www.care-challenge.com/. Information Shareapy, which will launch in 2013, is a prototype patient education service for nurses and midwives to share links to high quality, reputable health resources with their patients, families, friends, or colleagues. The goals of Information Shareapy include to help nurses: connect with each other and with other health professionals; in their interactions with patients; and stay updated. This initiative therefore shares some of the features of collaborative projects, content communities, and social networks.

Selected Risks Associated With Social Media

The examples above, and many more in the literature, leave little doubt that social media has much to offer. However, there are risks associated with its use. This section will address such worldwide concerns as unmoderated content, privacy violation, unprofessional behaviour, and organisational risk.

Unmoderated Content

There is evidence to suggest that members of the public are discerning in terms of their willingness to trust health information on the Internet... There is evidence to suggest that members of the public are discerning in terms of their willingness to trust health information on the Internet and use a range of criteria, such as sponsorship by a health organisation, and/or taking recommendations from and discussing findings with health professionals, to assess the reliability of online information (Diaz et al, 2002). However, one potential risk associated with social media results from the un-moderated distribution of information; this may lead to bad decisions by both healthcare providers and members of the public. Jones (2011) provides an example of this from Japan. In the aftermath of the 2011 Great East Japan Earthquake, there was growing concern about radiation leaks and rumours spread though social media and other means that drinking iodised wound cleaner and consuming large quantities of salt would reduce potential adverse effects. However, WHO was able to successfully counter these rumours through similar means (i.e. using Twitter^®) to dismiss the rumours and provide more accurate information. This resulted in a decrease in the number of messages being circulated advising people to buy salt.

Privacy Concerns

According to the U.S.-based National Council of State Boards of Nursing (NCSBN) (2011), breaches of privacy and confidentiality can be intentional or inadvertent and can have serious implications for nurses, their patients, and their employer.  These breaches can occur in a variety of ways, including via comments on social media sites in which a patient is described in sufficient detail to be identified; referring to a patient in a degrading or demeaning manner; or posting videos or photos of patients.

In a survey conducted by NCSBN around the misuse of social networking, 33 state boards of nursing (of the 46 that responded) indicated having received complaints about nurses who had violated patient privacy by posting information on social networking sites. Twenty six of those boards took disciplinary action (Cronquist & Spector, 2011). A 2010 survey of Canadian nursing regulators revealed similar concerns around activities such as posting pictures of clients, posting descriptions of identifying events, and using social networks to air grievances and complaints about colleagues, clients, and employers (Anderson & Puckrin, 2011).

...as online activity increases, [professional] boundaries can become blurred. Nurses are professionally accountable for developing an understanding of the boundaries between private, public, and professional life and acting accordingly. However, as online activity increases, such boundaries can become blurred (Anderson & Puckrin, 2011).

Nevertheless, employers, regulators, and the public expect privacy to be maintained and healthcare professionals to be respectful when using ICT, including social media, and have taken action when violations have occurred (Anderson & Puckrin, 2011). Nurses need to understand that breaching confidentiality is not only risking the trust that exists between patient and nurse, it may also result in discipline or termination at the employer level, in professional sanctions against the nurse’s license to practice, or even in legal action. For example, a bulletin that provides legal protective advice to Canadian nurses describes how one nurse was found guilty of unprofessional conduct by her professional licensing body because she posted a patient's first name and the patient's personal health information on a co-worker's Facebook^® page (CNPS, 2010). The same bulletin indicated that the breach of professional standards, in these contexts, could also be a breach of privacy legislation and could result in charges being brought against the nurse.

Unprofessional Behaviour

Areas where social media has been inappropriately used by health care professionals, in addition to breaches of privacy, include bullying of colleagues (or for students, bullying of other students); online criticism of colleagues or employers; and unprofessional behaviour that may be in breach of codes of conduct (CNPS, 2010). Thompson et al. (2008) reported that in an evaluation of the social networking accounts of medical students and residents, 70% were found to have included images containing alcohol, racially toned language, misogynistic statements, and foul language in their postings.

Presenting an unprofessional image not only is bad for the image of healthcare professions as a whole, but may affect employment opportunities. Presenting an unprofessional image not only is bad for the image of healthcare professions as a whole, but may affect employment opportunities. Potential employers sometimes monitor an applicant's use of social media when making hiring decisions (RCNA, 2011b). While controversy exists regarding the legal and moral basis of this practice, at the moment there are few, if any, formal regulations in place to prevent this monitoring. Users of social media are left to navigate this evolving venue and should consider the overall image they present.

Nurses also need to use caution regarding what they post using social media about others. If defamatory comments are made by a nurse about another person or institution on a social media site, a civil lawsuit alleging defamation could be commenced against the nurse (Cronquist and Spector, 2011). As well, nurses may face loss of employment if the nurse’s actions violate the policies of the employer (Cronquist and Spector, 2011).

Organisational Risk

For employers, there may be a number of concerns regarding the use of social media impacting, among other things, corporate reputation. The NSCBN White Paper (2011) provides an example where the inadvertent post of a student with information and a photo about a paediatric patient she cared for resulted in not only the student being expelled, but also the clinical placement hospital being reviewed under privacy legislation (i.e., HIPAA). Another outcome was the nursing education institution was banned from use of the unit as a clinical site for future students.

Employers need to have in place a formal policy on the use of social media... From a human resource perspective, there are obvious issues concerning productivity, efficiency, and attention (Lyncheski, 2010). Employers must decide how to strike the balance between a workplace that permits access to social media sites and one that protects confidentiality, security, and the employer’s legal interests (Lyncheski, 2010). Employers need to have in place a formal policy on the use of social media and to communicate widely and enforce the policy, providing clear consequences for any violations (Burke & Goldstein, 2010) bearing in mind that published guidelines and documents are effective only when nurses have support applying them to practice issues (Anderson & Puckrin, 2011).

Conclusion: Practice Implications for Individuals, Healthcare and Educational Institutions, Professional Associations, and Regulators

In light of growing use of social media, with potential for both benefit and harm, nurses throughout the world need to draw on available guidance as necessary. The following list, although not comprehensive, is applicable to global settings and draws on current published guidance by professional organisations, regulators and others, to provide pointers for the responsible use of social media so that nurses are well-placed to avoid any potential pitfalls.

For Individuals

• Legal authority is of particular importance when providing health information, advice, or services through social media, as the recipient of these services could reside outside the area in which the nurse is licensed to practice. Be aware of and adhere to legal, regulatory, educational institution, and/or employer requirements, guidelines, and polices.  As with any other area of nursing practice, if nurses are providing health services through ICT, they should ensure they have the required competencies, are practicing within their scope of practice, and are legally authorized to do so (Canadian Nurses Association, 2007). Legal authority is of particular importance when providing health information, advice, or services through social media, as the recipient of these services could reside outside the area in which the nurse is licensed to practice.
• Maintain patient privacy and confidentiality at all times.  Do not take photographs or videos of patients on personal devices, including cell phones. Do not distribute by any electronic media, any patient-related image, or information that may be reasonably anticipated to violate a patient’s rights to privacy or confidentiality, or otherwise degrade or embarrass the patient (NCSBN, 2011).
• Do not use social networking sites to distribute sexually explicit material, nor in any way which is unlawful (NMC, 2011).
• Maintain clear and appropriate boundaries. Do not accept patients as social network “friends.” Socializing with patients online may damage the nurse-patient relationship (NMC, 2011). A “friend request” does not authorise the nurse to engage in a personal relationship with a patient (NCSBN, 2011).
• Do not discuss work-related issues online, including conversations about patients or complaints about colleagues (NMC, 2011). Do not criticize or otherwise project an unflattering image of your educational institution, workplace, teacher, co-workers, or supervisor.
• Be judicious in the use of social media.  Reputations can be affected by information found online and can affect the outcome of future endeavors. Go back to your social media sites and ask the questions, “Is this how I want to be seen?” and “Can any of the information be taken out of context?” (RCNA, 2011b).
• If the answer is anything other than “yes” to the question: “Would I pin this on a public notice board?” do not post it via social media (CRNBC, 2011). Strongly consider if you really want information in the public domain and whether the information is respectful, appropriate, and inoffensive (NMBA, 2010).
• Be aware that everything you post online is public, even with the strictest privacy settings. Once something is online, it can be easily copied and redistributed. Presume that everything you post online will be permanent and will be shared (NMC, 2011).
• Report objectionable material (ANA, 2011; NCSBN, 2011) and take action if you are the subject of complaints or abuse via social media (NCSBN, 2011).
• Keep your personal and professional lives separate. If you are using social media in a professional venue, create different accounts for professional and personal activities (CRNBC, 2011; Stryker McGinnis, 2011).
• If you are going to engage in the use of social media become “tech savvy” (i.e. knowledgeable about technology) (Stryker McGinnis, 2011). For example, ensure that you understand the social media service’s privacy policy, and use appropriate privacy settings (ANA, 2011, NMBA, 2010, NMC, 2011).
• Recognize with every post and every tweet, you are helping to create and reinforce a global image of nursing (McGinnis, 2011).

For Healthcare and Educational Institutions

• Set clear policies and guidelines, widely distribute them, and enforce them consistently (Burke & Goldstein, 2011; Lyncheski, 2010).
• Provide guidance for nurses to apply policies and guidelines and put them into practice (Anderson & Puckrin, 2011).

For Professional Associations and Regulators

• Engage registrants and members in dialogue and reflection regarding responsible use of social media (Anderson & Puckrin, 2011)
• Raise awareness of the power of social media and the possibility that information shared on the Internet may be universally and indefinitely accessible (Anderson & Puckrin, 2011)
• Utilise case studies and practice standards to delineate between private, public, and  professional actions (Anderson & Puckrin, 2011)
• Support nurses and their employers in the development of social media resources (Anderson & Puckrin, 2011).

Educators, employers, and regulators across the world need to communicate clearly and effectively to students, nurses, and healthcare consumers about the appropriate use of social media. Social media continues to evolve, and its use continues to increase exponentially. Educators, employers, and regulators across the world need to communicate clearly and effectively to students, nurses, and healthcare consumers about the appropriate use of social media. It is essential that policies and guidelines continue to evolve to keep pace with socio-technical advances and in accord with educational, employment, regulatory, and legal decisions that are made regarding its use. Individual students and nurses need to be aware of and adhere to these polices to intentionally avoid the pitfalls around use of social media – pitfalls that can negatively and profoundly impact patients, colleagues, educational institutions, employers, and the healthcare professions. We are in exciting times with unprecedented opportunities for rapid and wide-reaching communication and sharing and it is essential that nursing and healthcare communities safely harness the power of social media for global outreach.

Authors

Jean Barry, MSN, RN
E-mail: barry@icn.ch

Jean Barry is a Consultant, Nursing and Health Policy, at the International Council of Nurses. Jean’s portfolio at ICN includes addressing ICN’s work in nursing regulation, nursing education, and issues related to maternal/child health. She has worked in the area of nursing regulation for over 20 years, first at the provincial level in Canada; then at the national level at the Canadian Nurses Association as the Director of Regulatory Policy; and for the last two years at the international level at ICN. Jean works regularly with the World Health Organisation; non-governmental organisations; and national and international organisations addressing health care professional education and regulation. Her global work in nursing regulation includes regular environmental scanning, where the issue of the appropriate use of social media has recently surfaced as a significant issue.

Nicholas R. Hardiker, PhD, RN
E-mail: n.r.Hardiker@salford.ac.uk

Nicholas R. Hardiker is Professor and Associate Head (Research & Innovation) of the University of Salford School of Nursing, Midwifery & Social Work. Nick has a background in nursing and has Bachelors, Masters, and Doctoral degrees in computer science from the University of Manchester, UK. He has nearly 20 years experience of theoretical and applied research in health informatics, with a particular focus on health records and terminologies. Nick holds an adjunct position of Professor at the University of Colorado, Denver, USA, and is currently Director of the International Council of Nurses eHealth Programme. He has published widely and is asked regularly to speak at conferences and seminars. He is Editor-in-Chief of Informatics for Health and Social Care; is a member of national and international standards bodies and think tanks; and regularly provides advice to organisations such as the UK Department of Health on informatics issues

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