We nurses are change agents. We are also skilled collaborators and communicators. We communicate and collaborate with patients and families, nursing staff, physicians, allied health professionals, faculty, students, community and governmental leaders, organizations, and the general public. The profession of nursing has consistently been ranked as the most respected profession for ethics and honesty since 1999 (ANA, 2009) and patients ask to hear from nurses when seeking health information (Smith, 2010). As change agents, nurses bring expertise and resources to the table to help create healthier local and global communities; but often our voices are not heard, and we find ourselves left out of the healthcare conversation. As health collaborators and communicators, we are called upon to synthesize and disseminate our nursing knowledge. Yet we often fall behind other professions in adopting and actively engaging in communication technology to more effectively reach our target populations. In this column we will discuss the history of collaborative digital communication in the form of social media and Web 2.0 and share opportunities for active engagement in healthcare and health policy through social media. Additionally, we will highlight some unique challenges that social media poses for use in healthcare environments.

Social Media and Web 2.0

Social media can be defined as the constellation of Internet-based tools that help a user to connect, collaborate, and communicate with others in real time. Social media enables one to participate in an active, digital dialog or conversation in contrast to a passive, digital monologue, for example, the reading of a static webpage. Web 2.0 refers to active, as compared to passive, use of the Internet. Websites, such as blogs, wikis, YouTube, and LinkedIn, that allow for user-generated content or comments are classified as Web 2.0 websites. Social media tools are a subset of Web 2.0 sites. As its name implies, social media creates a social interaction or a conversation between users.

Two of the more familiar social media tools in use today are Facebook and Twitter. Facebook embraces the networking capabilities of the Internet by allowing individuals to connect with others through sharing of personal or professional information and interests. Professional sites can be set up by groups, organizations, and businesses. They can be completely separate from an individual’s personal Facebook page. Instead of ‘friends,’ a professional or organizational Facebook page has ‘fans’ or users who ‘like’ the page. This is an important distinction in the use of social media by healthcare professionals concerned with privacy or boundary issues. Twitter is considered a micro-blogging platform which means entries are limited to 140 characters. Twitter is the fastest growing social media platform because of its versatility and ability to quickly hyperlink to external sources of information. Again, individuals can have both a personal and a professional or organizational Twitter account. Both Facebook and Twitter are free applications, as are most social media tools, enabling a larger sector of the general public to be able to access these tools.

The concept of social media and real-time information exchange may seem faddish and unnecessary to many of us, but we don’t need to look too far back in history to find that the idea of instantaneous global information sharing is not a new idea. The term “Victorian Internet” was coined by author Tom Standage in his book of the same name to describe how the invention of the telegraph in the 19^th century created a qualitative shift in terms of real-time communication; the advent of the modern Internet in the late 20^th century became another qualitative shift in information delivery (Standage, 1998). In this early part of the 21^st century, we have now come to another new qualitative shift in global communication and information delivery with the introduction of Web 2.0 and social media tools. Viewing these tools as the logical progression on the continuum of global, real-time information sharing enables one to include these methods as helpful adjuncts alongside more traditional methods of communication and collaboration.

The demographics of Internet use have changed dramatically over the past decade, allowing greater access to health information for many population groups. According to the Pew Internet and American Life Project, in 2000 only 5% of the adult population had access to broadband Internet services in the United States (US) contrasted with 79% of U.S. adults having broadband Internet services in 2009 (Pew Research Center, 2009). This Pew project found that 61% of U.S. adults search the Internet specifically for health information (Pew Research Center, 2009). As mobile devices, such as Smartphones, become more readily available, the number of broadband Internet users will climb exponentially. It is anticipated that mobile cell phone applications will also give underserved populations increased access to the Internet.

As health educators, we are cognizant that health promotion and behavioral changes that are presented through traditional forms of education do not always meet with success. Because of the growth of Internet connectivity, many healthcare organizations are now taking note of the possibilities of including new audiences in the healthcare dialog through use of mobile and wireless devices. To highlight this growth, as of July 2010 there were 762 hospitals in the US currently using social media tools (with a total of 1581 social media accounts – reflecting multiple social media tools such as Facebook, Twitter, YouTube, and blogs) as compared to September 2006 when less than 10 hospitals were using any type of social media.

At the University of Massachusetts-Boston College of Nursing and Health Sciences we have been engaged in piloting a social media initiative since March 2010. We have launched a Facebook (2010) page, "University of Massachusetts-Boston College of Nursing and Health Sciences," as well as a Twitter (2010b) account, "UMassBostonCNHS," and have focused on providing an exchange of relevant and timely information about issues pertaining to nursing and health sciences, health policy, and health promotion involving both internal and external participants. Our readership has grown exponentially since launching these sites with a marked increase in online engagement as noted by the increasing number of views as well as comments posted. We are envisioning additional creative uses of social media in healthcare and see these media tools as important components in promoting collaboration, connection, and conversation in the healthcare dialog with a diverse audience.

Opportunities for Social Media in Healthcare

Phil Baumann was one of the early adopters of social media in healthcare. He was the founder of "RNChat" on Twitter (2010a). Baumann, a critical care nurse, saw the need for nurses to discuss a range of issues related to nursing, including the nursing shortage, clinical trials, best practices, safety, and health policy. In explaining why he, as a nurse, became interested in social media, he stated, in a Robert Wood Johnson Foundation report (2010), “I got frustrated with how behind the health care community was when it came to communications and sharing information.” In 2009, Mr. Baumann compiled a list of 140 healthcare uses for Twitter. A few uses are listed below, but the possibilities are endless:

• Disaster alerting and response
• Drug safety alerts from the Food and Drug Administration
• Diabetes management (blood glucose tracking)
• Rare diseases tracking and resource connection
• Broadcasting infant care tips to new parents
• Shift-bidding for nurses and other healthcare professionals

As we educate a new generation of nurses, use of social media will be an integral component in their ability to practice competently, effectively, and collaboratively with team members, patients, and families. We expect to see greater interest in social media in nursing education as nursing educators familiarize themselves with these tools. Nurse educators Bob Green and Allison Hope recently described the role of social media as an important patient teaching tool for synthesizing and disseminating information to patients and families (Green & Hope, 2010).

Risks and Challenges of Social Media

As we become more accustomed to the role of social media in healthcare, issues of privacy, we need to address inappropriate sharing of information, and professional-personal boundary issues. There has been discussion regarding the appropriate level of disclosure for individuals to reveal on social media sites, such as Facebook, and this is a concern for healthcare professionals. Social media is still in its infancy. As with the evolution of other Internet applications, security  features and more robust privacy controls are likely to be added as the technology grows. Users of social media need to be aware, however, that anything they post on open access sites is publicly available and will be available in perpetuity. According to a recent survey by Microsoft, 75% of human resource managers and recruiters do online research about prospective job candidates by checking sites such as Facebook, Twitter, video-sharing sites, personal websites, and blogs (Rosen, 2010).

Patient confidentiality, Health Insurance Portability and Accountability Act (HIPAA) regulations, and patient-professional boundaries should remain foremost in nurses’ minds as they choose how and what to post through social media. A good rule of thumb when evaluating an item to post on Facebook or Twitter is: “Would I be comfortable with this item being shared in a public forum with my employer, patients, and colleagues?”. There have been some noteworthy incidents where discretion was not used by healthcare professionals using social media. One of these incidents, reported in the national news, took place in Wisconsin when a patient was brought into the emergency room and two nurses, independently, took cell phone photos of an x-ray showing the patient’s body part and a foreign object (Nurses Fired Over Cell Phone Photos, 2009). One of the nurses allegedly posted the photos on her personal Facebook page. Both nurses have been terminated from their positions. The FBI is investigating this case for HIPAA violations.

Boards of nursing, as well as hospital administrators have cautioned professionals on privacy issues surrounding social media sites, but many currently available professional guidelines have not been updated to include social media. For example, the National Council of State Boards of Nursing’s 2007 publication addressing professional boundaries does not yet mention issues involving social media. Because of social media’s growing use and potential for privacy issues in healthcare settings, updated guidelines on appropriate use for participating on social media sites should be available to all individuals posting and commenting on social media pages. An example of one hospital’s social media participation guidelines on a public Facebook page can be found on MassGeneral Hospital for Children’s Facebook page under the notes section. We believe that social media will continue to play a larger role in healthcare information sharing, advocacy, communication, and collaboration. It is incumbent upon those who adopt social media tools to apply the same level of caution and common sense that one applies to traditional communication tools in healthcare regarding privacy, professionalism, and patient rights.

The Mayo Clinic (2010), in announcing the launch of the new Center for Social Media stated, “The social media revolution is the most far-reaching communications development since Gutenberg’s printing press.” While this may be a bit of hyperbole, we believe that we do have a new set of tools available that will change how we can communicate, collaborate, and connect with patients, colleagues, and health policy leaders to promote change. Nurses are on the front line of healthcare. Through use of the tools of social media nurses have a voice that is now global in reach. Table 1 and Table 2 list a few of the many social media sites that can engage providers and consumers alike in dialoging about healthcare issues that matter to them. As patients enter the digital age through mobile devices and greater connection to the Internet, nurses can assume a leadership role in synthesizing and sharing timely and accurate health information through the social media. Smith (2010) in a recent online poll asked the question, “As a patient or family member what hospital representative do you want to see Tweets from most?”. Over half of the respondents (55%) said nurses or caregivers. Nurses are change agents and as change agents we can embrace these social media tools of engagement with patients and the broader healthcare community to foster healthcare dialog and to shape a healthier global community together.

Pamela Katz Ressler, BSN, RN, HN-BC
E-mail: Pamela.Ressler@umb.edu

Greer Glazer , RN, CNP, PhD, FAAN
E-mail: Greer.Glazer@umb.edu

Standage, T. (1998). The Victorian Internet: The remarkable story of the telegraph and the nineteenth century’s on-line. 

Twitter. (2010a). RNChat. Retrieved October 10, 2010 from 
www.twitter.com/rnchat

Twitter. (2010b). UMassBostonCNHS. Retrieved October 10, 2010 from www.twitter.com/umassbostoncnhs

© 2010 OJIN: The Online Journal of Issues in Nursing
Article published October 22, 2010