Contemporary nursing requires nurses to use the best available tools and techniques within their practice to facilitate patients make decisions about their care. Consequently, nurses strive to keep pace with change and stay reliably informed of health issues such as the recent COVID-19 pandemic (Mattiuzzi and Lippi, 2020; Mesko and Gyo˝rffy, 2019; Pizzuti et al, 2020). Social media is a tool that is increasingly being incorporated into nursing care and is defined as an online resource that enables sharing, collaboration, discussion and curation through private or public networks (Hazzam and Lahrech, 2018). The power of social media rests in the scalability and participatory nature, revolutionising patient centred care by democratising knowledge (Mesko and Gyo˝rffy, 2019). This discussion details the risks and benefits that social media presents to nurses, patients, and the health community. A background is provided to explain social media and the application of nursing obligations, and risks will be identified as they relate to legal, political, and social outcomes. Finally, benefits relating to communication, promoting professional nursing, and improving patient outcomes while providing support networks are considered.
Engaging with social media
According to the Nursing and Midwifery Council (NMC) there are 660 000 registered nurses and midwives in the UK, and 355 000 are regular users of Facebook (NMC, 2019). Facebook is the most used social networking web 2.0 platform in the UK and Europe, with Google+ being the second most used, and the third most widely used web 2.0 application is Instagram (Drahošová and Balco, 2017). Many professional organisations have published guidance and recommendations on social media use (NMC, 2019; Royal Society for Public Health, 2019; Royal College of Nursing, 2020). These organisations set out broad principles and advice for nurses to enable them to think through issues, to act professionally, to promote trust, to ensure public protection at all times, to know how to safely use social media to improve their care and reputation, and to have an awareness and knowledge of how to protect children and young people from the pitfalls of social media. The Royal Society for Public Health was involved in establishing the All-Party Parliamentary Group on Social Media, to drive policy change that might minimise the negative effects of social media use for young people's mental health and wellbeing, and to promote the positive aspects of social media use (Royal Society for Public Health, 2019; 2021).
It is important for health institutions and regulatory bodies to have a social media policy so that nurses can clearly distinguish between personal and professional boundaries when using social media. The NMC (2019) has provided a document titled Guidance on using Social Media Responsibly that provides clear direction for the nursing and midwifery professions (see Box 1).
Box 1.Main points to remember when engaging with social media
- Do not share confidential information inappropriately
- Do not post photographs/information of patients receiving care without their consent
- Do not post inappropriate comments about patients
- Do not bully, intimidate or exploit people
- Do not build or pursue relationships online with patients or service users
- Do not steal personal information or use someone else's identity
- Do not encourage violence or self-harm
- Do not incite hatred or discrimination
Source: Nursing and Midwifery Council, 2019
The blurring of personal and professional boundaries within social media has been associated with relationships established between staff and patients. Nurses should have clearly defined criteria when accepting a ‘friend’ request from patients on their social media platforms. This avoids violating nurse-person, nurse-family relationships, which may result in loss of societal trust in the discipline of nursing (Milton, 2014; Naeem and Ozuem, 2021). Violation of professional boundaries can also happen with ill-advised use of social media within the workplace. Institutions usually have guidelines and policies in place to avoid subjective interpretation of professional boundaries, and nurses should abide by institutional policies (Mariano et al, 2018).
Professional ethical, regulatory and legal issues
Nurses have integrated the power of social media to advance the nursing profession. This includes their own professional development through supporting patients, improving workforce conditions, undertaking education and developing policy, procedure and research (Ferguson, 2017). However, the blurring of personal and professional boundaries, spread of misinformation, and breach of staff and patient privacy and confidentiality, are some of the major risks associated with the use of social media by nurses (Ross and Cross, 2019). Nurses are required to be extremely cautious regarding discussions about patients in social media networks, even within closed groups created for learning purposes. It has been known for group members to take screenshots of conversations and circulate them anonymously (Jain et al, 2014). Discussion and sharing of patient details, without de-identifying personal information, breaches the privacy of the patient and it can have serious ramifications (Ryan, 2016; NMC, 2019). Intentional or inadvertent breaches of privacy and confidentiality can have serious implications for nurses, their patients and the employer. It can result in disciplinary action by regulatory agencies and suspension of registration (NMC, 2019).
The General Data Protection Regulation (GDPR) sets up a responsibility to protect personal data, and it is important that social media platforms are secure and deal with personal data appropriately (Sirur et al, 2018). The collection and processing of personal data is secured by the actual social media platforms and not by users of social media. However, it is up to users of social media to understand that GDPR only applies to individuals' personal data and not to any information about organisations (Kročil and Pospíšil, 2020).
Ethical use of social media should be practised within clinical environments. Social media should only be used for improving patient care, and not for leisure purposes by nurses when working. Self-regulation is key when using social media within clinical environments, as it can disrupt patient care if not used appropriately (Mariano et al, 2018). As members of the nursing profession, even when nurses are not actually working they still need to maintain a level of professionalism online, otherwise they run the risk of crossing ethical and moral boundaries.
Trust in the nursing profession is a vital aspect of the nurse-patient relationship. Therefore, open and honest disclosure about the purpose and intent of using social media within the clinical environment needs to be discussed with the patient, as transparency is paramount—avoiding any potential misunderstanding being perceived by the patient or parties involved. It is an individual's personal right to control what information they share with others (Aylott, 2011).
Virtual or online socialisation may sometimes deprive nurses from gaining skills associated with authentic real-life human interactions. Social skills such as verbal and non-verbal communication, empathy and active listening are some of the essential skills nurses should possess to maintain a therapeutic relationship with patients and offer person-centred care (Wang et al, 2019). The social skills of nurses have been reported as an important facilitating factor for positive patient outcomes, and social media can influence nurses' ability to communicate verbally and non-verbally with patients and relatives (Mariano et al, 2018).
Interruptions to nursing care can be a cause of concern if social media is accessed within the clinical environments by nurses while working (Javed et al, 2019; Lefebvre et al, 2020). Due to the dynamic nature of the healthcare environment, situational awareness and critical thinking are important in providing safe patient care. Inappropriate use of social media at work can have a negative impact on situational awareness and critical thinking and timely patient interventions (Demiray et al, 2020). Self-discipline with regard to how social media is used by nurses at work is important to avoid such issues. This is because mobile phones and wearable devices (such as smart watches) can receive texts, emails and notifications from messaging platforms while nurses are working. Nurses who engage with social media are likely to have significant ‘traffic’ from such platforms. Even with device alerts turned off or reduced to the essentials, they should be mindful of the temptation to check on social media channels. This is an area of conflict in the clinical environment as it may result in the nurse's attention being diverted from patient care and possible missed medications (Cho and Lee, 2016; Lefebvre et al, 2020).
Privacy is a vital issue and must be considered by healthcare institutions when advising staff about maintaining patient privacy, and also recommending particular platforms and apps for use by nurses (Hammack, 2019). Nurses should be aware of risks such as data breaches and third-party use of information (Terrasse et al, 2019). Data privacy can often be subject to lengthy user agreements that often give the platform provider unlimited rights to use personal information, and some nurses may find using use privacy settings effectively difficult due to a lack of e-literacy (Hammack, 2019). Research suggests that university schools/colleges of nursing should develop approaches promoting social media literacy within nursing education (Oducado et al, 2019). Nurses may mistakenly believe that they are participating in a safe, closed group when personal information is shared, but this may demonstrate a lack of clarity about patient consent when social media data are used in research and public policy (Dol et al, 2019; Terrasse et al, 2019). Nurses are trusted by the public to understand privacy and confidentiality issues, therefore keeping data confidential online is essential in protecting the public and the profession (Huo et al, 2019).
Benefits and risks of social media to nurses
There are various benefits and risks involved with social media usage. These can include political (activism and participation) (Buck-McFadyen and MacDonnell, 2017), legal (privacy, confidentiality, and consent) (Yousuf et al, 2017), and social (bullying and social influences) (Byrne et al, 2018) aspects. Social media has influence and a certain amount of power to facilitate support for nurses due to its varying forms and accessibility. The various types of engagement—for example, forums, blogs and wikis—provide accessibility, reach across boundaries and help to remove barriers that may cause a nurse to feel isolated (Kantor et al, 2018).
Social media can provide an inherent trust in others that facilitates actual support, as members of a network are trusted to provide genuine advice and support that is expected to be independent and free from commercial interests (Kantor et al, 2018). Nurses using social media are able to pursue emotional and moral support, express concerns or seek support and insight from peers (Zhou et al, 2018; Nasurdin et al, 2020). Networking opportunities offered by the use of social media can also help nurses to establish professional groups to critique nursing practice or health service delivery and devise recommendations to improve practice. Sharing wisdom gained from experience working with different patient cohorts, clinical procedures, equipment, and technology are invaluable, and social media is optimal in sharing this with peers. This has been demonstrated by the @WeNurses group, formed on Twitter to share ideas, knowledge, provide support and improve patient care, which has more than has 100 000 followers.
From a different perspective, Pizzuti et al (2020) explored the use of social media as an educational resource, as a means of disseminating conference findings, health and journal alerts. The authors concluded that users must first understand their workplace policy relating to social media, as this will ensure that no breaches of patient privacy, or damage to the profession through sharing poor-quality information. If these areas are all addressed, then social media has the potential to be an effective educational platform. Social media is also an efficient tool for interprofessional education, and can help nurses to become networked practitioners, branching into different knowledge specialities, offering access to professional expertise of various industry leaders, innovators, educators (Rankin et al, 2019). Gaining and sharing information through networking has been identified as a major driver for creating a virtual community of practice, or professional social network groups (Rolls et al, 2016).
When using social media for disseminating research information, nurses are advised to have a clear understanding about the policy of the platform regarding the use of data. For articles in peer-reviewed journals, there are rigorous processes to protect the integrity of data. There are basic rules that are incorporated by all research institutions and to which all researchers must adhere to ensure ethical behaviour in science and medicine (Shaw and Erren, 2015). This is not the case with social media information. Expert fact-checking implemented by some of the social media platforms (Trethewey, 2020), is a robust pathway for clarification. It is important to prevent the spread of medical misinformation and promote scientifically valid information. Social media should be used carefully as a tool to guide targeted audiences to research findings. Therefore, the administrators of social media profiles have a significant responsibility in ensuring quality control, and prevention of the spread of incorrect information or misinformation.
Social media can empower nurses to improve health outcomes for patients by directly affecting how nurses can engage with patients, using empathy in care provision (Mesko and Gyo˝rffy, 2019). Patient outcomes are directly linked to clinical skills and professional development, and latest evidence-based practice can be promoted via social media (Pizzuti et al, 2020). This can occur through access to educational material and latest published research, which can replace outdated printed versions of books and curricula. It has been suggested that social media complements direct engagement between nurses and patients, but does not replace it (Charalambous, 2019). This is because social media facilitates either short-term or long-term participation in groups and conversations, providing flexibility to create online relationships or search for information (Griffiths et al, 2015). One criticism regarding online information is the accuracy of reliable information, and this factor is often cited as a reason for nurses to ignore social media as a source of credible information (Zhou et al, 2018); however, research suggests that errors and false claims made online are quickly rectified (Clayton et al, 2020). Ghazal Aghagoli et al (2020) identified a relevant point when exploring the false information circulated relating to the COVID-19 pandemic. They noted that research findings or academic writing can be difficult for the ‘lay person’ to understand, and that inadvertent misinterpretation of the facts can occur and be disseminated via the online platform (Ghazal Aghagoli et al, 2020). This is supported by Pulido et al (2020), who explored Twitter posts relating to COVID-19. Findings highlighted that false posts were tweeted more than factual posts relating to the COVID 19 pandemic, but were subsequently retweeted less often than the factual evidence-based posts.
The nursing profession can also benefit from social media campaigns that can be used to change public health behaviours, achieve community goals through social reinforcement and provide peer support during stressful times. This element came to the forefront recently as hospital resources worldwide were overwhelmed because of the COVID-19 pandemic (Chan et al, 2020). The power of social media to influence nurses rests in the ever-present, accessible nature of platforms and the characteristics of users (Terrasse et al, 2019). However, one of the risks in the use of social media is the considerable potential for harm to mental health caused by online bullying, also known as cyberbullying. The social media environment facilitates the anonymity of bullies, who are able to post messages to large audiences across geographic and demographic divides (D'Souza et al, 2018; Brewer et al, 2020).
Conclusion
Social media usage is common among nurses, and perceptions and practices among nurses vary considerably. Well-informed policy and targeted education are required to guide nurses when engaging in social media use. Furthermore, social media has the ability to influence and affect a wide range of people of all ages, races, and genders, so careful use of this platform is vital for nurses wishing to use this within their private lives as well as those wishing to use it for professional aspects such as disseminating information, research findings and networking. Using social media for leisure activities while working has negative impacts on patient care, trust and professional boundaries and should never be deemed acceptable by the nursing profession, the organisation and the general public.
KEY POINTS
- Social media is a platform with valid uses for nurses, however, there are pitfalls that users must be aware of
- The use of social media to disseminate research findings to the wider audience is something that many nurses now explore, although patient confidentiality and privacy must be maintained at all times
- Social media can affect how nurses engage with patients because of easy access to educational material and latest published research
- Accepting friend requests from patients either current or past is something that requires caution, as this may put the nurse at risk of compromising their professional boundary
- Social media can facilitate support for nurses due to its varying forms and accessibility and help a nurse to feel less isolated
CPD reflective questions
- How can we as nurses incorporate the risks and benefits that social media presents to patients, and the health community into our practice?
- Has social media use impacted on your mental health or clinical practice?
- Can you identify with any area of social media that may lead you to be vulnerable within your own practice?
- When was the last time that you reviewed your privacy setting within your social media accounts to ensure that you are not inadvertently breaching any social media policies?