FRAZIER, BLAKE RN, BSN; CULLEY, JOAN M. PhD, MPH, RN, CWOCN; HEIN, LAURA C. PhD, RN, NP-C; WILLIAMS, AMBER DNP, APRN, BC, FNP; TAVAKOLI, ABBAS S. DrPH, MPH, ME
Many people, including nurses and nursing students, use social networking. Social networking requires a dedicated Web site or other applications that enable users to communicate with each other by posting information, comments, messages, images, and so on.1 Although there are many social networking Web sites, such as Twitter, Yammer, and LinkedIn, Facebook is by far the most popular and perhaps the most well-known social networking Web site. As of September 2012, Facebook had more than 937 million users around the world.2 However, the problem facing nursing is not how many people are using social networking; the problem is that there have been instances of misuse by nurses and nursing students resulting in the intentional or unintentional violation of patient privacy.3 Federal regulation, specifically HIPAA,4 defines what information can be legally disclosed online. The nursing profession must educate current and future nurses about the ethical and legal boundaries of social networking to maintain patient privacy. The purpose of this study was to identify current use of social media by faculty and students and a need for policies within nursing education.
In 2011, the National Council of State Boards of Nursing (NCSBN) released “White Paper: A Nurse’s Guide to the Use of Social Media”5 to provide guidance for nurses using social media in ways that ensure patient privacy. As a part of the white paper, a survey of state boards of nursing was conducted in 2010. The survey reported that 33 of 46 state boards of nursing received complaints about the improper use of social media by nurses, and in some cases, nurses were censured or had their licenses suspended.5 Included were seven scenarios highlighting improper use of social media by nurses and explanations pertaining to the type of violation. In addition to the NCSBN, the National Student Nurses Association (NSNA)6 and the American Nurses Association (ANA)7 have issued recommendations on the use of social networking for nurses and nursing students.
One case highlighting the misuse of social networking by a nursing student occurred at a Kansas nursing school. Four nursing students were expelled from the program after one student posted a picture of a patient’s placenta on her Facebook page. Although there was no information linking the placenta to a patient, the school deemed that this was an unprofessional behavior.8
Junco9 highlighted the need for student social networking policies in higher education. Although this article did not focus on nursing or privacy concerns, it did focus on the policy development process for higher education by comparing social networking policies to honor codes, which have long been a standard practice for universities and colleges for academic integrity purposes. Honor codes are contingent upon adherence to the ethical principles of honesty and integrity.
Stokowski10 focused on both the advantages and disadvantages of social networking for nursing. Although she also discussed the positive side of social networking, she did highlight some harmful consequences related to both nurses and nursing students. In addition to losing the right to practice nursing, nurses and nursing students can be fired from their place of employment, be expelled from school, or face criminal or civil litigation if social media is misused in an unprofessional way.11,12
Cain13 discussed the need for social networking policies for healthcare workers in places of employment. Implementation of social networking policies would hold employees accountable to standards.13 In addition to the implementation of a policy, Cain stated the need for employee education related to acceptable behavior when it comes to using social networking.
The theory guiding this study is Kohlberg’s stages of Moral Development (Kohlberg and Hersh, 1977).14 Kohlberg’s theory posits six stages of moral development: (1) reward or punishment for behavior; (2) right action is what satisfies my needs; (3) good behavior is what satisfies others; (4) law and order—desire for fixed invariable rules and authority; (5) right action is defined by society; however, the relativity of personal values is understood; and (6) one’s conscience determines what’s right—abstract concepts such as justice and dignity are embraced.13 A 20-year longitudinal study testing Kohlberg’s theory supports the posited stage sequence and found the stage of moral development to be most strongly correlated to age, followed by education and IQ.14 In addition, these authors found stage 5 was not entered until age 24 years, and only 10% of participants ever reached stage 5; none reached stage 6.
Socialization in an educational environment has been equated to teaching ethics, values, and morality.13 A goal of education is to assist students to advance through these moral stages; however, schools tend to function in stages 1 and 4 (reward/punishment and law and order).13 Interpreting the ANA Code of Ethics, nursing requires our students and graduates to function at stage 6 of Kohlberg’s model.15,16 Benner,17 considering nursing skill development and knowledge, places students in the novice category, approximately equivalent to Kohlberg’s stage 4, a stage insufficient for the ethical and moral nursing care we and society expect of students and graduates. At this early stage of moral and professional development, it is appropriate to provide concrete guidance in the form of policies, such as a policy guiding social media use.
The literature review was conducted using CINAHL, PubMed, and organizational Web sites such as NCSBS, NSNA, ANA, and the Web sites of nursing schools. Search criteria included the terms nursing and social networking, nursing education and social networking, social media, social networking policies, and nursing policies and social media. Time was not limited because of the widespread use of social media in the past 10 years. Despite the few recommendations discovered for the ethical use of social networking for healthcare providers, nothing was found relating the impact of social networking policies to a reduction in the occurrences of improper use of social media.
An Internet search of US nursing programs sought evidence of social media policies in handbooks or on Web sites. A quick Google search for nursing program social media policies found that few schools of nursing had social networking policies or procedures in place. Of 30 schools of nursing that were reviewed, only seven had policies that were specific to the use of social media in place at the time of the study. Although there were recent published recommendations from NCSBN, nursing students and faculty may not have been aware of these. Therefore, some of the misuse may have been due to a lack of knowledge or lack of education surrounding the professional use of social media. Given what the literature search revealed, the specific aims of this study were to identify nursing students’ and nursing educators’
1. perceptions of social networking;
2. personal, professional, and ethical use of social networking; and
3. beliefs regarding the need for policies in schools of nursing.
An investigator-developed survey was sent electronically to all undergraduate and graduate nursing students and all faculty members at a university-based college of nursing located in the southeastern United States. The survey asked class level, social media sites used and frequency of use, and ethical questions related to social media use and patient interaction. A four-point Likert scale of strongly disagree to strongly agree was used for ethical questions; a five-point scale of no use to daily use was used for frequency-of-use questions. The study was approved by the Office of Research and Institutional Review Board at the university. For convenience and expediency, the research was conducted online via SurveyMonkey (SurveyMonkey, Portland, OR) and sent electronically to more than a thousand nursing students and faculty members. Faculty chosen to distribute the survey to students had access to all students in a class level, which ensured that every student was contacted. Faculty agreed to distribute the survey to all students in their courses through their course online portal. Because all students and faculty receive official communication through the online portal, this limited the potential for e-mails to be deleted or sent to a spam folder. In addition, to ensure that every student received the notification, a reminder e-mail was sent via a discussion list that included all students in the college. Faculty members were sent the survey via a faculty discussion list. The survey did not allow multiple responses to be collected, and only one survey per computer and IP address was allowed.
Participation was voluntary. An e-mail sent from SurveyMonkey included a disclaimer and agreement to participate. Inclusion criteria for student participation included current enrollment as an undergraduate or graduate student at the university and the ability to read and write English. Faculty criteria required a current faculty position at the university, ability to read and write English, and current licensure as an RN.
Participants were given the option to exit the survey and not participate or to click “next” if they agreed to participate. By clicking the next button, participants provided consent. Before clicking next, participants viewed an explanation of the purpose of the study, procedures, risk and discomforts, benefits and costs, and confidentiality. The participants were assured that the survey was anonymous and that names would not appear on any survey materials. All data were reported only in an aggregated form. Participants had 2 weeks to complete the survey, and a second notice was sent 1 week before the end of the study to encourage participation.
The investigators developed a brief 21-question survey for faculty and a 20-question survey for students to better understand how the respondents used and perceived social networking. The faculty was asked one additional question related to their teaching of social networking ethics for nurses and other healthcare professionals. Likert scales were used in combination with open-ended questions. Only one demographic question was asked of students regarding their current class level (freshman to graduate student).
Results were downloaded to Excel (Microsoft, Redmond, WA) and converted to SAS 9.3 (SAS Institute Inc, Cary, NC), which was used to analyze the data. Descriptive statistics were computed on the variables. For categorical variables, the univariate constructions included frequency distributions. For continuous variables, statistics included measure of central tendency (mean and median) and measure of spread (SD and range). Inferential statistics included χ2, Fisher exact test, t test, and General Linear Model (GLM). Cronbach coefficient alpha was used to assess internal consistency of social media scales.18 Table 1 includes the frequency distribution for all questions asked on the survey.
Participants included 33 faculty members (33% response rate), 236 undergraduate students enrolled in a traditional BSN program (22% response rate), and 37 graduate students who represented the graduate school population (19% response rate). Response rate varied by the level of undergraduate student: lower division (freshmen and sophomores, 19%) and upper division (junior and senior, 27%).
Social Networking Use
A major aim of this study was to identify how nursing faculty members and students utilize and perceive the use of social networking in the nursing profession. Of the 33 faculty members taking the survey, 23 (70%) responded that they use some form of social networking. Meanwhile, 240 students (90%, seven students declined to answer) responded that they use social networking. Facebook was the most popularly used Web site among both faculty and students. Of students, 190 (71%) responded that they used some form of social networking at least daily. In sharp contrast, only eight of 23 faculty members (27%) responded to using social networking daily.
A majority of both students (n = 248, 93%) and faculty members (n = 29, 88%) agreed that it is not acceptable to “friend” or interact with patients on a social networking Web site. In addition, the students (n = 229, 86%) and faculty members (n = 29, 88%) agreed that it is unacceptable to talk about clinical or work experiences on a social networking site, even if the patient’s name is not used because identifiable information is not limited to the patient’s name. Nursing students (n = 230, 87%) and faculty (n = 30, 94%) overwhelmingly agreed that RNs as professionals should be held to higher standards when using social networking. Students (n = 180, 68%) and faculty members (n = 21, 81%) acknowledged that they have seen unprofessional behaviors exhibited by their peers and other RNs on social networking Web sites.
Half of the student respondents indicated that social networking etiquette was not discussed during their nursing education curriculum. However, 22 faculty members (71%) reported that they had discussed social networking etiquette with students (P < .03). Despite this discrepancy between students and faculty, this survey did yield similarities in responses between nursing students and educators.
Only 15 faculty members (47%) and 15 nursing students (6%) surveyed were familiar with the NCSBN’s “White Paper: A Nurse’s Guide to the Use of Social Media.”3 Furthermore, 31 faculty members (97%) and 211 students (81%) believed that it was important for nursing schools to create social networking policies. An almost equal number of faculty members (n = 30, 94%) and students (n = 225, 87%) believed that social networking policies would help better educate nurses and nursing students on proper social networking etiquette. Both faculty members (n = 31, 97%) and students (n = 211, 81%) believed that it was necessary for a social networking policy to be implemented in colleges of nursing.
Only one qualitative question was asked. Students and faculty members were given the opportunity to state what they would like to see included in a social media policy for schools of nursing. The common consensus was that students and faculty would like to see a reference to HIPAA and very specific guidelines for the use of social media by student nurses. Many of the students and the faculty indicated that the policy must clearly state that posting any information about patients is not acceptable. In addition, some faculty stated support for a restriction on students talking about faculty or staff in a negative manner. One faculty member addressed the issue regarding the ethical use of photographs on social media and thought that it should be included in a policy as well. Although a majority of the qualitative comments were in support of social media policies, some students stated that they were strongly against social media policies in nursing education and felt that what they posted on their social media Web sites should not be of any concern to schools of nursing.
Tables 1 and 2 indicate the frequency distributions of social media questions by group (student and faculty). The χ2 results indicate there were differences by group for use of social media (P = .0006), particular social media site used (P = .0012), average times per week the social media site is used (P = .0001), if social networking etiquette was discussed in class (P = .009), if social networking policies should be made in schools of nursing (P = .028), and if a policy should be made at the individual school of nursing where the study was conducted (P = .0005).
Table 3 displays the mean, SD, and minimum-maximum for social media questions by student and faculty. t Test results indicate there were significant differences between students and faculty for an average of the belief that social media policies can be used to educate nurses on good social networking etiquette (P = .0127), for patient assurance (P = .0315), and to create a policy at the school where the study was conducted (P = .0013). However, the results did not reveal any significant difference with all other individual social media Likert scale questions and total scales. Internal consistency (Cronbach’s α) coefficients for social media Likert scale questions were .76 and .60 for students and faculty, respectively.
Table 4 shows the mean, SD, and minimum-maximum for social media questions by class level. To examine the difference of means for social media questions and total scales by class level, GLM was used. The analyses revealed significant differences for friending a patient with a bond between freshmen and seniors; freshmen were more likely to believe it was appropriate to friend patients they had bonded with in clinical settings. Both juniors and seniors were significantly more likely to report having seen unprofessional posts than freshmen, and seniors significantly more than sophomores. Graduate students were significantly more likely than sophomores to believe the college of nursing needed a social media policy. However, the results did not indicate any other differences when analyzing the data by class level.
This was a small sample of participants from one university. The results may not reflect the same knowledge or practices related to use of social networking for students and faculty members at all universities throughout the United States. The tool was newly developed and was not validated before use. The use of an electronic medium for survey submission may have limited the number of respondents within the sample group. Replication of this survey at other universities across the country may or may not reveal consistencies in their knowledge or practices, but would lend validity to this survey and this argument. In addition, if there were similar survey results at similar institutions, the argument for having such policies would be strengthened.
The specific aims of this study were to identify nursing students’ and nursing educators’ (1) perceptions of social networking; (2) personal, professional, and ethical use of social networking; and (3) beliefs regarding the need for policies in schools of nursing. We will address our findings relative to each aim.
Perceptions of Social Networking
Perceptions of social networking varied both by class level and between students and faculty. Students were using social media significantly more frequently than faculty. This is not surprising because the millennial generation is technology savvy. The investigators anticipated that students used social networking more than faculty members, which was confirmed with the results. The difference in use of social networking may be due to the different reasons students and faculty used social networking. Students may be using Facebook, and so on, to stay connected to friends. It is possible faculty are using social networking as a professional networking and development tool (ie, LinkedIn), where professional posts are important. In our sample, just 1% of students were using LinkedIn, whereas 15% of faculty reported use of this site. Another perception of note is the discrepancy between students and faculty on whether social networking was discussed in the classroom (21% difference). There are several possibilities for this discrepancy: students may have been absent the day it was discussed; faculty may have briefly mentioned social network professional behavior in class and felt they had adequately covered the material—students may have felt it was an aside; or faculty may be mistaken about having covered this topic.
Personal, Professional, and Ethical Use of Social Networking
Personal, professional, and ethical use of social networking also varied by class level and between students and faculty. Similar numbers of students and faculty felt that what they posted on Facebook or other social media was their business as long as they were not violating HIPAA. The similar response to this question between students and faculty was interesting. Students may have been responding from a law and order (Kohlberg stage 4) mindset. However, faculty may have been intuitively responding from Kohlberg stage 5 or 6 and resented being forced back into a law and order (stage 4) box. Freshmen (not yet in a clinical site) believed it was okay to “friend” a patient on a social media site. This differed from seniors, who did not feel friending a patient was appropriate.
Beliefs Regarding the Need for Policies in Schools of Nursing
High levels of students and faculty felt there was a need for social networking policies. Based on Kohlberg and Benner’s work and the probable developmental level of moral development of undergraduates, this is likely appropriate. According to both Kohlberg’s and Benner’s theories, novices and traditional undergraduate students are functioning at stage 4—law and order morality. Policies function as institutional statutes fulfilling this desire for guidance and boundaries. With the fairly recent advent of social networking sites and faculty’s generational distancing from the development of these technologies, many colleges of nursing do not have social networking policies in place. Faculty and administrators may be incorrectly assuming that our undergraduates are functioning at a higher level of moral development (level 5 of 6) than is chronologically probable. Although higher functioning students (and faculty) may resent additional rules and policies, policies may be needed by the majority of students to avoid personal and institutional liability. The efficacy of policies as a moral teaching tool is questionable. Kohlberg and Hersh’s15 work supports the utility of case-driven teaching in morality.14 However, policy-driven moral education is uncertain. Policies are merely institutional torts providing boundaries.
IMPLICATIONS FOR RESEARCH AND PRACTICE
Further research is needed to better understand the development of professional boundaries as students mature and engage in professional experiences as undergraduate and graduate students/practitioners. Our understanding and application of ethics must be taught in a way that transcends the evolving use of technology so that students and practitioners are able to apply the principles of ethics throughout their careers. Ethics and morality must be taught in a way that is developmentally accessible to students. Social networking policies may appropriately meet this goal. Replication of this research is needed with a sample of universities located in different regions of the country, including those with and without social media policies.
As we evolve and mature in our use of various forms of online communication both social and professional, ethical discussions are critical to the protection of privacy. As the boundaries of social and professional online communication become more intertwined and blurred, further research is needed to determine the impact of social networking policies in schools and colleges of nursing. As faculty, we need to anticipate future technologies and teach ethics in a way that transcends the classroom and specific social media. We need to develop ethical nurses.
© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.