The Pew Research Center reported that only 5% of American adults used at least one social media platform in 2005, and that share had risen to 50% by 2011; in 2018, 69% of the public uses some type of social media.1 Although all age groups from 18 to 65+ years increased their use of social media, the age group from 18 to 29 years had the largest increase, expanding from 7% in 2005 to 88% in 2018. Gagnon et al2 reported that 84% of physical therapist students used Facebook for personal purposes, 49% for academic purposes, and 12% for professional purposes.
Social media offers opportunities for creativity, innovation, and collaboration for the physical therapy community.3 Social media allows physical therapists to advertise their clinic and services at no cost and to posteducational information for patients. Although social media has enormous potential in health care, it also poses possible legal, ethical, and professional issues; and inappropriate use of social media can result in disciplinary action and licensing issues for health professionals.4-7, Posting of objectionable material on social media sites may result in disciplinary action against both the professional student and the licensed professional.4,8 However, the definition of objectionable material has not been definitively established. New professionals becoming familiar with the professional health care environment may be particularly vulnerable to potential ethical lapses. Gagnon and Sabus9 suggested that physical therapy educators should help students develop “digital professionalism.” Digital professionalism may be guided by following these simple rules from the Mayo Clinic Social Media Network: “Don't Lie, Don't Pry, Don't Cheat, Can't Delete, Don't Steal, Don't Reveal”.9,10
REVIEW OF LITERATURE
A number of publications have reported survey data on social media use by medical students and physicians,11-24 physical therapy students,2 and multiple other health care professionals.25-31 Facebook is the most common social media site, with younger people more likely to use social media than older people.1 Several studies found that medical students and residents frequently posted material that was found to be objectionable from an ethical or professional standpoint. The objectionable material included profanity,11,12,14; “friending” a supervisor or patient15,20; posting inappropriate pictures of themselves, friends, or patients16,21,22; and searching the Internet for information on patients.17,23
O'Sullivan et al29 surveyed health science students from 8 universities in 7 countries and found that 20.5% of the students who used social media “almost always” reported sharing clinical pictures, but only after obtaining explicit permission. Gagnon et al2 surveyed physical therapy students at 3 different universities regarding utilization of social media. They found that 84% of the respondents used social media on a daily basis; however, only 62% of the students were comfortable using social media for professional purposes, and only 35% reported that their physical therapy program provided education on using social media as part of patient care.
There have been a number of Health Insurance Portability and Accountability Act (HIPAA) violations using social media that involved licensed practitioners in nursing and a number of other medical fields.5,6,8 Numerous licensing agencies have taken disciplinary action against health care practitioners for violations related to the use of social media, in particular breaches of patient confidentiality and violations of HIPAA regulations.4,8 Greysen et al32 found that medical and osteopathic licensure boards were most likely to investigate physicians who posted patient images without consent, posted pictures involving intoxication, violated patient confidentiality, or posted discriminatory speech. Students may not be aware of the professional repercussions that unprofessional social media conduct can have on their careers, particularly if the student posts something in violation of the HIPAA Privacy Rules.8
Disciplinary actions have been taken against professional students for inappropriate social media behavior. Improper use of social media has resulted in dismissal of nursing students from professional programs; improper use included posting obscene remarks on social media sites about patients and posting unprofessional pictures of themselves.4 Acvi et al24 found that, although social media was being used extensively by medical students, the students appeared unaware of possible ethical issues and therefore social media guidelines should be developed.
Our literature review revealed several important points. First, Facebook is the most popular social media site and it is widely used by health professionals and students.1,2 Second, inappropriate use of social media or posting questionable material was common among students, and if the student is in a clinical environment, some of the postings could result in a violation of HIPAA regulations.8 Third, physical therapist students reported a lack of social media education in their physical therapy programs.2 Clearly, there is a need for social media policies and education regarding the proper use of social media. It appears that focused workshops and or classroom discussions regarding social media professionalism may be the best methods to educate students about the proper use of social media.33,34 However, there is no existing physical therapy student data regarding the types of content students are posting, what constitutes objectionable material, or how students judge posted content and professional behavior on social media. Without those data, it is difficult to design a focused discussion regarding professionalism and the use of social media for physical therapy students.
The purpose of our study was to survey students enrolled in professional physical therapy programs regarding their use of social media, the types of materials they and others posted, their judgments about behaviors of others using social media, and their rating of privacy concerns given different clinical scenarios. The information gathered from the students will help determine existing issues and problems that may frame questions for student discussions regarding professional and ethical behaviors when using social media.
We surveyed first-, second-, and third-year physical therapist students from physical therapy programs at the University of North Dakota (UND), University of Tennessee at Chattanooga, and the University of South Florida during the 2016 and 2017 academic years. The survey was developed using the Qualtrics software program and a web site link was emailed to all enrolled students in the three programs (N = 392). The students were invited to voluntarily complete the online survey. There were no incentives given to complete the survey. Some of the students were enrolled in didactic coursework on campus and some students were on their off-campus clinical experiences at the time the surveys were available. Follow-up emails were sent to encourage students to participate in the survey.
In our survey, the term “social media” was defined as the various forms of electronic communication through which users create online communities to share information, ideas, personal messages, and other content.3 We asked questions regarding familiarity with program and clinical site social media policies, personal use of social media sites, time usage of social media sites, posting habits of the students, ratings of behavior in regards to other peoples' posts to social media sites, ratings of acceptable use of social media sites, and reactions to privacy concerns related to a variety of scenarios. Our survey included general topics regarding social media use, similar to other published studies.13,20,21,25,27,31 We modified specific survey items from 2 other published studies (copyright permission was granted) regarding social media behaviors and clinical scenarios that asked respondents to make judgments on appropriate behavior or privacy concerns.15,18 The collected data contained no information that could identify the individual respondent. The survey and the study were approved by the Institutional Review Boards at all three universities. The survey instrument is presented in the Supplemental Digital Content 1 (Appendix, http://links.lww.com/JOPTE/A59).
Although we collected information regarding students' access and use of social media, the focus of this survey was aimed at the students' knowledge of their program's social media policy, the types of content the students posted, and their ratings of “acceptable” behaviors regarding other people's posts to social media sites. In addition, we were interested in the respondents' ratings of the level of “privacy” concern they had given several clinical scenarios. We defined “acceptable” as the use of social media that is professional, ethical, and in accordance with the social media guidelines established for the environments specific to this study. Privacy was defined as the intrusion into an individual's personal information or personal life without just cause.
Although we asked questions regarding kissing, smoking, and drinking, there was no intent to imply a judgment about the respondent's sexual orientation or whether they were smoking illegal substances or whether they were old enough to smoke or drink alcoholic beverages. Our intent was to look at these types of postings in general rather than specific terms.
Surveys were completed online through a link provided to the students by an email sent from each of the physical therapy programs. All data were collected anonymously and stored on a secure server at the respective university. The survey response data were downloaded from Qualtrics into SPSS for analysis. The data from the three programs were merged and analyzed using descriptive statistics. Descriptive statistics were used to report the respondent's gender, year in program, age, and program attended. Frequencies and percentages of responses were calculated and reported for each of the survey items. Missing data were excluded from the analysis.
Of the 392 students who were invited to participate in the survey, 215 students completed the surveys (response rate of 55%). Table 1 provides participant demographics. Sixty-nine percent of the respondents were female participants. Most students (61%) were in the age range of 23–25 years. Most respondents were attending the UND physical therapy program, which is the largest of the 3 programs.
Social Media Policy
When asked whether their professional program had a social media policy, 52% of respondents did not know if there was a policy, and even though all three programs have social media policies in place, 73% of the students had not read it (Figure 1). Similar responses were given when asked about whether clinical sites had a policy and whether they had read the policy. Although 33% of the respondents did not think clinical site administrators monitored their social media sites, 55% did not know if their sites were being monitored. Almost all (96%) the respondents thought that prospective employers would monitor their social media sites as a screening tool prior to employment.
Social Media Behaviors
Table 2 shows the responses to questions regarding whether the respondent had posted or shared pictures of themselves or others in a variety of situations. The most commonly posted pictures were of individuals holding an alcoholic beverage (59%) or while at parties (61%), and 38% posted or shared pictures of someone who was intoxicated. The least commonly posted pictures were of individuals during sexual activity (0%), with a patient (0.5%), and while smoking (2%). Kissing someone of the opposite gender (36%) was much more commonly posted than kissing someone of the same gender (3%). A large percentage (39%) of the students posted or shared pictures taken during physical therapy classroom or laboratory activities. Table 3 shows the students' ratings of acceptable behavior related to other peoples' posts. Even though 59% of the respondents shared pictures of themselves or others holding alcoholic beverages (Table 2), only 36% rated that as an acceptable behavior (Table 3). Related to that, 38% posted or shared pictures of someone who was intoxicated; however, only 8% found that to be acceptable behavior.
Table 4 shows the responses when participants were asked about classmates engaging in negative behaviors. Although most participants (97%) were not aware of their classmates posting information that violated patient confidentiality or posting examination questions, there were apparently some students (3%) posting this type of information. Twenty-two percent of the respondents said their classmates ridiculed a faculty member, although 94% of the respondents rated this behavior as not acceptable (Table 3). Eleven percent said their classmates ridiculed another classmate. Twenty-nine percent of the respondents were aware of their classmates posting pictures that reflected unprofessional behavior.
Using Social Media
Almost all the respondents (98%) thought that sending and accepting a friend request to and from classmates was acceptable (Table 5). A vast majority (over 84%) of the respondents thought that looking up patients, communicating with patients, friending current patients, and using a fake identity was not acceptable. Forty-eight percent or more of the respondents thought that conducting Internet searches on coworkers, classmates, faculty members, future employers, and future colleagues was acceptable. Fifty-seven percent of the respondents thought that it was not acceptable and 19% thought it was acceptable to send a friend request to a current faculty member. Sending a friend request to a former faculty member was acceptable for a majority (63%) of the respondents. Most respondents thought that it was not acceptable to conduct an Internet search on current or former patients.
We asked the respondents to indicate how concerned they were about privacy given a number of different scenarios that a student might encounter (Table 6). The two scenarios that generated definite concerns for respondents were where a student takes a picture of a patient's pressure sore and sends it to classmates (88%) and where a student emails the results of a patient's examination to a professor with intact patient information (98%). However, if patient identifiers were removed, 53% of the respondents had only some concern and 25% had no concern for that same email. For the most part, respondents felt there was a definite concern anytime a patient's picture, medical history, behavior, or confidential information was posted. The greatest variability in responses was apparent anytime the scenario mentioned de-identified information or having the patient's permission.
Although all three physical therapy programs have social media policies, and all three require students to read the policy, most students did not know if there was a policy and had not read the policy even if they knew one existed. We realized our educational programs must do a better job of ensuring that students are aware of program policies, have read them, and are able to apply them to professional behavior in the current health care environment. Gagnon and Sabus9 point out that educators are tempted to reduce digital citizenship to proper etiquette, appropriate manners and norms in electronic correspondence. They further suggest that educators support students in developing “digital professionalism” and that it should be threaded throughout the curriculum using social media experiences and assignments. We agree with this assessment, and we agree that merely expecting students to read the policies does not appear to work very well.
Our findings are consistent with Chretien et al35 that beyond frank privacy violations, students have differing views on content they consider appropriate to post online. One of the challenges when educating students about social media professionalism is that the definition of unprofessionalism in the online community is somewhat unclear.36 Although actions such as HIPAA violations, breaches of patient confidentiality, communications about patients, or posting discriminatory language are clear violations, there are other situations that are less clear.15,35,36 To help educators, Gagnon and Sabus9 developed Social Media Guidelines for Health Care Providers, which could be used as a starting point for student discussions. In addition, they suggested that the American Physical Therapy Association's Standards of Conduct in the Use of Social Media might also be of use to physical therapy education programs.37
Findings of this study are consistent with the nature of professional behavior itself.38 Codes of ethics and professional guidelines delineate behaviors that are ideal, required, prohibited, or acceptable under certain circumstances. Student respondents recognized situations that were legally or ethically prohibited (posting patient information in violation of HIPAA) and were less certain about social media postings of behavior that was not “ideal” (posting picture of intoxicated professional students). What is considered ethically or professionally “appropriate” also includes consideration of context. Results of this study suggest that physical therapy students may require more guidance in determining what is appropriate in different contexts.
Professionals have historically been able to draw distinctions between personal and professional domains.38 However, the use of social media results in new issues to consider regarding professional and personal boundaries. Some behaviors in one's personal life (such as driving while impaired, fraud, and sexual misconduct) have additional legal and ethical ramifications. Although becoming intoxicated occurs in a personal domain, posting a photo depicting the intoxication to social media places the behavior in the public domain and, potentially, in the professional domain. The fact that respondents in our survey considered specific behaviors, such as intoxication, inappropriate but posted information/photos about such behaviors on social media, may represent a disconnect between personal values and conduct. Social media usage may be contributing to the blurring of the distinctions between personal and professional boundaries.
To date, an unanswered question is whether social media presents fundamentally new challenges to professionalism or whether these professionalism challenges are simply the “old” challenges presented differently. For example, is there a “disinhibiting” aspect to social media that may influence participants to engage in behavior or commentary that they would judge as inappropriate? Theories of moral agency38 and moral behavior39,40 suggest that knowing the “right thing to do” does not necessarily result in moral behavior, and student professionals require learning activities to bridge the gap between knowledge and action. Findings from this study indicate that physical therapy curricula should include learning activities (professional guidelines, case scenarios, and role play) focused on appropriate social media professionalism. Additionally, the professionalism curriculum should foster professional identity and moral agency that will translate to professional behavior in both clinical and virtual environments.
There is very little evidence-based information regarding the best practices used to teach students about social media professionalism. Jalali and Wood33 reported positive results in teaching medical students about social media professionalism using an interactive session. The session consisted of an introduction to social media tools (eg, Facebook) followed by a discussion of case scenarios that illustrated issues relating to social media professionalism. Students discussed the cases in small groups reported out to the large group and debated their decisions regarding professionalism within the cases. Flickinger et al34 piloted a similar approach, which included an introductory workshop, group discussions, and reflections posted on a blog. Students shared posts regarding medical topics, cases where students were reprimanded for inappropriate behavior, and social media guidelines from medical organizations. Both these approaches appeared to be successful according to comments and surveys of students. Gomes et al41 also used a workshop format using student-generated social media examples for discussion. Most students thought the workshop increased their social media awareness and they made changes in their social media behavior. We suggest, based on limited evidence, that an active learning approach with group discussions facilitated by faculty members might be the most effective way to teach social media professionalism. Chretien et al35 found that although students did not want strict control on what they should post, they found it acceptable for the program to offer guidance and recommendations regarding online behaviors.
Most respondents have posted pictures showing themselves or others holding an alcoholic beverage and attending parties, and a large percent (38%) showed someone who was intoxicated. White et al27 reported that students determined a picture of someone holding an alcoholic beverage was not unprofessional, but showing a picture of someone who was intoxicated was unprofessional. We found similar responses in our study where 59% of the respondents posted or shared pictures of someone holding an alcoholic beverage, but only 36% thought it was acceptable behavior. Twenty-two percent of our respondents were aware of classmates who ridiculed faculty members on their social media sites. White et al27 also found that students ridiculed faculty members even though most of the students, as in our study, found the behavior unprofessional. If students are suspecting that faculty or employers are monitoring their social media sites, they may want to consider research that shows faculty members, members of the public, and older generations tend to be more conservative than students about the appropriateness of content posted on social media sites and that what the student believes to be acceptable behavior may not be acceptable by others.21,35
Chretien et al15 found that a majority of physician Clerkship Directors thought it was inappropriate for a faculty members and current students to become friends or to become friends with a current patient. Most of our respondents agreed with the results of that study. Although Internet searches on coworkers or patients is generally not considered to be an invasion of privacy as social media profiles are public information,42 some authors warn against conducting searches on patients.17 Other researchers found that most medical residents and physicians thought searching for patients online was unethical.23 Most respondents in our study agreed that friending a current patient or conducting Internet searches on patients with whom they are working is not acceptable. However, a majority of our respondents thought that it was acceptable to conduct searches on faculty members. Knowing this, faculty members should be diligent in making sure their own social media sites only contain information they deem as professional and appropriate. Kitsis et al43 found that students were more likely to remove objectionable material about themselves from their social media sites than were faculty members.
Students are often unaware of the professional repercussions that unprofessional conduct on social media can have on their careers, particularly if the student posts something in violation of the HIPAA Privacy Rule.8 When we asked students to rate scenarios concerning privacy, none of the scenarios garnered a 100% response. We had assumed that the scenarios about emailing a patient's history and physical to a professor with intact information would have been a clear violation of HIPAA along with the posting of photographs without explicit written consent. Posting of patient photographs is not recommended.4,8,16 Although we assumed that all physical therapy students understood the HIPAA Privacy Rules, that was not the case.
There are several limitations to the study. Although we surveyed a large group of students, the fact that they came from three different geographic areas may explain some of the variability in their responses. The number of respondents from each program varied with over half of the respondents coming from one program; this may have influenced the results. Although we required that all students read the program's social media policy, we had no way to enforce that rule, which may help explain why so many students were unaware of program policies. In addition, we did not know if any clinical sites had social media policies, which may have varied the students' responses to that survey item. Although there are some data regarding physical therapy students' use of social media, most studies involved medical students. This limited our ability to extrapolate those data to physical therapy students. In the online survey, we defined privacy as “the intrusion into an individual's personal information or personal life without just cause.” This was based on another study from which we used similar questions.18 In retrospect, confidentiality may have been a better word than privacy and may have been more familiar to students, particularly when it relates to patient confidentiality.
Although other studies have reported social media use among physical therapy students, our study is the first to explore physical therapy students' perceptions of social media behaviors and privacy concerns. There was a significant disparity between the respondents' level of concern for negative behaviors and the acceptability and appropriateness of social media posts. Even though all three programs had social media policies, a large percentage of the students did not know about the policies, did not read the policies, or did not understand the relevance of the policies for professional students. Although we believe that physical therapy programs should develop social media policies, the literature suggests that a policy alone, without some facilitated discussion, may not be enough to teach “digital professionalism.” Our literature review suggests that threading social media professionalism throughout the curriculum might be the best approach. Future studies should explore the best methods for teaching social media professionalism to physical therapy students.
Students should be reminded that their perceptions of appropriate and inappropriate social media content may not be the same as those of faculty members, potential employers, clinical site administrators, or the public. Students should be diligent in making sure they have appropriate privacy settings in place and that they remove any inappropriate postings from their personal sites. Physical therapy programs should be diligent in making sure that students understand the implications, positive and negative, of social media usage. Facilitated discussions appear to be the best method to teach social media professionalism, and the results of this study should help faculty develop scenarios that will aid in developing those discussions.
2. Gagnon K, Sabus C, Robertson E, Derrick MK. Social media and mobile technology use among physical therapist students: A multisite descriptive study. J Phys Ther Educ. 2016;30:14–22.
4. Ventola CL. Social media and health care professionals: Benefits, risks, and best practices. P T. 2014;39:491–520.
7. Cain J, Fink JL. Legal and ethical issues regarding social media and pharmacy education. Am J Pharm Educ. 2010;74:184.
8. Bouldrick D. HIPAA violations on social media: Think before you post. AMT Events. 2015;32:24–27.
9. Gagnon K, Sabus C. Professionalism in a digital age: Opportunities and considerations for using social media in health care. Phys Ther. 2015;95:406–414.
11. Thompson LA, Dawson K, Ferdig R, et al. The intersection of online social networking with medical professionalism. J Gen Intern Med. 2008;23:954–957.
12. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009;302:1309–1315.
13. Yu AY, Tian SW, Vogel D, Kwok RC. Can learning be virtually boosted? An investigation of online social networking impacts. Comput Edu. 2010;55:1494–1503.
14. MacDonald J, Sohn S, Ellis P. Privacy, professionalism and Facebook: A dilemma for young doctors. Med Educ. 2010;44:805–813.
15. Chretien KC, Farnan JM, Greysen SR, Kind T. To friend or not to friend? Social networking and faculty perceptions of online professionalism. Acad Med. 2011;86:1545–1550.
16. Thompson LA, Black E, Duff WP, Black NP, Saliba H, Dawson K. Protected health information on social networking sites: Ethical and legal considerations. J Med Internet Res. 2011;13:e8.
17. Jent JF, Eaton CK, Merrick MT, et al. The decision to access patient information from a social media site: What would you do? J Adolesc Health. 2011;49:414–420.
18. Whipple EC, Allgood KL, Larue EM. Third-year medical students' knowledge of privacy and security issues concerning mobile devices. Med Teach. 2012;34:e532–e548.
19. Osman A, Wardle A, Caesar R. Online professionalism and Facebook—falling through the generation gap. Med Teach. 2012;34:e549–e556.
20. Brown J, Ryan C, Harris A. How doctors view and use social media: A national survey. J Med Internet Res. 2014;16:e267.
21. Jain A, Petty EM, Jaber RM, et al. What is appropriate to post on social media? Ratings from students, faculty members and the public. Med Educ. 2014;48:157–169.
22. Walton JM, White J, Ross S. What's on your Facebook profile? Evaluation of an educational intervention to promote appropriate use of privacy settings by medical students on social networking sites. Med Educ Online. 2015;20:28708.
23. Ben-Yakov M, Kayssi A, Chu J, Hicks CM, Devon K. Do emergency physicians and medical students find it unethical to look up their patients on Facebook or Google? West J Emerg Med. 2015;16:234–239.
24. Avci K, Celikden SG, Eren S, Aydenizaz D. Assessment of medical student's attitudes on social media use in medicine: A cross sectional study. BMC Med Educ. 2015;15:18.
25. Usher W. Types of social media (Web 2.0) used by Australian allied health professionals to deliver early twenty-first-century practice promotion and health care. Soc Work Health Care. 2011;50:305–329.
26. Giordano C, Giordano C. Health professions students' use of social media. J Allied Health. 2011;40:78–81.
27. White J, Kirwan P, Lai K, Walton J, Ross S. Have you seen what is on Facebook? The use of social networking software by healthcare professions students. BMJ Open. 2013;3:e003013.
28. Suit L, Winkler P, Campbell L, et al. A correlational study of social network usage among health care students. J Nurs Educ. 2015;54:207–213.
29. O'Sullivan E, Cutts E, Kavikondala S, et al. Social media in health science education: An international study. JMIR Med Educ. 2017;3:e1.
30. Peluchette J, Karl K, Coustasse A, Emmett D. Professionalism and social networking: Can patients, physicians, nurses and supervisors all be friends? Health Care Manag. 2012;31:285–294.
31. Tuckett A, Turner C. Do you use social media? A study into new nursing and midwifery graduates' uptake of social media. Int J Nurs Pract. 2016;22:197–204.
32. Greysen SR, Johnson D, Kind T, et al. Online professionalism investigations by state medical boards: First, do no harm. Ann Intern Med. 2013;158:124–130.
33. Jalali A, Wood TJ. Teaching medical students social media: Must or bust. Med Educ. 2014;48:1128–1129.
34. Flickinger TE, O'Hagan T, Chisholm MS. Developing a curriculum to promote professionalism for medical students using social media: Pilot of a workshop and blog based intervention. JMIR Med Educ. 2015;1:e17.
35. Chretien KC, Goldman EF, Beckman L, Kind T. It's your own risk: Medical students' perspectives on online professionalism. Acad Med. 2010;85:S68–S71.
36. Peck JL. Social media in nursing education: Responsible integration for meaningful use. J Nurs Educ. 2014;53:164–169.
38. Fry ST, Veatch RM, Taylor CR. Case Studies in Nursing Ethics. 3rd ed. Sudbury, Mass: Jones and Bartlett Publishers; 2006.
39. Rest JR. Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, NJ: Psychology Press; 1994.
40. Bebeau MJ. The defining issues test and the four component model: Contributions to professional education. J Moral Educ. 2002;31:271–295.
41. Gomes AW, Butera G, Chretien KC, Kind T. The development and impact of a social media and professionalism course for medical students. Teach Learn Med. 2017;29:296–303.
42. Chretien KC, Kind T. Social media and clinical care: Ethical, professional, and social implications. Circulation. 2013;127:1413–1421.
43. Kitsis EA, Milan FB, Cohen HW, et al. Who's misbehaving? Perceptions of unprofessional social media use by students and faculty. BMC Med Educ. 2016;16:67.
Technology in education; Professional development; Ethics and morality
Supplemental Digital Content
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