annotated bibliography for english literature
Ethics, Law, and Policy Social Media:
Managing the Ethical Issues "S ocial media is a generalized term for a group of online software tools that allow for increased interaction, authorship, and devel- opment of online content by any web user" (Kuhns, 2012, p. 4). Social media include the well-known sites, such as Facebook, Linkedin, and Twitter, but also wikis, blogs, microblogs, podcasting, and other social network- ing and social bookmarking sites (see Figure 1 for defini- tions and examples). The first goal of this article is to introduce social media and outline ethical issues sur- rounding their use for medical-surgical nurses. A second goal is to identify existing guides from professional and regulatory associations that nurses can use to navigate social media ethically.
Social media are changing the way people and organi- zations communicate. The social media statistics are amazing: Facebook has 751 million monthly active users, with 79% outside the United States and Canada (Facebook, 2013). Twitter now has almost 555 billion reg- istered users, with an average of 58 billion tweets per day (StatisticBrain, 2013). Why do nurses need to become familiar with social media?
Patients and their caregivers are searching online for medical information and seeking support; 60% of patients now seek both support and information online.
Looking for health care information is the third most popular online activity, after Internet search and email.
When 3,014 survey participants were asked to think about the last time they hunted for health or medical information, 77'^/a of these online health seekers said they began at a search engine, such as Google, Bing, or Yahoo (Pew Internet & American Life Project, 2013). Clearly these survey participants reflected the fact that one in three American adults go online to research their medical conditions. These statistics go beyond millennial (born 1982-2004), who have lived with computers and Internet all their lives; they also include baby boomers as the fastest growing age group of persons using social media tools, with over 51% using some form of social media (Pew Research Center & American Life Project, 2011).
Clearly patients and families are using this technology routinely. Therefore, nurses have an obligation to under- stand this use and find ways to bring these technologies into the health care arena for safe use.
Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L Associates, a Consulting and Coaching Company, Philadeiphia, PA.
She serves on the American Nurses Association Ethics and Human Rights Advisory Board.
Ethical Issues with Social Media The simplicity with which personal information can be distributed for public scrutiny presents grave chal- lenges to privacy and professionalism. The unregulated nature of the Internet allows the possibility of unintend- ed self-disclosure by nursing professionals and possible violations of confidentiality laws. Therefore, prior to engaging in social media platforms, all nurses should clearly understand the Health Insurance Portability and Accountability Act (HIPAA) and how to avoid possible privacy ethical violafions.
HIPAA introduced the term protected health infonnation (PHI) and established rules on how to protect this infor- mation (U.S. Department of Health and Human Services [USDHHS], 2003). This Privacy Rule protects all "individ- ually identifiable health information held or transmitted by a covered entity, whether electronic, paper, or oral" (p.
3).
Two ways to include actual patient information in a social media platform are acceptable to HIPAA. A patient can sign a consent form allowing PHI in a social outlet.
Interchangeably, the information can be de-identified.
De-identified health information neither identifies nor provides any practical way to identify an individual, a process that is done by removing specified identifiers of the individual and the individual's relatives, household members, and employers. Lifchez, McKee, Raven, Shafritz, and Tueting (2012) provided a table of standards for de-identification of patient information. If nurses choose to use patient examples in any social media plat- form, they must follow this outlined privacy rule. This can be done by changing the sex, age, location, time- fiame, and in the case of rare diseases, the diagnosis (Chretien & Kind, 2013).
The Code of Ethics for Nurses with Interpretative Statements (American Nurses Association [ANA], 2001) also offers guidance to nurses on meeting the ethical obli- gation of confidentiality.
The patient's well-being could be jeopardized and the fundamental trust between patient and the nurse be destroyed by unnecessary access to data or by the inappropriate disclosure of identifiable patient infor- mation. The rights, well-being, and safety of the indi- vidual patient should be the primary factors in arriv- ing at any professional judgment concerning the dis- position of confidential information received from or about the patient, whether oral, written, or electron- ic, (p. 12) It further indicates a distinct effort should be made to sustain data security in all electronic communications.
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S MEDSURG Social Media: Managing the Ethical Issues FIGURE 1.
Definitions and Examples of Social Media Terms Social network Blogs Microblog Wikis Social bookmarking Podcast Definitions Use to stay connected with friends and family, and to share and express what mat- ters to the person.
World's largest professional network Provide commentary on a particular subject; others function as more personal online diaries, or as online brand advertising of a particular individual or company.
Use 140 characters to update followers.
Text, images, music, video, chats Images, not text Piece of server software that allows users to create and edit web page content freely using any web browser; ideal for collective projects.
Centralized online services that enable users to add, annotate, edit, and share book- marks of web documents. Tagging enables users to organize their bookmarks in flex- ible ways and develop shared vocabularies.
A multimedia digital file made available on the Internet to download to a portable media player, computer, etc.
===, = =, Examples Facebook Linkedin WordPress Twitter Tumblr Pinterest Wikipedia Delicious YouTube iTunes Once electronic medical records become normative in health care, accessing patient information for use in social media will become easier. Nurses need to take seri- ously their obligation to safeguard the patient's right to privacy.
Spector and Kappel (2012) gave multiple examples of the violation of the ethical principles outlined in regula- tory and professional codes. They identified complaints in the following categories:
1.
Breach of privacy or confidentiality against patients 2.
Failure to report others' violations of privacy against patients 3.
Lateral violence against colleagues 4.
Communication against employers 5.
Boundary violation 6. Employer/faculty use of social media against employ- ees/students (p.
6) These ethical issues will be discussed further and resources will be provided to guide nurses.
Breach of Privacy or Confidentiality Against Patients HIPPA (USDHHS, 2003) and the Code of Ethics for Nurses (ANA, 2001) were discussed previously; however, another breach of confidentiality is possible that nurses may not recognize.
The patient has a right to disclose information about himself or herself, but this does not presume nurses have a right to disclose this private infor- mation to anyone via Internet without the patient's per- mission.
It is also improper for nurses to refer to patients by nickname, room number, diagnosis, or condition (Cronquist & Spector, 2011; Spector & Kappel, 2012).
Failure to Report Violations The National Council of State Boards of Nursing (NCSBN) (2011) provided an example of an inappropri- ately forwarded email, rather than protecting patient pri- vacy and reporting the incident to the nurse's supervisor.
Again the Code of Ethics for Nurses (ANA, 2001) offers guid- ance:
"Acquiescing and accepting unsafe or inappropriate practices, even if the individual does not participate in the specific practice, is equivalent to condoning unsafe practices" (p.
21). This interpretative statement charges nurses with an obligation to report concerns about the health care setting through the proper channels.
Lateral Violence Against Colleagues Negative online posts about co-workers affect the team environment. Such posts can be seen as bullying; when made via the web, they are referred to as cyber-bidlying (Spector & Kappel, 2012).
The Code of Ethics for Nurses (ANA, 2001) again provides direction concerning rela- tionships with colleagues and others:
The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues...The standard of conduct precludes any and all prejudicial actions, any form of harass- ment or threatening behavior, or disregard for the effect on one's actions on others, (p.
9) Communication Against Employers The National Labor Relations Board indicates workers have a right to discuss work conditions freely and with- out fear of retribution, whether the discussion takes place at the office or on Facebook (Greenhouse, 2013).
The board's rulings generally indicate it is illegal for compa- nies to adopt broad social media policies, such as bans on disrespectful comments or posts that criticize the employ- er, if those policies discourage workers from exercising their right to communicate with one another with the aim of improving wages, benefits, or working conditions.
MEDSURG September-October 2013 • Vol. 22/No.
5 327 Ethics, Law, and Policy Federal law has long protected the right of employees to discuss work-related matters. With social media, organiza- tional leaders must apply traditional rules to a new tech- nology. Because broad polices have been struck down, social media polices need to mimic other organizational communication polices (e.g., prohibiting inappropriate postings that may include discriminatory remarks, harassment, and threats of violence or similar inappropri- ate or unlawful conduct).
Boundary Violation Again an interpretive statement in the Code of Ethics for Nurses (ANA, 2001) offers guidance for nurses concerning professional boundaries: "When acting within one's role as a professional, the nurse recognizes and maintains boundaries that establish limits to relationships" (p. 11).
Nurses need to practice caution when having social con- tact with patients or former patients (Anderson & Puckrin, 2011).
"The Federation of State Medical Boards specifically discourages physicians from interacting with current or past patients on personal social websites such as Facebook" (Faman et al., 2013, p.
622). This prohibi- tion supports the nurse's ethical obligation to aviod blur- ring nurse-patient boundaries.
Employer/Faculty Use of Social Media Against Employees/Students Invasion of privacy or prevention of organizational lia- bility because of misuse of social media - which is it?
The National Conference of State Legislatures (NCSL, 2013a) presented information on employer access to social media usernames and passwords legislation. Beginning in 2012, state legislators introduced bills to prevent employ- ers from requesting passwords to personal Internet accounts - including email, banking, and social network- ing sites - in order to get or keep a job. Some states have similar legislation to protect students in public colleges and universities from having to grant access to their social networking accounts.
Six states (California, Delaware, Illinois, Maryland, Michigan, and New Jersey) enacted legislation in 2012 that prohibits requesting or requir- ing an employee, student, or applicant to reveal a user name or password for a personal social media ac- count. California, Illinois, Maryland, and Michigan laws apply to employers. California, Delaware, Michigan, and New Jersey have laws that apply to academic institu- tions.
In all, 14 states introduced legislation in 2012 to restrict employers from demanding access to social net- working usernames and passwords of applicants, stu- dents, or employees. Legislation has been introduced or is pending in at least 36 states.
In 2013, legislation has been enacted in seven states: Arkansas, Colorado, New Mexico, Oregon, Utah, Vermont, and Washington (NCSL, 2013b).
So far it appears legislators are focused on protecting pri- vacy of individuals.
However, some common misunderstandings lead indi- viduals to believe erasing information from a site destroys what was posted.
The truth is that once "something is posted, it exists on the server and can always be discover- able in the court of law" (Spector & Kappel, 2012, p. 9).
Nurses need to remember online postings may have future implications for their professional lives. The online behaviors nurses demonstrate may harm employability, result in limitations in professional advancement, and reflect poorly on the profession (Baer & Schwartz, 2011; Faman et al., 2013; Lui, 2013; Schmitt, Sims-Giddens, & Booth, 2012).
Guides for Social Media to Maintain Professionalism For nurses to navigate safely the world of social media, they need to follow some general principles. Both the ANA (2011) and NCSBN (2011) have provided assistance.
Some specific directions have been listed previously, but additional advice from these documents will be enumer- ated.
A white paper from NCSBN (2011) focused on issues of confidentiality and privacy, common myths and misun- derstandings of social media, and how to avoid problems.
It also provided illustrative cases. These seven cases are actual events reported to boards of nursing and describe inappropriate uses of social and electronic media. Nurses can learn a great deal from the analysis of each case and the overview of the outcomes.
One case illustrated a vio- lation of one principle, "Do not take photos or videos of patients on personal devices." Another principle is, "Do not refer to patients in a disparaging manner, even if the patient is not identified" (NCSBN, 2011, p. 3).
Baer and Schwartz (2011) gave an example from one of the cases they used to teach physicians about professionalism.
A resident had posted the following comment on Facebook as a status update: "Wasting my time seeing another worthless crackhead" (p. 308).
Though this is an egre- gious comment, I have heard equally offensive com- ments about patients with other mental health issues, single women with multiple pregnancies, and frequently seen patients in emergency rooms.
Six principles are outlined in the ANA Principles for Social Networking and the Nurse (2011). Kuhns (2012) pro- vided examples and further elaboration on these princi- ples, and her information also will be included at times with each principle that follows. Though some of the key points of these principles have been mentioned previous- ly, these principles will act as summary guidance.
Principle 1.
Nurses must not transmit or place online indi- vidually Identifiable patient information.
Nurses should not post any patient information, pictures, or possibly identi- fying data (following HIPAA polices), and never post any- thing associated with patients on personal networking pages.
This includes pictures from medical missions.
Principle 2.
Nurses must observe ethically prescribed pro- fessional patient-nurse boundaries.
Kuhns (2012) offered a question to clarify the concept of friend on Facebook.
"In absence of social media, would I maintain a friendship with this patient following discharge?" (p. 4). Boundaries should not be different online than in person.
Principle 3.
Nurses should understand patients, col- leagues, institutions, and employers may view postings.
Derogatory comments about any of these entities are a 328 September-October 2013 • Vol.
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5 MEDSURG Social Media: Managing the Ethical Issues reflection on the nurse, hut also on the profession of nursing. Posted insulting comments have haunted nurs- es in their careers or in their applications for further edu- cation (Spector & Kappel, 2012).
Principle 4. Nurses should take advantage of privacy set- tings and seek to separate personal and professional informa- tion online. I admit ignorance of privacy settings, but decided to check settings on two social networking sites and one blog to which I subscribe. On Facehook alone, I had to change two privacy settings to increase security.
One of these settings must have changed with system updates. Routinely checking the privacy settings is now something I do quarterly.
Principle 5. Nurses should bring content that could harm a patient's privacy, rights, or welfare to the attention of the appropriate authorities.
Provision 3.5 in the Code of Ethics for Nurses (Acting on questionable practice) addresses this ethical obligation (ANA, 2001). What most direct-care nurses do not understand is that their obligation to report a questionable practice does not stop with reporting to their supervisors. If a supervisor chooses to not act, nurs- es then have an obligation to report the problem to exter- nal authorities (Lachman, 2008a, 2008b).
Principle 6. Nurses should participate in developing insti- tutional polices governing online conduct Provision 6.2 in the Code of Ethics for Nurses (Influence of the environment on ethical obligations) (ANA, 2001) indicates nurses' obli- gations to create polices that support an ethical environ- ment. Using these ANA principles and information from NCSBN (2011), they could help the organization craft an effective social media policy.
Conclusion The growth of social media and networking options has been phenomenal. Nurses have the obligation to pro- tect patient privacy and confldentiality, as well as act in a professional manner in the public arena. The public's trust of nurses and the nursing profession could be dam- aged by derogatory comments about patients, colleagues, and health care organizations. Both ANA (2011) and NCSBN (2011) go to great lengths to provide nurses with guidance in navigating the world of social media.
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