Nurse Educator Vol. 40, No. 3, pp. 119-123 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
Unprofessional Content Posted Online Among Nursing Students Suzanne Marnocha, PhD, RN, CCRN & Mark R. Marnocha, PhD, MS & Tiffany Pilliow, BSN, RN This study investigated the posting of unprofessional content online among nursing students. Surveys of 293 schools of nursing revealed that 77% had encountered at least 1 incident of students posting such content. Respondents reported greatest concerns about content pertaining to educational and professional affiliations and to patient confidentiality. Most schools are developing responses to online unprofessionalism. Nursing education must stay current with social networking technologies and students’ educational needs. Keywords: ethics; incivility; internet; nursing students; social media
S
ocial media and networking use are increasing among people of all ages, backgrounds, and professions,1 with most frequent use among adults aged 18 years to 30 years.2 Social networking may prove to be a valuable learning tool, although such use is still underexplored.3 Social networking has the potential to enhance nursing students’ communication skills, professionalism, and grasp of policy and ethics in health care,4,5 while facilitating learners’ selfefficacy and engagement with peers.3 Although there may be benefits to the use of social networking in nursing education, such technologies have already created risks of highly visible unprofessionalism within diverse health care professions in addition to nursing, including medicine,6 pharmacy,7 and psychology.8 Such risks include verbal or pictorial violations of patient confidentiality and Health Insurance Portability and Accountability Act (HIPAA) standards; unprofessional online content pertaining to substance use and sexuality; demeaning content about patients, peers, educators, clinical sites, or the profession as a whole; discriminatory content; profanity; and aggressive/bullying content toward coworkers.9–13 Violations of HIPAA mandates have stringent legal penalties, and violations of patient confidentiality may have other significant consequences, including Author Affiliations: Assistant Dean and Prelicensure Program Director (Dr S. Marnocha), University of Wisconsin–Oshkosh, Clinical Psychologist and Associate Professor (Dr M. R. Marnocha), University of Wisconsin School of Medicine and Public Health, Fox Valley Family Medicine Residency Program, Appleton; Staff Nurse-Resident (Ms Pilliow), Zablocki Veteran’s Administration Medical Center, Milwaukee, Wisconsin. The authors declare no conflicts of interest. Correspondence: Dr S. Marnocha, University of Wisconsin–Oshkosh, 800 Algoma Blvd, Oshkosh, WI 54901 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: November 1, 2014 Published ahead of print: December 10, 2014 DOI: 10.1097/NNE.0000000000000123
Nurse Educator
students’ dismissal from clinical sites, expulsion from training programs, and practicing nurses’ loss of licensure.9,11 Clark and colleagues12,13 have developed overviews of advantages and risks within the online learning environment and take note of the potential impact of incivility and bullying. The rapid and widespread visibility of online postings, as well as their permanence on social networking sites, increases the potential for adverse outcomes. Despite the belief that social media are part of private life and distinct from public and professional identities,4,6,14,15 risky comments or online actions, such as friending patients, may have consequences not readily foreseen, and online postings may remain archived indefinitely.4,11,16 Because the personal-public boundary is so readily blurred by social media, educational programs, licensure boards, and professional associations have mobilized attention to social media standards. The American Nurses Association (ANA)17 and National Council of State Boards of Nursing (NCSBN)18 have developed guidelines to clarify patient privacy and confidentiality issues with social media. The ANA17 and the National Student Nurses Association4 have published ethical and behavioral standards specific to online and social media environments. The American College of Physicians and Federation of State Medical Boards19 online medical professionalism statement addresses ways in which online content may adversely affect public/patient trust of physicians. Despite these guidelines, uncertainties and risks remain.14,20,21 A majority of nursing and physician licensure boards report having addressed 1 or more complaints involving social media: 72% of state boards of nursing surveyed by NCSBN18 and 71% of state medical boards surveyed by Greysen et al.22 However, state medical boards’ responses to 10 online complaint vignettes demonstrated lack of consensus concerning the need for further investigation,23 and NCSBN18 indicated that outcomes of cases reported to boards of nursing will vary from jurisdiction to jurisdiction. Volume 40 & Number 3 & May/June 2015
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Recent nursing research on social media and education shows a mix of consensus and ambiguity among students and faculty. Frazier et al24 surveyed nursing students and faculty, with both groups in general agreement that ‘‘friending’’ patients and posting clinical experiences were unacceptable, but less certain whether postings were acceptable if there were no HIPAA violations. In their sample, 68% of students and 81% of faculty indicated they had seen unprofessional postings, and both groups indicated the value of social media policies; however, a significantly lower proportion of students than faculty felt their own program needed social media policies. Only 47% of faculty and 6% of students were aware of the NCSBN’s social media guide.4 Frazier et al24 emphasize the value of ethical and moral teaching that is developmentally accessible to students. Englund et al25 developed 21 online posting examples that were in violation of the ANA Code of Ethics, which were then rated for degree of ethical violation by samples of sophomore and senior nursing students. Englund et al concluded that online professionalism in nursing education requires further investigation and effort. Nursing educators’ online concerns parallel those noted in other health care fields, including pharmacy26 and medicine.27 Chretien et al27 found that 60% of 130 medical school deans reported student postings of unprofessional content, which was defined as violations of patient privacy, use of profanity or discriminatory language, depiction of intoxication or sexual suggestiveness, failure to reveal conflicts of interest, or communication in a negative tone about profession or patients. Only 38% of medical school deans27 reported specific policies covering student-posted online content. The current study draws upon Chretien and colleagues’27 work to survey deans and their proxies of US schools of nursing. The study is intended to assess presence, intensity, and content areas of cyberprofessionalism incidents among nursing students and to gain general information about institutional responses to such issues and incidents.
Methods With permissions of the author and the copyright holder, Chretien and colleagues’27 survey instrument was adapted for use in this study with deans and directors of schools with accredited associate and/or bachelor’s degree nursing programs. The survey was distributed in 2 waves to 1107 deans and directors of nursing programs within the United States via an e-mail that contained an anonymous and confidential link to a Web-based Qualtrics survey administered by the first author’s institution. Approval as an exempt study was granted by the authors’ institutional review boards. The survey requested quantitative data concerning school and respondent characteristics, incidents of student-posted unprofessional content online, level of respondents’ concern about such incidents, and institutional policies and responses. Narrative content was obtained via open-ended responses to 2 questions requesting examples of incidents at one’s own school and at another school. Other questions requested examples of other sources reporting unprofessional content, other resources used for cyberprofessionalism committees, and other disciplinary actions taken. Quantitative responses were analyzed using SPSS 11.5 (SPSS, Inc, Chicago, Illinois). Qualitative responses were analyzed for keywords and placed into content categories, which were reviewed for consensus by all authors. 120
Respondent Characteristics There was a 26% response rate, with 293 schools completing the survey. Respondents’ schools most frequently offered AD or BSN training (65% and 27%, respectively), in community/ rural settings (56%), with incoming class sizes less than 120 (76%). Respondents were 96% female, most between 51 and 60 years of age (55%). Their daily use of computers or other electronic devices was most frequent for communication, such as e-mails (98%) and Web surfing (63%), but less so for social networking, such as Facebook (26%). The majority of respondents (70%) estimated three-quarters or more of their students posted online. Most respondents’ schools (67%) used social networking (including blogs, wikis) as part of educational programs. Detailed results are available as a Table, Supplemental Digital Content 1, http://links.lww.com/NE/A193.
Findings Quantitative Responses Of the 293 respondents, 225 (77%) were aware of incidents of unprofessional content posted online by nursing students in their schools, and 46% were aware of such incidents involving nursing students at other schools (Table 1). Among respondents reporting incidents in the past year, the most frequently occurring types were negative comments about patients, peers, their work environment, or the nursing profession (58%); profanity (37%); patient confidentiality (31%); and discriminatory language (29%). Depicted intoxication and sexually suggestive incidents were each reported by less than 20% of respondents. The number of incidents in the past year for each of the specific content areas was predominantly either ‘‘uncertain’’ or less than 5. The respondents’ levels of concern about the posting of unprofessional content online were assessed using a 5-point Likert scale. Ratings of 4 or 5 were considered a high level of concern, a rating of 3 a moderate level of concern, and a rating of 1 or 2 a low level of concern. Overall concern was high for 59% of respondents, with a mean of 3.82. Less than 9% of programs reported a low level of concern about such content. Greatest specific concerns were for unprofessional postings concerning professional affiliation, program affiliation, or patient confidentiality, all with means greater than 4. These areas were assigned a high level of concern by at least two-thirds of respondents. Approximately one-half of respondents reported high levels of concern about discriminatory language, profanity, sexually suggestive content, and depicted intoxication. Detailed results are available as a Table, Supplemental Digital Content 2, http://links.lww.com/NE/A194. Compared with respondents who were not aware of unprofessional postings, those with awareness were significantly more concerned overall, as well as more concerned about postings pertaining to professional and school affiliations (2-tailed independent samples t tests, P G .05). Respondents were asked if their school’s professionalism policies covered content posted online by students and if the policies specifically addressed blogs and social networking sites. The majority of respondents (70%) reported that their policies covered student-posted content online, and among those, 89% of their policies specifically addressed blogs and social networking sites. Some respondents (35%) reported an inability to deal effectively with unprofessional student postings,
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Table 1. Unprofessional Online Content Observations and Policies Question Are you aware of any incidents at your school in which your students have posted unprofessional content online? (n = 293) Did any incidents in the past year involve content in the following areas? Negative comments about patients, peers, work, or professiona (n = 111) Profanity (n = 225) Patient confidentiality (n = 225) Discriminatory language (n = 225) Depicted intoxication (n = 225) Sexually suggestive (n = 225) Do your school’s current professionalism policies cover student-posted online content? (n = 292) Does your school’s policy specifically address issues of Internet use such as blogs and social networking sites? (n = 204) Given your existing policies, do you feel you are able to effectively deal with unprofessional student-posted online content? (n = 288) Is there a committee or task force at your school that is responsible for addressing student-posted unprofessional content online? (n = 289) Are your aware of any incidents at other schools in which nursing students posted unprofessional content online? (n = 290) a
Yes, n (%)
No or Not Sure, n (%)
225 (77)
68 (23)
64 (58) 95 (37) 69 (31) 84 (29) 41 (18) 39 (17) 204 (70) 181 (89)
47 (42) 130 (63) 156 (69) 141 (71) 184 (82) 186 (83) 88 (30) 23 (11)
186 (65)
102 (35)
106 (37)
183 (63)
132 (46)
158 (54)
Item added to second wave of surveys.
although most respondents (78%) with policies covering online content felt they were effective in dealing with postings. Only 21% of respondents indicated they were not revising or developing such policies. Committees or task forces responsible for addressing students’ online professionalism were reported by 106 respondents (37%). Those committees or task forces were noted to include both nursing and institutional resources. Respondents’ programs learned of online unprofessionalism incidents most frequently via reports from students (72%), faculty (49%), nonfaculty staff (12%), or other (17%). More infrequent (G8%) sources included employer or clinical site; online observations, such as Facebook, blog, or class discussion; anonymous sources; or patient or patient family member (Table 2). Most respondents (55%) received reports from just 1 of these sources. Respondents aware of online unprofessionalism reported their most frequent response to be an informal warning, written or verbal (58%), whereas 31% reported formal disciplinary meetings. Dismissal was noted by 11% of respondents, whereas 18% indicated other disciplinary actions. Text responses describing other measures were examined, and 40 distinct disciplinary actions were identified and fell into 1 of 6 content areas: formal meeting or administrative actions (28%), remedial assignments (20%), academic penalties (18%), institutional changes (18%), academic failure (10%), and termination/withdrawal (8%). Formal meetings or administrative actions included meetings involving an honor council, student services, instructors, deans, and/or the students involved; other aspects of due process; and actions such as written warnings, mandatory removal of offending content, referral for drug testing/counseling, and formal documentation placed in student file. Remedial assignments were diverse, including special projects, community service, presentations to college or to fellow students concerning social media and professionalism, or mandatory attendance of sessions on topics such as HIPAA and social media. Academic penalties included probation, delayed graduation, exclusion from pinning ceremony, and warnings. Failures Nurse Educator
were within clinicals, entire courses, or specific grades in professional behaviors.
Qualitative Responses Open-ended narrative content was requested for 2 items: an example of any incident of unprofessional online postings at (a) the respondents’ nursing program and (b) another school. Multiple events within a single response were categorized as separate incidents. Examples of unprofessional postings in respondents’ own schools were provided by 184 programs (63%), yielding 203 incidents. Incidents were categorized into 6 general content themes: Table 2. Reporting and Disciplinary Actions Survey Items and Response Categories How did unprofessional student-posted online content come to your attention? (n = 225) Reported by students Reported by faculty Reported by nonfaculty staff Reported by employer or clinical site Online observation (eg, Facebook, blog, online class) Anonymous Reported by patient or patient family member Other (narrative examples coded and included in above categories) What disciplinary actions have been taken at your school because of unprofessional student-posted online content? (n = 225) Informal warning (verbal or written) Formal disciplinary meeting No action taken Dismissal Temporary suspension Don’t know Other
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n (%)
161 (72) 111 (49) 26 (12) 15 (7) 11 (5) 7 (3) 2 (1) 38 (17)
131 (58) 70 (31) 27 (12) 25 (11) 3 (1) 18 (8) 40 (18)
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1. Affiliation with school or clinical site (41%). Incidents included students posting negative and inappropriate comments about faculty and teaching staff, the nursing program, the institution, or specific clinical rotation sites or staff. Several students posed inappropriately on Web sites in clothing that contained the school’s logo. One respondent described an incident in which a student created a Web site that contained the college’s logo and was falsely portrayed as an official college Web site. 2. Threats to patient confidentiality (19%). Postings involved photographs of patients or photographs of patient information posted on students’ social networking sites. Other examples involved students posting comments or writing blogs online that described patient interactions or contained patient identifying information. 3. Derogatory or unprofessional language (15%). Content included online cheating; allegations toward peers; language derogatory toward aspects of ethnicity, religion, gender, race, or other personal characteristics; misuse of secure computers; and other nonspecific mentions of unprofessional language online. 4. Cyberbullying (11%). Content included students threatening peers on social networking sites; posting negative or demeaning comments about classmates; or posting online content that involved teasing, profanity, or other demeaning language toward peers. One example described an incident in which 2 students exchanged words with one another on a social media site, and the dispute continued into a classroom disruption the next day. 5. Depiction of intoxication or substance use (8%). Incidents pertained to substance use, including photographs portraying intoxication and the use of drugs or alcohol. 6. Sexually suggestive content (5%). Such postings were sexually suggestive, including students posing in sexual poses, students dressed in minimal clothing, photographs of sexual organs, and comments that were sexual in nature. The overall content themes appear comparable to the content described among medical student incidents in Chretien and colleagues’27 survey, with the exception of cyberbullying. The content of incidents at other nursing schools described by respondents (102 responses) fell into the same 6 themes.
Discussion The majority of nursing school deans surveyed were aware of students posting unprofessional content online and at a higher rate than found in studies conducted among medical and pharmacy schools.26,27 This could reflect differences among disciplines or could reflect a trend toward increased occurrence and/or awareness of such incidents among health care education programs. More than 91% of respondents in the current study rated their concern about such postings as at least ‘‘moderate.’’ The most commonly reported incidents were those pertaining to profanity or discriminatory language, followed by those pertaining to professionalism. Content pertaining to sexuality or intoxication was reported least frequently 122
and generated less concern, whereas content of greatest concern pertained to affiliations with profession or with one’s school and patient confidentiality. This suggests that respondents’ greatest concerns are not with students’ immaturity, but rather with students’ professional identities, including patient confidentiality and civility. The greatest number of incidents had been reported by students, followed by faculty, suggesting that nursing students have both awareness and concern about professionalism and are applying the principles and policies in place. However, Englund et al25 found that students do not fully understand the ethical standards that guide decisions about what is appropriate or not appropriate to post online. Nursing students may welcome more intense guidance and curriculum pertaining to social networking,25 as has been noted among other health profession students.6,7,15 Online incident reports by nonfaculty staff and employer/ clinical sites totaled less than 20% of all such reports, and it may be that nursing programs and students are catching most professionalism issues prior to more widespread impact. It could also be that online professionalism issues are not yet detected or reported as frequently outside nursing education settings. More than two-thirds of respondents indicated use of social networking as part of the educational program, and this may be essential for cyberprofessional mentoring and students’ professional identity formation. The majority of programs have policies that cover students’ online content postings, and most of those programs’ policies are specific to blogs and social networking. Thus, well over half of all respondents have policies in place specific to cyberprofessionalism, although more than one-third of all respondents felt that existing policies were not adequate. Those who reported policies specific to online content felt far more effective dealing with online postings than did programs that did not report such policies. It appears that students are aware of professionalism issues and that programs with policies specific to the online realm feel more effective dealing with issues that students or faculty may report. Programs’ descriptions of other responses to online unprofessionalism included revision of policies and education concerning social media. Increasing experience with online unprofessionalism will likely prompt development of policy that guides due process, from the most common measure of ‘‘informal warning’’ through disciplinary meetings, remediation, or penalties, and more infrequently on to failure, suspension, or dismissal. However, a majority of programs either did not have or were unaware of any institutional group or committee responsible for addressing online professionalism. Such groups’ professional and academic resources may be essential for the large proportion of respondents with cyberprofessionalism policies under review or development. A significant finding was the presence of cyberbullying occurring against both faculty and peers, and this theme was not identified specifically by Chretien and colleagues’27 survey. The greater evidence of cyberbullying and derogatory or unprofessional language themes in the current research may reflect the emerging concerns about cyberbullying in diverse educational settings.12,13,28,29 A number of respondents’ examples in this study involved students posting negative comments about professors and/or their nursing program in retaliation
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for receiving what they felt was an unsatisfactory grade. Such comments may represent cyberbullying, but also may illustrate the growing trend of incivility within nursing education and practice. Some unprofessional and derogatory language may reflect poorly upon the posting student, the profession, or the school; however, if viewed more widely online, that same language may well be perceived as bullying, harassment, or slander by peers whose characteristics are maligned and could cross into domains of civil or criminal offense.
Limitations The study is limited by several factors, including response rate and sampling bias. Those already having experienced cyberprofessionalism incidents may have self-selected to respond based on the title of the online survey, and thus, the numbers and apparent frequency of such incidents may have been artificially inflated. Alternatively, program leadership most aware of such issues may not have received and completed the survey. The dynamic and evolving nature of online resources (eg, Twitter, Snapchat) and behaviors may limit the validity of social media research.
Conclusion Cyberprofessionalism is an important concern for nursing professionals and educators, and it appears that unprofessional online behavior among nursing students is prevalent. Educational institutions need to be proactive by implementing social media policies and ensuring effective and timely handling of student-posted unprofessional content. Faculty and students need to be educated on how to report and address incidents of cyberbullying. Students also need to be educated on ethical and professional standards that must be maintained in both clinical and nonclinical settings. This area of the nursing profession will likely grow in importance and complexity and will require attention and innovation
References 1. Lenhart A, Purcell K, Smith A, Zichuhr K. Social media and young adults. Pew Research Internet Project Web site. Updated February 3, 2010. Available at http://www.pewinternet.org/Reports/ 2010/Social-Media-and-Young-Adults.aspx. Accessed November 21, 2014. 2. The demographics of social media users—2012. Pew Research Center. Published February 14, 2013. Available at http://www .pewinternet.org/Reports/2013/Social-media-users.aspx. Accessed November 21, 2014. 3. Tower M, Latimer S, Hewitt J. Social networking as a learning tool: nursing students’ perception of efficacy. Nurs Educ Today. 2013;34(6):1012-1017. 4. National Student Nurse Association. Social media usage and maintaining privacy, confidentiality, and professionalism. Available at http://www.nsna.org/Portals/0/Skins/NSNA/pdf/NSNA_Social_ Media_Recommendations.pdf. Accessed November 21, 2014. 5. Wink MD. Social networking sites. Nurse Educ. 2010;35(2):49-51. 6. Chretien KC, Goldman EF, Beckman L, Kind T. It’s your own risk: medical students’ perspectives on online professionalism. Acad Med. 2010;85(10):S68-S71.
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7. Cain J, Scott DR, Akers P. Pharmacy students’ Facebook activity and opinions regarding accountability and e-professionalism. Am J Pharm Educ. 2009;73(6):1-5. 8. Weed D, Kincheloe M, Lack C. Psychotherapy trainees and social networking use. Poster session presented at the Annual Meeting of the Southwestern Psychological Association; 2010; Dallas, TX. 9. Melnik T. Avoiding violations of patient privacy with social media. J Nurs Regul. 2013;3(4):39-44. 10. National Crime Prevention Council. Cyberbullying. Published 2010. Available at http://www.ncpc.org/topics/cyberbullying. Accessed November 21, 2014. 11. Spector N, Kappel DM. Guidelines for using electronic and social media: the regulatory perspective. Online J Issues Nurs. 2012;17(3):1. 12. Clark CM, Werth L, Ahten S. Cyber-bullying and incivility in the online learning environment, part 1: addressing faculty and student perceptions. Nurs Educ. 2012;37(4):150-156. 13. Clark CM, Ahten S, Werth L. Cyber-bullying and incivility in the online learning environment, part 2: promoting student success in the virtual classroom. Nurs Educ. 2012;37(5):192-197. 14. DeCamp M. Social media and medical professionalism. Arch Intern Med. 2012;172(18):1418-1419. 15. Finn G, Garner J, Sawdon M. You’re judged all the time! Students’ views on professionalism: a multicentre study. Med Educ. 2010;44(8):814-825. 16. Holland HB. Privacy paradox 2.0. Widener Law Journal. Published April 4, 2010. Available at http://papers.ssrn.com/sol3/ papers.cfm?abstract_id=1584443. Accessed November 21, 2014. 17. American Nurses Association. Principles for Social Networking and the Nurse. Silver Spring, MD: ANA; 2011. 18. National Council of State Boards of Nursing. White paper: a nurse’s guide to the use of social media. Published August 2011. Available at https://www.ncsbn.org/Social_Media.pdf. Accessed November 21, 2014. 19. Farnan J, Sulmasy LS, Worster B, Chaudhry H, Rhyne J, Arora V. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8): 620-627. 20. Lerner B. Policing online professionalism: are we too alarmist?. JAMA Intern Med. 2013;173(19):1767-1768. 21. Simpson R. Social media creates significant risks for nursing. Nurs Inform. 2014;38(1):96-98. 22. Greysen SR, Chretien KC, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;307(11):1141-1142. 23. Greysen SR, Johnson D, Kind T, et al. Online professionalism investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;158(2):124-130. 24. Frazier B, Culley J, Hein L, Williams A, Tavakoli A. Social networking policies in nursing education. Comput Inform Nurs. 2014;32(3):110-117. 25. Englund H, Chappy S, Jambunathan J, Gohdes E. Ethical reasoning and online social media. Nurs Educ. 2012;37(6):242-247. 26. Kjos AL, Ricci DG. Pharmacy student professionalism and the internet. Curr Pharm Teach Learn. 2012;4(2):92-101. 27. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009;302(12): 1309-1315. 28. Skiba DJ. Nursing education 2.0: the need for social media policies for schools of nursing. Nurs Educ Perspect. 2011;32(2):126-127. 29. Minor MA, Smith GS, Brashen H. Cyberbullying in higher education. J Educ Res Pract. 2013;3(1):15-29.
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Unprofessional Content Posted Online Among Nursing Students Suzanne Marnocha, PhD, RN, CCRN & Mark R. Marnocha, PhD, MS & Tiffany Pilliow, BSN, RN This study investigated the posting of unprofessional content online among nursing students. Surveys of 293 schools of nursing revealed that 77% had encountered at least 1 incident of students posting such content. Respondents reported greatest concerns about content pertaining to educational and professional affiliations and to patient confidentiality. Most schools are developing responses to online unprofessionalism. Nursing education must stay current with social networking technologies and students’ educational needs. Keywords: ethics; incivility; internet; nursing students; social media
S
ocial media and networking use are increasing among people of all ages, backgrounds, and professions,1 with most frequent use among adults aged 18 years to 30 years.2 Social networking may prove to be a valuable learning tool, although such use is still underexplored.3 Social networking has the potential to enhance nursing students’ communication skills, professionalism, and grasp of policy and ethics in health care,4,5 while facilitating learners’ selfefficacy and engagement with peers.3 Although there may be benefits to the use of social networking in nursing education, such technologies have already created risks of highly visible unprofessionalism within diverse health care professions in addition to nursing, including medicine,6 pharmacy,7 and psychology.8 Such risks include verbal or pictorial violations of patient confidentiality and Health Insurance Portability and Accountability Act (HIPAA) standards; unprofessional online content pertaining to substance use and sexuality; demeaning content about patients, peers, educators, clinical sites, or the profession as a whole; discriminatory content; profanity; and aggressive/bullying content toward coworkers.9–13 Violations of HIPAA mandates have stringent legal penalties, and violations of patient confidentiality may have other significant consequences, including Author Affiliations: Assistant Dean and Prelicensure Program Director (Dr S. Marnocha), University of Wisconsin–Oshkosh, Clinical Psychologist and Associate Professor (Dr M. R. Marnocha), University of Wisconsin School of Medicine and Public Health, Fox Valley Family Medicine Residency Program, Appleton; Staff Nurse-Resident (Ms Pilliow), Zablocki Veteran’s Administration Medical Center, Milwaukee, Wisconsin. The authors declare no conflicts of interest. Correspondence: Dr S. Marnocha, University of Wisconsin–Oshkosh, 800 Algoma Blvd, Oshkosh, WI 54901 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: November 1, 2014 Published ahead of print: December 10, 2014 DOI: 10.1097/NNE.0000000000000123
Nurse Educator
students’ dismissal from clinical sites, expulsion from training programs, and practicing nurses’ loss of licensure.9,11 Clark and colleagues12,13 have developed overviews of advantages and risks within the online learning environment and take note of the potential impact of incivility and bullying. The rapid and widespread visibility of online postings, as well as their permanence on social networking sites, increases the potential for adverse outcomes. Despite the belief that social media are part of private life and distinct from public and professional identities,4,6,14,15 risky comments or online actions, such as friending patients, may have consequences not readily foreseen, and online postings may remain archived indefinitely.4,11,16 Because the personal-public boundary is so readily blurred by social media, educational programs, licensure boards, and professional associations have mobilized attention to social media standards. The American Nurses Association (ANA)17 and National Council of State Boards of Nursing (NCSBN)18 have developed guidelines to clarify patient privacy and confidentiality issues with social media. The ANA17 and the National Student Nurses Association4 have published ethical and behavioral standards specific to online and social media environments. The American College of Physicians and Federation of State Medical Boards19 online medical professionalism statement addresses ways in which online content may adversely affect public/patient trust of physicians. Despite these guidelines, uncertainties and risks remain.14,20,21 A majority of nursing and physician licensure boards report having addressed 1 or more complaints involving social media: 72% of state boards of nursing surveyed by NCSBN18 and 71% of state medical boards surveyed by Greysen et al.22 However, state medical boards’ responses to 10 online complaint vignettes demonstrated lack of consensus concerning the need for further investigation,23 and NCSBN18 indicated that outcomes of cases reported to boards of nursing will vary from jurisdiction to jurisdiction. Volume 40 & Number 3 & May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
119
Recent nursing research on social media and education shows a mix of consensus and ambiguity among students and faculty. Frazier et al24 surveyed nursing students and faculty, with both groups in general agreement that ‘‘friending’’ patients and posting clinical experiences were unacceptable, but less certain whether postings were acceptable if there were no HIPAA violations. In their sample, 68% of students and 81% of faculty indicated they had seen unprofessional postings, and both groups indicated the value of social media policies; however, a significantly lower proportion of students than faculty felt their own program needed social media policies. Only 47% of faculty and 6% of students were aware of the NCSBN’s social media guide.4 Frazier et al24 emphasize the value of ethical and moral teaching that is developmentally accessible to students. Englund et al25 developed 21 online posting examples that were in violation of the ANA Code of Ethics, which were then rated for degree of ethical violation by samples of sophomore and senior nursing students. Englund et al concluded that online professionalism in nursing education requires further investigation and effort. Nursing educators’ online concerns parallel those noted in other health care fields, including pharmacy26 and medicine.27 Chretien et al27 found that 60% of 130 medical school deans reported student postings of unprofessional content, which was defined as violations of patient privacy, use of profanity or discriminatory language, depiction of intoxication or sexual suggestiveness, failure to reveal conflicts of interest, or communication in a negative tone about profession or patients. Only 38% of medical school deans27 reported specific policies covering student-posted online content. The current study draws upon Chretien and colleagues’27 work to survey deans and their proxies of US schools of nursing. The study is intended to assess presence, intensity, and content areas of cyberprofessionalism incidents among nursing students and to gain general information about institutional responses to such issues and incidents.
Methods With permissions of the author and the copyright holder, Chretien and colleagues’27 survey instrument was adapted for use in this study with deans and directors of schools with accredited associate and/or bachelor’s degree nursing programs. The survey was distributed in 2 waves to 1107 deans and directors of nursing programs within the United States via an e-mail that contained an anonymous and confidential link to a Web-based Qualtrics survey administered by the first author’s institution. Approval as an exempt study was granted by the authors’ institutional review boards. The survey requested quantitative data concerning school and respondent characteristics, incidents of student-posted unprofessional content online, level of respondents’ concern about such incidents, and institutional policies and responses. Narrative content was obtained via open-ended responses to 2 questions requesting examples of incidents at one’s own school and at another school. Other questions requested examples of other sources reporting unprofessional content, other resources used for cyberprofessionalism committees, and other disciplinary actions taken. Quantitative responses were analyzed using SPSS 11.5 (SPSS, Inc, Chicago, Illinois). Qualitative responses were analyzed for keywords and placed into content categories, which were reviewed for consensus by all authors. 120
Respondent Characteristics There was a 26% response rate, with 293 schools completing the survey. Respondents’ schools most frequently offered AD or BSN training (65% and 27%, respectively), in community/ rural settings (56%), with incoming class sizes less than 120 (76%). Respondents were 96% female, most between 51 and 60 years of age (55%). Their daily use of computers or other electronic devices was most frequent for communication, such as e-mails (98%) and Web surfing (63%), but less so for social networking, such as Facebook (26%). The majority of respondents (70%) estimated three-quarters or more of their students posted online. Most respondents’ schools (67%) used social networking (including blogs, wikis) as part of educational programs. Detailed results are available as a Table, Supplemental Digital Content 1, http://links.lww.com/NE/A193.
Findings Quantitative Responses Of the 293 respondents, 225 (77%) were aware of incidents of unprofessional content posted online by nursing students in their schools, and 46% were aware of such incidents involving nursing students at other schools (Table 1). Among respondents reporting incidents in the past year, the most frequently occurring types were negative comments about patients, peers, their work environment, or the nursing profession (58%); profanity (37%); patient confidentiality (31%); and discriminatory language (29%). Depicted intoxication and sexually suggestive incidents were each reported by less than 20% of respondents. The number of incidents in the past year for each of the specific content areas was predominantly either ‘‘uncertain’’ or less than 5. The respondents’ levels of concern about the posting of unprofessional content online were assessed using a 5-point Likert scale. Ratings of 4 or 5 were considered a high level of concern, a rating of 3 a moderate level of concern, and a rating of 1 or 2 a low level of concern. Overall concern was high for 59% of respondents, with a mean of 3.82. Less than 9% of programs reported a low level of concern about such content. Greatest specific concerns were for unprofessional postings concerning professional affiliation, program affiliation, or patient confidentiality, all with means greater than 4. These areas were assigned a high level of concern by at least two-thirds of respondents. Approximately one-half of respondents reported high levels of concern about discriminatory language, profanity, sexually suggestive content, and depicted intoxication. Detailed results are available as a Table, Supplemental Digital Content 2, http://links.lww.com/NE/A194. Compared with respondents who were not aware of unprofessional postings, those with awareness were significantly more concerned overall, as well as more concerned about postings pertaining to professional and school affiliations (2-tailed independent samples t tests, P G .05). Respondents were asked if their school’s professionalism policies covered content posted online by students and if the policies specifically addressed blogs and social networking sites. The majority of respondents (70%) reported that their policies covered student-posted content online, and among those, 89% of their policies specifically addressed blogs and social networking sites. Some respondents (35%) reported an inability to deal effectively with unprofessional student postings,
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Table 1. Unprofessional Online Content Observations and Policies Question Are you aware of any incidents at your school in which your students have posted unprofessional content online? (n = 293) Did any incidents in the past year involve content in the following areas? Negative comments about patients, peers, work, or professiona (n = 111) Profanity (n = 225) Patient confidentiality (n = 225) Discriminatory language (n = 225) Depicted intoxication (n = 225) Sexually suggestive (n = 225) Do your school’s current professionalism policies cover student-posted online content? (n = 292) Does your school’s policy specifically address issues of Internet use such as blogs and social networking sites? (n = 204) Given your existing policies, do you feel you are able to effectively deal with unprofessional student-posted online content? (n = 288) Is there a committee or task force at your school that is responsible for addressing student-posted unprofessional content online? (n = 289) Are your aware of any incidents at other schools in which nursing students posted unprofessional content online? (n = 290) a
Yes, n (%)
No or Not Sure, n (%)
225 (77)
68 (23)
64 (58) 95 (37) 69 (31) 84 (29) 41 (18) 39 (17) 204 (70) 181 (89)
47 (42) 130 (63) 156 (69) 141 (71) 184 (82) 186 (83) 88 (30) 23 (11)
186 (65)
102 (35)
106 (37)
183 (63)
132 (46)
158 (54)
Item added to second wave of surveys.
although most respondents (78%) with policies covering online content felt they were effective in dealing with postings. Only 21% of respondents indicated they were not revising or developing such policies. Committees or task forces responsible for addressing students’ online professionalism were reported by 106 respondents (37%). Those committees or task forces were noted to include both nursing and institutional resources. Respondents’ programs learned of online unprofessionalism incidents most frequently via reports from students (72%), faculty (49%), nonfaculty staff (12%), or other (17%). More infrequent (G8%) sources included employer or clinical site; online observations, such as Facebook, blog, or class discussion; anonymous sources; or patient or patient family member (Table 2). Most respondents (55%) received reports from just 1 of these sources. Respondents aware of online unprofessionalism reported their most frequent response to be an informal warning, written or verbal (58%), whereas 31% reported formal disciplinary meetings. Dismissal was noted by 11% of respondents, whereas 18% indicated other disciplinary actions. Text responses describing other measures were examined, and 40 distinct disciplinary actions were identified and fell into 1 of 6 content areas: formal meeting or administrative actions (28%), remedial assignments (20%), academic penalties (18%), institutional changes (18%), academic failure (10%), and termination/withdrawal (8%). Formal meetings or administrative actions included meetings involving an honor council, student services, instructors, deans, and/or the students involved; other aspects of due process; and actions such as written warnings, mandatory removal of offending content, referral for drug testing/counseling, and formal documentation placed in student file. Remedial assignments were diverse, including special projects, community service, presentations to college or to fellow students concerning social media and professionalism, or mandatory attendance of sessions on topics such as HIPAA and social media. Academic penalties included probation, delayed graduation, exclusion from pinning ceremony, and warnings. Failures Nurse Educator
were within clinicals, entire courses, or specific grades in professional behaviors.
Qualitative Responses Open-ended narrative content was requested for 2 items: an example of any incident of unprofessional online postings at (a) the respondents’ nursing program and (b) another school. Multiple events within a single response were categorized as separate incidents. Examples of unprofessional postings in respondents’ own schools were provided by 184 programs (63%), yielding 203 incidents. Incidents were categorized into 6 general content themes: Table 2. Reporting and Disciplinary Actions Survey Items and Response Categories How did unprofessional student-posted online content come to your attention? (n = 225) Reported by students Reported by faculty Reported by nonfaculty staff Reported by employer or clinical site Online observation (eg, Facebook, blog, online class) Anonymous Reported by patient or patient family member Other (narrative examples coded and included in above categories) What disciplinary actions have been taken at your school because of unprofessional student-posted online content? (n = 225) Informal warning (verbal or written) Formal disciplinary meeting No action taken Dismissal Temporary suspension Don’t know Other
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n (%)
161 (72) 111 (49) 26 (12) 15 (7) 11 (5) 7 (3) 2 (1) 38 (17)
131 (58) 70 (31) 27 (12) 25 (11) 3 (1) 18 (8) 40 (18)
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1. Affiliation with school or clinical site (41%). Incidents included students posting negative and inappropriate comments about faculty and teaching staff, the nursing program, the institution, or specific clinical rotation sites or staff. Several students posed inappropriately on Web sites in clothing that contained the school’s logo. One respondent described an incident in which a student created a Web site that contained the college’s logo and was falsely portrayed as an official college Web site. 2. Threats to patient confidentiality (19%). Postings involved photographs of patients or photographs of patient information posted on students’ social networking sites. Other examples involved students posting comments or writing blogs online that described patient interactions or contained patient identifying information. 3. Derogatory or unprofessional language (15%). Content included online cheating; allegations toward peers; language derogatory toward aspects of ethnicity, religion, gender, race, or other personal characteristics; misuse of secure computers; and other nonspecific mentions of unprofessional language online. 4. Cyberbullying (11%). Content included students threatening peers on social networking sites; posting negative or demeaning comments about classmates; or posting online content that involved teasing, profanity, or other demeaning language toward peers. One example described an incident in which 2 students exchanged words with one another on a social media site, and the dispute continued into a classroom disruption the next day. 5. Depiction of intoxication or substance use (8%). Incidents pertained to substance use, including photographs portraying intoxication and the use of drugs or alcohol. 6. Sexually suggestive content (5%). Such postings were sexually suggestive, including students posing in sexual poses, students dressed in minimal clothing, photographs of sexual organs, and comments that were sexual in nature. The overall content themes appear comparable to the content described among medical student incidents in Chretien and colleagues’27 survey, with the exception of cyberbullying. The content of incidents at other nursing schools described by respondents (102 responses) fell into the same 6 themes.
Discussion The majority of nursing school deans surveyed were aware of students posting unprofessional content online and at a higher rate than found in studies conducted among medical and pharmacy schools.26,27 This could reflect differences among disciplines or could reflect a trend toward increased occurrence and/or awareness of such incidents among health care education programs. More than 91% of respondents in the current study rated their concern about such postings as at least ‘‘moderate.’’ The most commonly reported incidents were those pertaining to profanity or discriminatory language, followed by those pertaining to professionalism. Content pertaining to sexuality or intoxication was reported least frequently 122
and generated less concern, whereas content of greatest concern pertained to affiliations with profession or with one’s school and patient confidentiality. This suggests that respondents’ greatest concerns are not with students’ immaturity, but rather with students’ professional identities, including patient confidentiality and civility. The greatest number of incidents had been reported by students, followed by faculty, suggesting that nursing students have both awareness and concern about professionalism and are applying the principles and policies in place. However, Englund et al25 found that students do not fully understand the ethical standards that guide decisions about what is appropriate or not appropriate to post online. Nursing students may welcome more intense guidance and curriculum pertaining to social networking,25 as has been noted among other health profession students.6,7,15 Online incident reports by nonfaculty staff and employer/ clinical sites totaled less than 20% of all such reports, and it may be that nursing programs and students are catching most professionalism issues prior to more widespread impact. It could also be that online professionalism issues are not yet detected or reported as frequently outside nursing education settings. More than two-thirds of respondents indicated use of social networking as part of the educational program, and this may be essential for cyberprofessional mentoring and students’ professional identity formation. The majority of programs have policies that cover students’ online content postings, and most of those programs’ policies are specific to blogs and social networking. Thus, well over half of all respondents have policies in place specific to cyberprofessionalism, although more than one-third of all respondents felt that existing policies were not adequate. Those who reported policies specific to online content felt far more effective dealing with online postings than did programs that did not report such policies. It appears that students are aware of professionalism issues and that programs with policies specific to the online realm feel more effective dealing with issues that students or faculty may report. Programs’ descriptions of other responses to online unprofessionalism included revision of policies and education concerning social media. Increasing experience with online unprofessionalism will likely prompt development of policy that guides due process, from the most common measure of ‘‘informal warning’’ through disciplinary meetings, remediation, or penalties, and more infrequently on to failure, suspension, or dismissal. However, a majority of programs either did not have or were unaware of any institutional group or committee responsible for addressing online professionalism. Such groups’ professional and academic resources may be essential for the large proportion of respondents with cyberprofessionalism policies under review or development. A significant finding was the presence of cyberbullying occurring against both faculty and peers, and this theme was not identified specifically by Chretien and colleagues’27 survey. The greater evidence of cyberbullying and derogatory or unprofessional language themes in the current research may reflect the emerging concerns about cyberbullying in diverse educational settings.12,13,28,29 A number of respondents’ examples in this study involved students posting negative comments about professors and/or their nursing program in retaliation
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for receiving what they felt was an unsatisfactory grade. Such comments may represent cyberbullying, but also may illustrate the growing trend of incivility within nursing education and practice. Some unprofessional and derogatory language may reflect poorly upon the posting student, the profession, or the school; however, if viewed more widely online, that same language may well be perceived as bullying, harassment, or slander by peers whose characteristics are maligned and could cross into domains of civil or criminal offense.
Limitations The study is limited by several factors, including response rate and sampling bias. Those already having experienced cyberprofessionalism incidents may have self-selected to respond based on the title of the online survey, and thus, the numbers and apparent frequency of such incidents may have been artificially inflated. Alternatively, program leadership most aware of such issues may not have received and completed the survey. The dynamic and evolving nature of online resources (eg, Twitter, Snapchat) and behaviors may limit the validity of social media research.
Conclusion Cyberprofessionalism is an important concern for nursing professionals and educators, and it appears that unprofessional online behavior among nursing students is prevalent. Educational institutions need to be proactive by implementing social media policies and ensuring effective and timely handling of student-posted unprofessional content. Faculty and students need to be educated on how to report and address incidents of cyberbullying. Students also need to be educated on ethical and professional standards that must be maintained in both clinical and nonclinical settings. This area of the nursing profession will likely grow in importance and complexity and will require attention and innovation
References 1. Lenhart A, Purcell K, Smith A, Zichuhr K. Social media and young adults. Pew Research Internet Project Web site. Updated February 3, 2010. Available at http://www.pewinternet.org/Reports/ 2010/Social-Media-and-Young-Adults.aspx. Accessed November 21, 2014. 2. The demographics of social media users—2012. Pew Research Center. Published February 14, 2013. Available at http://www .pewinternet.org/Reports/2013/Social-media-users.aspx. Accessed November 21, 2014. 3. Tower M, Latimer S, Hewitt J. Social networking as a learning tool: nursing students’ perception of efficacy. Nurs Educ Today. 2013;34(6):1012-1017. 4. National Student Nurse Association. Social media usage and maintaining privacy, confidentiality, and professionalism. Available at http://www.nsna.org/Portals/0/Skins/NSNA/pdf/NSNA_Social_ Media_Recommendations.pdf. Accessed November 21, 2014. 5. Wink MD. Social networking sites. Nurse Educ. 2010;35(2):49-51. 6. Chretien KC, Goldman EF, Beckman L, Kind T. It’s your own risk: medical students’ perspectives on online professionalism. Acad Med. 2010;85(10):S68-S71.
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7. Cain J, Scott DR, Akers P. Pharmacy students’ Facebook activity and opinions regarding accountability and e-professionalism. Am J Pharm Educ. 2009;73(6):1-5. 8. Weed D, Kincheloe M, Lack C. Psychotherapy trainees and social networking use. Poster session presented at the Annual Meeting of the Southwestern Psychological Association; 2010; Dallas, TX. 9. Melnik T. Avoiding violations of patient privacy with social media. J Nurs Regul. 2013;3(4):39-44. 10. National Crime Prevention Council. Cyberbullying. Published 2010. Available at http://www.ncpc.org/topics/cyberbullying. Accessed November 21, 2014. 11. Spector N, Kappel DM. Guidelines for using electronic and social media: the regulatory perspective. Online J Issues Nurs. 2012;17(3):1. 12. Clark CM, Werth L, Ahten S. Cyber-bullying and incivility in the online learning environment, part 1: addressing faculty and student perceptions. Nurs Educ. 2012;37(4):150-156. 13. Clark CM, Ahten S, Werth L. Cyber-bullying and incivility in the online learning environment, part 2: promoting student success in the virtual classroom. Nurs Educ. 2012;37(5):192-197. 14. DeCamp M. Social media and medical professionalism. Arch Intern Med. 2012;172(18):1418-1419. 15. Finn G, Garner J, Sawdon M. You’re judged all the time! Students’ views on professionalism: a multicentre study. Med Educ. 2010;44(8):814-825. 16. Holland HB. Privacy paradox 2.0. Widener Law Journal. Published April 4, 2010. Available at http://papers.ssrn.com/sol3/ papers.cfm?abstract_id=1584443. Accessed November 21, 2014. 17. American Nurses Association. Principles for Social Networking and the Nurse. Silver Spring, MD: ANA; 2011. 18. National Council of State Boards of Nursing. White paper: a nurse’s guide to the use of social media. Published August 2011. Available at https://www.ncsbn.org/Social_Media.pdf. Accessed November 21, 2014. 19. Farnan J, Sulmasy LS, Worster B, Chaudhry H, Rhyne J, Arora V. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8): 620-627. 20. Lerner B. Policing online professionalism: are we too alarmist?. JAMA Intern Med. 2013;173(19):1767-1768. 21. Simpson R. Social media creates significant risks for nursing. Nurs Inform. 2014;38(1):96-98. 22. Greysen SR, Chretien KC, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;307(11):1141-1142. 23. Greysen SR, Johnson D, Kind T, et al. Online professionalism investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;158(2):124-130. 24. Frazier B, Culley J, Hein L, Williams A, Tavakoli A. Social networking policies in nursing education. Comput Inform Nurs. 2014;32(3):110-117. 25. Englund H, Chappy S, Jambunathan J, Gohdes E. Ethical reasoning and online social media. Nurs Educ. 2012;37(6):242-247. 26. Kjos AL, Ricci DG. Pharmacy student professionalism and the internet. Curr Pharm Teach Learn. 2012;4(2):92-101. 27. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009;302(12): 1309-1315. 28. Skiba DJ. Nursing education 2.0: the need for social media policies for schools of nursing. Nurs Educ Perspect. 2011;32(2):126-127. 29. Minor MA, Smith GS, Brashen H. Cyberbullying in higher education. J Educ Res Pract. 2013;3(1):15-29.
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