Social Media JNR

Nurses and Social Media:
Regulatory Concerns and Guidelines
Rene Cronquist, JD, RN, and Nancy Spector, PhD, RN
Social media possess tremendous potential for strengthening professional relationships and providing valuable information to
health care consumers. However, the inappropriate use of social media by nurses is causing concern among educators, employers,
and regulators, and nursing organizations are beginning to develop guidelines. When using social media, nurses must protect the
patient’s rights to privacy and confidentiality and consider the potential effects of their communications on their patients, their
employers, their profession, and themselves. This article describes the professional, ethical, and legal implications of using social
media inappropriately and provides guidelines from the National ouncil of State !oards of Nurs"ing for using them appropriately.
Inappropriate use of social media by nurses causes concerns
for employers, educators, and regulators. Employer concerns
include the potential for damage to the reputation of the
organization and liability for disclosure of protected health infor-
mation (Genova, 200! "lich-#eartt $ %rion, 20&0'. Educators
are concerned about boundary violations and privacy issues,
(hich can affect relationships (ith clinical sites and the reputa-
tion of the nursing program ()ehavot, 200! *rossman, 20&0'.
*he concerns of regulatory bodies center on the potential harm to
patients and the public from the inappropriate use of social
media (+nderson $ %uc,rin, 20&&! -pector, 20&0'.
.ursing organizations are beginning to develop guide-lines
for using social and electronic media. *he .ational /ouncil of
-tate 0oards of .ursing (./-0.' published a (hite paper,
(hich included guidelines for using social media, for the nursing
community, upon (hich this article is based (./-0., 20&&'.
*he +merican .urses +ssociation is revising its code of ethics to
include social media (%rinz, 20&&'. -igma *heta *au recently
published a boo, on the effective use of social media, devot-ing a
chapter to guidelines for avoiding pitfalls (1raser, 20&&'.
Internationally, the 2oyal /ollege of .ursing in the 3nited
"ingdom has published legal advice on using social media ap-
propriately (2oyal /ollege of .ursing, 200', and /anada has
been e4ploring the issue from a regulatory perspective (+nderson
$ %uc,rin, 20&&'.
In 20&0, the ./-0. conducted a survey of boards of
nursing (05.s! ./-0., 20&&' to gauge the prevalence of
complaints regarding the use of social media. *he ma6ority of
responding 05.s (77 of 89 respondents' reported receiving
complaints about nurses (ho violated patient privacy by post-ing
photos or information on social net(or,ing sites. 5f these 77
05.s, 29 reported ta,ing disciplinary action based on the
complaints. +ctions included censuring the nurse, issuing a let-
ter of concern, placing conditions on the nurse:s license,
and suspending the nurse:s license.
Case Study: Report to the BON
*he follo(ing case depicts conduct that can result in a report to a
05.. -ally, a nurse employed at a hospital, arrived at (or, one
morning and found a strange e-mail on her laptop. +ttached to
the e-mail (as a photo of a (oman in a hospital go(n, e4posing
her bac,side (hile bending over. -ally as,ed other staff
members about the e-mail, and some said they had received it on
their office computers, too. .obody ,ne( the source of the e-
mail or the identity of the (oman, but the bac,ground appeared
to be a patient:s room in the hospital. *o find out (hether others
,ne( anything about the e-mail, -ally for(arded it to the
computers and cell phones of several staff members (ho said
they had not received it. -ome staff members discussed the photo
(ith an air of concern, but others laughed about it as they found
it amusing. 5ne staff member started a betting pool regarding the
identity of the patient, and another staff member posted the photo
on his blog.
+lthough staff members did not bring the e-mail to the
attention of their supervisors, by midday the director of nursing and
hospital management (ere a(are of the photo and began an
investigation because of their concerns about a possible violation of
patient rights. *he local media also became a(are of the mat-ter and
covered the story so e4tensively that it eventually made national
ne(s. )a( enforcement (as called to investigate (hether any
crimes involving se4ual e4ploitation had been committed. #ospital
management placed several staff members on admin-istrative leave
and loo,ed into violations of facility rules that emphasize patient
rights, dignity, and protection. ;anagement reported the matter to
the 05., (hich opened investigations
<olume 2=Issue 7 5ctober 20&& (((.6ournalofnursingregulation.com 7>
to determine (hether state or federal regulations
enforceable by the 05. had been violated. Eventually, the
patient (as identi-fied, and the family threatened to sue the
hospital and everyone involved.
#ad the nurses ta,en a professional stand and reported the
e-mail photo from the beginning, the problems could have been
avoided. Instead, the situation escalated, involving the 05., the
county prosecutor, and the national media. *he patient felt hu-
miliated and violated. *he hospital (as embarrassed by national
media coverage and faced possible legal conse?uences.
Background
*he use of social media and other electronic communication is
increasing e4ponentially (ith the gro(ing number of social
media outlets, platforms, and applications, including blogs, so-
cial net(or,ing sites, video sites, and online chat rooms and
forums ("lich-#eartt $ %rion, 20&0'. .urses often use electronic
media personally and professionally. -ocial media can benefit
health care in a variety of (ays, including fostering professional
connections, promoting timely communication (ith patients and
family members, and educating and informing consumers and
health care professionals (1raser, 20&&! %rinz, 20&&! -,iba,
/onnors, $ @effries, 200A'. #o(ever, instances of inappropriate
use of electronic media by nurses have been reported to 05.s.
-ome cases have been reported in nursing literature and by the
media (%rinz, 20&&! -pector, 20&0! *rossman, 20&0'
.urses are increasingly using blogs, forums, and social net-
(or,ing sites to share (or,place e4periences, particularly events
that have been challenging or emotionally charged. *hese outlets
provide a venue for nurses to e4press their feelings and reflect or
see, support from friends, colleagues, peers, or virtually anyone on
the Internet. @ournaling and reflective practice have been identified
as effective tools in nursing practice, and the Internet provides media
for these helpful activities. Bithout a sense of caution, ho(ever,
these understandable needs and potential ben-efits may result in a
nurse disclosing too much information and violating patient privacy
and confidentiality.
#ealth care organizations that use electronic and social media
often have policies governing employee use in the (or,-place. -uch
policies often address the personal use of employer computers and
e?uipment and personal computing during (or, hours. %olicies may
also address the types of (ebsites that may or may not be accessed
from employer computers. #ealth care orga-nizations carefully
control (ebsites maintained by or associated (ith the organization,
limiting (hat may be posted to the site and by (hom. 1or an
e4ample of policy guidelines, visit httpC==
sharing.mayoclinic.org=guidelines=for-mayo-clinic-employees=.
*he employer:s policies usually do not address the
nurse:s use of social media outside the (or,place, though
nurses (ho use social media inappropriately in that
situation may face seri-ous conse?uences.
Confidentiality and Priacy
*o understand the limits of appropriate use of social media, one
must understand confidentiality and privacy in the health care
conte4t. /onfidentiality and privacy are related but distinct con-
cepts. +ny patient information a nurse learns during the course of
treatment must be safeguarded by the nurse. -uch informa-tion
may be disclosed only to other members of the health care team
for health care purposes. /onfidential information should be
shared only (hen one has the patient:s informed consent, (hen
disclosure is legally re?uired, or (hen a failure to disclose could
result in significant harm. 0eyond these limited e4cep-tions, the
nurse:s obligation to safeguard confidential information is
universal.
%rivacy relates to the patient:s e4pectation and right to be
treated (ith dignity and respect. Effective nurse-patient re-
lationships are built on trust. %atients need to be confident that
their most personal information and their basic dignity (ill be
protected by the nurse. %atients (ill be hesitant to disclose
personal information if they fear it (ill be disseminated beyond
those (ho have a legitimate need to ,no(. +ny breach of this
trust, even inadvertent, damages the nurse-patient relationship
and the general trust(orthiness of the profession of nursing.
1ederal la( reinforces and further defines privacy through
the #ealth Insurance %ortability and +ccountability +ct
(#I%++'. #I%++ regulations are intended to protect patient
privacy by defining individually identifiable information and
establishing ho( the information may be used, (ho may use it,
and under (hich circumstances it may be used. Individually
identifiable information includes any information that relates to
the past, present, or future physical or mental health of an
individual or enough information to lead someone to believe the
information could be used to identify an individual.
0reaches of patient confidentiality or privacy can be
inten-tional or inadvertent and can occur in a variety of (ays.
.urses may breach confidentiality or privacy by posting
information using social media. E4amples include ma,ing
comments about a patient (ho is described (ith sufficient
detail to be identified, referring to patients in a degrading or
demeaning manner, and posting video or photos of patients
(ithout consent or for non-health-related purposes.
Consequences
*he conse?uences of a nurse:s inappropriate use of social
and electronic media vary and depend in part on the nature
of the nurse:s conduct.
BON Consequences
Instances of inappropriate use of social and electronic media may
be reported to the 05.. *he la(s outlining the basis for disci-
plinary action vary among 6urisdictions. Depending on the la(s
7A @ournal of .ursing 2egulation
of a 6urisdiction, a 05. may investigate reports of inappropriate
disclosures on social media by a nurse on the follo(ing groundsC
3nprofessional conduct
3nethical conduct
;oral turpitude
;ismanagement of patient records
2evealing a privileged communication
0reach of confidentiality
If the 05. finds the allegations to be true, the nurse
may face disciplinary action, including a reprimand or
sanction, an assessment of a monetary fine, or a temporary
or permanent loss of licensure.
Other Consequences
Improper use of social media by nurses may violate state and
federal la(s established to protect patient privacy and confiden-
tiality. -uch violations may result in civil and criminal penalties,
including fines and 6ail time. + nurse may face personal liability.
+ nurse can be sued for defamation, invasion of privacy, or
harass-ment. %articularly flagrant misconduct on social media
(ebsites may also raise liability under state or federal regulations
focused on preventing patient abuse or e4ploitation.
If the nurse:s conduct violates the policies of the employer,
the nurse may face employment conse?uences, including termi-
nation. +dditionally, the actions of the nurse may damage the
reputation of the health care organization or sub6ect the organi-
zation to a la(suit or regulatory conse?uences.
*he misuse of social media can also adversely affect team-
based patient care. 5nline comments regarding co(or,ers, even
if posted from home during non-(or, hours, may constitute
lateral violence, (hich is receiving greater attention as more is
learned about its impact on patient safety and ?uality clini-cal
outcomes. )ateral violence includes disruptive behaviors of
intimidation and bullying (-tanley, ;artin, ;ichel, Belton, $
.emeth, 200>', (hich may be perpetuated in person or via the
Internet, sometimes referred to as cyber-bullying. -uch activity
causes concern for current and future employers and regulators
because of the patient-safety ramifications.
*he line bet(een speech protected by labor la(s and the
1irst +mendment and the ability of an employer to impose e4-
pectations on employees outside of (or, is still being deter-
mined (.ational )abor 2elations 0oard, 20&&'. .onetheless,
inappropriate comments can be detrimental to a cohesive health
care delivery team and may result in sanctions against the nurse.
Co!!on "yths and "isunderstandings
#$out Social "edia
+lthough instances of intentional or malicious misuse of social
media have occurred, in most cases, inappropriate disclosure or
posting is unintentional. + number of factors may contribute to a
nurse inadvertently violating patient privacy and confiden-
tiality (hile using social media. /ontributing factors
include the follo(ingC
A mistaken belief that the communication or posting is private
and accessible only by the intended recipient. *he nurse may
not rec-ognize that content, once posted or sent, can be
disseminated to others. In fact, the terms for using a social
media site may include an e4tremely broad (aiver of rights to
limit use of the content. 5ne such (aiver states, E0y posting
user content to any part of the site, you automatically grant
the company an irrevocable, perpetual, none4clusive
transferable, fully paid, (orld(ide license to use, copy,
publicly perform, publicly display, reformat, translate,
e4cerpt (in (hole or in part', distribute such user content
for any purposeF (%rivacy /ommission of /anada, 200>'.
A mistaken belief that content deleted from a site is no
longer acces-sible. In fact, Beb administrators can
retrieve almost anything that has been deleted, and the
information can be subpoenaed by courts of la(.
A mistaken belief that disclosing private or confidential
information about patients is harmless if the communication is
accessed only by the intended recipient. -uch disclosure is still a
breach of confiden-tiality and represents unprofessional conduct.
A mistaken belief that discussing or referring to patients is acceptable if
they are not identified by name, but by a nickname, room number,
diagnosis, or condition. -uch disclosure is also a breach of con-
fidentiality and demonstrates disrespect for patients: dignity.
Confusion regarding a patient’s right to disclose personal
information (or a health care organization’s right to disclose
otherwise protected information with a patient’s consent and the
need for health care providers to refrain from disclosing patient
information without a care-related need for the disclosure.
!he ease of posting and the commonplace nature of sharing
informa-tion via social media. *hese t(o factors may appear
to blur the line bet(een one:s personal and professional lives.
*he ?uic,, easy, and efficient technology enabling use of
social media reduces the amount of time needed to post
content and to consider the appropriateness of the post and the
ramifications of inappropriate content.
Ne% &uidelines: 'o% to #oid Pro$le!s
Bith a(areness and caution, nurses can avoid inadvertently
disclosing confidential or private information about patients.
2egulatory bodies, educational programs, and employers are
encouraged to revie( the guidelines belo(! modify them to
comport (ith other, e4isting statements and applicable la(s!
and share them (ith nurses and nursing students.
*he follo(ing guidelines from the ./-0. are
intended to minimize the ris,s of using social mediaC
.urses must recognize that they have an ethical and
legal obligation to maintain patient privacy and
confidentiality at all times.
<olume 2=Issue 7 5ctober 20&& (((.6ournalofnursingregulation.com 7
.urses are prohibited from transmitting by (ay of any elec-
tronic media any patient-related information or image that is
reasonably anticipated to violate patient rights to confidential-
ity or privacy or to other(ise degrade or embarrass the patient.
.urses should not share, post, or other(ise disseminate any
information, including images, about a patient or
information gained in the nurse-patient relationship (ith
anyone unless there is a patient careGrelated need to
disclose the information or other legal obligation to do so.
Do not identify patients by name or post or publish
informa-tion that may lead to the identification of a
patient. )imiting access to postings through privacy
settings is not sufficient to ensure privacy.
Do not refer to patients in a disparaging manner, even if
they are not identified.
Do not ta,e photos or videos of patients on personal devices,
including cell phones. 1ollo( employer policies for ta,ing
photographs or video of patients for treatment or other legiti-
mate purposes using employer-provided devices.
;aintain professional boundaries in the use of electronic me-
dia. *he nurse has the obligation to establish, communicate,
and enforce professional boundaries (ith patients in the online
environment. .urses should use caution (hen having online
social contact (ith patients or former patients. 5nline contact
(ith patients or former patients blurs the distinction bet(een a
professional and personal relationship. *he fact that a patient
may initiate contact (ith the nurse does not permit the nurse
to engage in a personal relationship (ith the patient.
/onsult employer policies or an appropriate leader (ithin the
organization for guidance regarding (or,-related postings.
%romptly report any identified breach of confidentiality
or privacy.
0e a(are of and comply (ith employer policies regarding the use
of employer-o(ned computers, cameras, and other elec-tronic
devices and the use of personal devices in the (or,place.
Do not ma,e disparaging remar,s about employers or
co(or,-ers. Do not ma,e threatening, harassing,
profane, obscene, se4ually e4plicit, racially derogatory,
homophobic, or other offensive comments.
Do not post content or other(ise spea, on behalf of the
em-ployer unless authorized to do so, and follo( all
applicable policies of the employer.
Conclusion
-ocial and electronic media possess tremendous potential for
strengthening personal relationships and providing valuable
information to health care consumers. 2egulatory agencies,
employers, and schools of nursing need to develop policies and
guidelines regarding the appropriate use of social media by
nurses. .urses should be mindful of employer policies, relevant
state and federal la(s, and professional standards regarding pa-
tient privacy and confidentiality and their application to social
and electronic media. .urses need to be a(are of the potential
ramifications of disclosing patient-related information via social
media. 0y being careful and conscientious, nurses may en6oy the
personal and professional benefits of social and electronic media
(ithout violating patient privacy and confidentiality.
References
+nderson, @., $ %uc,rin, ". (20&&'. -ocial net(or, useC + test of
self-regulation. "ournal of #ursing $egulation, %(&', 79G8&.
1raser, 2. (20&&'. !he nurse’s social media advantage& 'ow
making connec-tions and sharing ideas can enhance your
nursing practice. Indianapolis, I.C -igma *heta *au.
Genova, G. ). (200'. .o place to playC /urrent employee privacy
rights in social net(or,ing sites. (usiness Communication
)uarterly, *%, >G&0&.
"lich-#eartt, E. I., $ %rion, -. (20&0'. -ocial net(or,ing and #I%++C
Ethical concerns for nurses. #urse +eader, ,(2', H9GHA.
)ehavot, ". (200'. E;y -paceF or yoursI *he ethical dilemma of
grad-uate students: personal lives on the Internet. -thics and
(ehavior, ./(2', &2G&8&.
.ational )abor 2elations 0oard. (20&&'. -ettlement reached in case
in-volving discharge for 1aceboo, comments. 2etrieved from
(((. nlrb.gov=ne(s=settlement-reached-case-involving-
discharge-face-boo,-comments
.ational /ouncil of -tate 0oards of .ursing. (20&&'. Bhite paperC
+ nurse:s guide to the use of social media. 2etrieved from
(((.nc-sbn.org=-ectionJII.pdf
%rinz, +. (20&&'. %rofessional social net(or,ing for nurses. American
#urse !oday, 0(>'. 2etrieved from
(((.americannursetoday.com= article.asp4IidKA0&9$fidK>A9
%rivacy /ommission of /anada. (200>'. %rivacy and social
net(or,s L<ideo fileM. 2etrieved from
httpC==(((.youtube.com= (atchIvKN>gBEg#eNc+
2oyal /ollege of .ursing. (200'. )egal advice for 2/. members us-
ing the Internet. 2etrieved from (((.rcn.org.u,=JJdata=assets=
pdfJfile=000A=2>2&H=007HH>.pdf
-,iba, D. @., /onnors, #. 2., $ @effries, %. 2. (200A'. Information
tech-nology and the transformation of nursing education.
#ursing 1ut-look, 20(H', 22HG270.
-pector, .. (20&0'. 0oundary violations via the Internet. +eader to
+ead-er. 2etrieved from (((.ncsbn.org=)2)J-pring20&0.pdf
-tanley, ". ;., ;artin, ;. ;., ;ichel, O., Belton, @. ;., $ .emeth, ).
-. (200>'. E4amining lateral violence in the nursing (or,force. 3s-
sues in 4ental 'ealth #ursing, %,(&&', &28>G&29H.
*rossman, -. (20&0'. -haring too muchI .urses nation(ide need
more information on social net(or,ing pitfalls. American
#urse !oday, 2(&&', 7AG7.
Rene Cronquist, JD, RN, is Director for %ractice and
%olicy at the ;innesota 0oard of .ursing. Nancy
Spector, PhD, RN, is Director of 2egulatory Innovations
at the .ational /ouncil of -tate 0oards of .ursing.
80 @ournal of .ursing 2egulation