E-professionalism in nurses: ethical and legal challenges in the use of social networks

Section: Editorial


Elena Plaza Moreno


Enfermera. Máster en urgencias hospitalarias. Experto en Competencias Digitales en Salud. Enfermera docente. Divulgadora sanitaria. Creadora y directora del proyecto digital www.urgenciasyemergen.com

Contact email: admin@urgenciasyemergen.com

Tvery day, 3,500 million persons (45% of the world population) use social networks (SSNN), and 64.4% are internet users (1). Many Health Sciences professionals, including us nurses in a prominent way, have found in these platforms an exceptional opportunity to conduct health education, extend the scope and visibility of our profession, and conquer further areas of professional autonomy (e.g. creation or direction of teaching projects, or healthcare, clinical or home care companies, etc.). The use of these digital platforms allows us to increase the interaction with nurse colleagues throughout the world, to build digital identity and reputation, to spread in a massive way evidence-based Nursing through our research projects, to interact with and learn from patients, and to offer Health Education to the population. With these platforms, new opportunities to provide care also emerge: we can reach the population through evidence-based contents, adapting the message. This is essential, because 80% of patients search for online information about their health problems. And this figure keeps increasing; it was 40% eight years ago.

However, SSNN also present many disadvantages, according to Vukušić (1). Those of us who conduct health education in a professional way are aware of personal drawbacks that have not been publicly discussed yet. But there are really three essential aspects which deserve attention: first, the spread of fake news in health, which we will not discuss here. Second, the likelihood of breaching the privacy of patients, institutions and colleagues. And third, that our online actions as nurses, in our personal capacity, will represent the nursing profession, and therefore can have an impact on the collective perception of our work by society. In order to address these two last drawbacks, it is essential to understand the concept of e-professionalism, electronic professionalism, or cyberprofessionalism.

E-professionalism was first defined in 2009 by Cain and Romanelli (2) as the ethical behaviour of health professionals in the digital age. Villa-García and Rodríguez (3) defined it as “a new construct which expands the paradigm of traditional professionalism to include the attitudes and behaviours shown through digital media”. Cain and Romanelli (2) detected that online or virtual settings “eliminate social inhibitions, which might lead persons to express thoughts, attitudes and behaviours which, otherwise, they might repress in face-to-face interactions”. Currently, physical location does not determine whether we are in public or in private, because we can reach any place with networks. In other words: SSNN act as a public window towards our life, and what we share can have a deep impact on the way in which we are perceived professionally. Unethical acts, such as the spread of wrong information, the invasion of the privacy of patients, the publication of inadequate comments, and the incorrect use of clinical images, can damage our professional reputation and have significant consequences. That is why we must reconsider what e-professionalism means for our profession.
It is necessary to think carefully about the change of paradigm between public and private, as well as the cognitive dissonance between what is right and what is wrong, what must be published and what should not be published. Moreover, we are facing a generation gap, where perceptions change and entail the start of a discussion about the problems derived from an inadequate use of SSNN for nurses and health professionals. There are questions which show the complexity of the digital age, and they require answers. Should the institutions where we work remain apart from our activities in SSNN? Do we represent institutions 24 hours, or only during our work hours? Can they retaliate for political opinions or unethical attitudes in a private setting? Should professors supervise the online information of students in the teaching setting? And what about the freedom of expression and right to privacy of the worker or student publishing these contents?

I don’t have the answer to these questions, but I agree with Cain and Romanelli (2) and with Villa-García and Rodríguez (3) that personal behaviours shown online are subject to the interpretation of users and professionals themselves, and that they have impact on the image and e-professionalism of the nursing profession. On the other hand, everything would be easier if there was a specific regulatory framework about the use of SSNN, health education, appearance in mass media, etc. This regulatory framework should collect policies, rights, duties and penalties, both in the university and in the work setting. Can professionals report in SSNN their working conditions if these prevent them from providing quality care and put the health and safety of their patients at risk? This aspect is addressed by González-Luis et al. (4), analysing the right to freedom of expression of nurses, and the conclusion is that the preparation of guidelines should include not only include ethical but also professional, institutional and legal aspects. Likewise, I consider that it is necessary to include training on digital skills, legal and effective use of SSNN, and e-professionalism in the university training plans for all healthcare professionals, as well as in continuous education.

Even though it is insufficient, some institutions, healthcare centres and scientific societies from different countries already have guidelines regarding this. The International Council of Nurses includes the use of SSNN in their Code of Conduct (2022). The American Nursing Association (ANA) and the National Council of State Boards of Nursing (NCSBN) have regulated the use of SSNN by nurses in the United States for many years. There are universities placing value on the controlled and directed use of SSNN with training purposes for Nursing Degree students, and educational purposes for the population (in the Universidad Europea from Madrid, Nursing students have issued a podcast to encourage the search for scientific evidence and communication (5)). In this sense, it seems logical to develop these digital skills in healthcare in different subjects and in all courses of the Nursing Degree.

However, according to Vukušić (1), González-Luis et al. (4) and Guraya et al. (6), it is necessary to create training activities at different levels. For example, interventions could be conducted with the purpose of reflecting on the digital image of each student or worker, using different roles (patient, potential employers, fellow student), aiming to develop this sense of e-professionalism. It would be advisable to include students in the creation of these training activities. In this way, authoritarianism is avoided, and they can contribute their view and experiences. They could also be included as educators and mentors for other students, and these spaces could be used for joint reflection.
Besides training activities, it would also be interesting that universities created documents on policy of SSNN use. This process should also include students; it would also be interesting to involve a lawyer and an Ethics Adviser.

Summing up, the use of SSNN and other communication platforms by nurses presents advantages and drawbacks. One of the main drawbacks is the presence of ethical problems or unprofessional behaviours, which might damage the concept of e-professionalism. In order to mitigate these effects, it is necessary to introduce training on ethics, use of social networks and digital skills in education programs, and even as training in working centres, before the trust of society in healthcare professionals starts to erode.