Thoughts on the ANA Social Media Policy Draft

Three cheers for the ANA who developed a task force late last year to help write some rules and regulations for nurses to refer to in the uncertain environment of social networking. We are on par with other health care disciplines in the scramble to determine the implications of potential boundary violation of both patient and provider before the lawyers carve out a new specialty branch of practice. I think this is an overall great start (even though it is a direct crib from the AMA's policy) but I would like to see some more specific and supportive language.  Naturally, this nurse has plenty of public comment which is lovingly provided alongside each of the following provisions in glorious technicolor!

APRIL 25, 2011
FOR PUBLIC COMMENT (click to add your 2 cents)
PRINCIPLES: SOCIAL NETWORKING AND THE NURSE (click for the full document)

Background

Relying on an Action of the 2010 ANA House of Delegates, “Social Networking and the Nurse,” ANA staff, in consultation with the CNPE Practice and Regulation Workgroup and the ANA  Ethics Advisory Board, developed an outline of professional principles to guide nurses in their use of social media. The House of Delegates Action resolved that ANA “support the application of ANA’s foundational documents – the Code of Ethics for Nurses, Nursing’s Social Policy Statement, and Nursing: Scope and Standards of Practice –to the use of social media.” The following provisions from these foundational documents helped to inform the draft principles for Social Networking and the Nurse.  Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) – The Code of Ethics for Nurses is a seminal ANA document establishing ethical standards for the nursing profession. It provides a framework for nurses to use in ethical analysis and decision-making. Each of the nine provisions of the Code, along with select Interpretive Statements, provides guidance on the application of professional values and personal judgment in nurses’ use of social networking and media.


In addition to reliance on ANA’s three foundational documents, the draft principles for Social Networking and the Nurse also consider pertinent statutes and legal documents,  the experience of health professionals with social networking as reported in the media,  as well as the social media policies of other health care organizations.

Preface

Nurses who are currently practicing or preparing to enter the workforce have a professional obligation to understand the nature and consequences of participating in social networking of all types. The social network and the Internet provide an opportunity for unmatched knowledge exchange shared quickly among many people. There are many positive implications for nurses and nursing practice: it provides an opportunity for broad dissemination and discussion of nursing and health –related education and communication; it can nurture relationships and mentoring among developing professionals; and it provides a forum for collegial interchange and the development of an online professional presence. It also offers the profession a vehicle for educating the public on many nursing and public health matters. At the same time, information contained on a social network has the capacity to propagate itself, taking on a life of its own in cyberspace. Nurses must be aware that the social media venue is shared by their patients, and that unintended consequences of poor decision-making can breach a patient’s privacy, damage a patient’s trust in the individual nurse and the profession, and further damage a nurse’s professional and personal future. Inaccuracies become “fact” by mere repetition, which is a particular danger when discussing public health needs. Despite the feeling that comments, videos, photos, or other online materials may seem transient or “gated,” the nature of the Internet is that such materials are permanent and just about anyone can and will see these postings. Thus, it becomes essential for nurses to consider a number of guidelines when functioning within the “virtual” world of social media:

Principles

1. Patient privacy is a fundamental ethical and legal obligation of nurses. Nurses must observe standards of patient privacy and confidentiality at all times and in all environments, including online. Nurses must not transmit or place online individually identifiable patient information. The nurse’s primary commitment is to the patient and nurses are ethically required to practice with compassion and respect for the inherent dignity and worth of every individual. The key here is "identifiable" and I would like the ANA to include a statement addressing acceptable or exemplar generic comments. Reporting a bad day at work or mentioning difficulties with performing a particular procedure should not be grounds to call "breech!" Likewise, mentioning the good feelings that come from providing benefit that day should not be labeled inappropriate if are patients not "identifiable." 

2. Nurses who interact with patients on social media must observe ethically prescribed patient –nurse professional boundaries. The precepts guiding nurses in these matters are no different online than they are in person. Does this refer to professional social networks such as those run by the CDC or Mayo Clinic or those which have private encryption such as the telemed/psych services at the VA? This provision needs to differentiate between personal and professional persona. Public social media outlets provide no guarantee of privacy, therefore engaging with a provider on a social network implies that the client understands confidentiality cannot be guaranteed. Just as a consumer cannot ask a provider a medical question on a talk-show or radio program and expect it to constitute a through and private assessment, the same is true for social media outlets. The client cannot ask the nurse a healthcare related question then accuse the provider of a violation if the provider answers the question or cry "patient abandonment" if they do not acknowledge the interaction - label it the "call-in clause." If a nurse chooses to maintain a professional site, a statement regarding privacy, who is allowed in the network, and reminder that members can see other members participation should be clearly noted so everyone knows what they are getting into if they choose to join, for example, a Facebook page or twitter feed. The ANA might consider creating example statements that nurses could post as an FYI to fellow networkers. For example, these are from my professional and personal facebook page (suggestions for improvement are welcome!): 


***Social Media Policy Statement: While Jing Acupuncture/OneDNP is a health care provider, this page is for entertainment, advocacy, and education by a private citizen - not diagnosis, treatment, and advice from a professional. All interactions on this social networking site are open to anyone who has the good fortune to visit this page. Visiting or "liking" this page does not constitute or imply a therapeutic relationship and is not bound by confidentiality, practice acts, or codes.


***The ANA's new social media policy recommends providers uphold our code of ethics by maintaining professional boundaries online. I am currently not accepting friend requests from current patients who have visited Jing in the past 3 years. To stay in touch professionally, "Like" my page at http://www.facebook.com/JingAcupuncture or follow me at http://www.twitter.com/JingAcupuncture 
My Social Media Policy Statement: While I am health care provider, I use Facebook as a private citizen for entertainment, advocacy, and education - I do not diagnosis, treat, or provide medical advice in any professional capacity whatsoever. All interactions on this social networking site are open to anyone with access to this page including "friends," random hackers, and administrators. "Friending" me does not constitute or imply a therapeutic relationship and is not bound by confidentiality, practice acts, or codes. (And yes, this necessity is ridiculous!)

3. Nurses should take advantage of privacy settings available on many social networking sites in their personal online activities, and seek to separate their personal and professional sites and information online.  I would also like to see the sanctity of provider privacy addressed in relation to self-care.  Curiosity about the personal lives of providers is natural, yet a patient may be able to gain access to a nurse's social network in spite of him/her taking reasonable privacy precautions. In such instances, the nurse should not be held to standards over-and-above those of maintaining privacy and confidentiality in good faith and be free to express personal opinions without fear of professional consequence. Many nursing associations recommend avoiding personal relationships of any kind with a patient after discharged from care for 6 months to 5 years to never -  virtual, "friending" patients does constitute a personal relationship that can have consequences in the 3-D world.  Having a general guideline for the nurse to fall back on would help lessen the potential feelings of personal rejection for clients who want to keep in touch. I feel the ANA should not condone any hiring practice that requires an applicant to allow the potential employer access to their social networking sites, and there should be words to that effect. Support from state boards, organizations, associations, and accrediting bodies would help protect the personal/professional buffer while preventing multiple guidelines that may conflict with each other. 

4. Use of privacy setting and separation of personal and professional information online does not guarantee, however, that information will not bleed through or be repeated in less protected forums. Therefore, it is prudent for the nurse to evaluate all his or her postings with the potential for patient, colleague, or employer viewing in mind. Online content and behavior has the potential to either enhance or undermine not only the individual nurse’s career, but also the nursing profession. This provision may be necessary because, as Voltaire said, "common sense is not so common," however it creates a culture of second guessing one's actions, lays the field wide open for unnecessary scrutiny into the life of a private citizen who works in public service, and implies that a nurse can never be "off-duty." Any implication that the ANA would support employers, accreditation bodies, or state boards taking punitive measures against employees for posting political, religious, social or other opinions as a private citizen demonstrates a distressing lack of advocacy. Ditto for supporting employer social media policies that allow a company to govern any aspect of personal online activity of employees and use it as part of an evaluation process. It is one thing to ask yourself if your post passes the "mother" or "headline" test, it is another to fear the thought police and think your license or job is in jeopardy when off the clock.

5. Nurses who view content posted by a colleague that is unprofessional or that potentially violates ethical or legal obligations should first bring the questionable content to the attention of the individual, so that the individual can take appropriate action. If the posting is egregious enough or if the individual does not remove the posting, the nurse has the obligation to report the matter to supervisors or other authorities. This is in keeping with what occurs in the real world, however, the lateral violence potential here is unlimited. I can envision managers or coworkers stalking social networking sites in search of dirt they can use against an unpopular peer. I do think there is a better likelihood of a peer confronting a peer online than in person because it seems less like a scolding and more like an FYI.