Natasha L. Hubbard Murdoch RN BSN MN PhD(c)
Interprofessional Education Coordinator,
School of Nursing and School of Health Sciences, Saskatchewan Polytechnic
natasha.hubbardmurdoch@saskpolytech.ca

Angela D. Ahlquist, RN BScN MA
Faculty
School of Nursing and School of Health Sciences, Saskatchewan Polytechnic
angela.ahlquist@saskpolytech.ca

Pamela M. Farthing, RN BA MS
Research Chair in Diabetes Care,
School of Nursing and School of Health Sciences, Saskatchewan Polytechnic
pamela.farthing@saskpolytech.ca

Justine N. Mennie RN BScN
Saskatchewan Health Authority
mennie2j@uregina.ca

Abstract

Social media policies exist in many nursing educational institutions. However, the effectiveness of these policies is questioned as many nursing students and faculty perceive a lack of awareness and understanding of both the policies and online professional behaviour.  A gap was apparent in the research literature on definitions and guidelines of how nurses should communicate. The purpose of this paper was to examine and synthesize the research available on faculty and student perceptions of professional presence on social media.  Student perceptions demonstrated an apparent lack of education and how this lack of knowledge created issues.  Additionally, the research outlined the benefits of social media in nursing education and indicated a need for more awareness of policy.  Faculty seemed to lack comfort and familiarity with social media. The resultant blurring of boundaries between faculty and students because of online platforms indicated the need for more education.  In reviewing the literature no clear definition was found on social media professional presence or how nursing students learn online professional presence.  It remained unclear as to how student nurses and future nurses will transition to the increased frequency of online communication. Research is required to ensure nurses and students are online in a professional manner.

 Keywords: education, faculty, presence, professional, policy, nursing student, online, registered nurse(s), social media

Social media can be defined as “information networks and information technology that utilizes a form of communication dealing with interactive and user-generated content and creating and maintaining relationships between people” (Tuominen, Stolt, & Salminen, 2014, p. 1).  Social media has begun to replace traditional face to face contact as a means of communication (Nyangeni, Du Rand, & Van Rooyen, 2015).  “Consequently, this increase in interpersonal communication has the potential to be integrated beyond social avenues and into professional fields” (Jacquemin, Smelser, & Bernot, 2014, p. 22).  The rapid growth in the usage of social media by young professionals and students shows potential in increasing interactions and facilitating a free flow of health information (Tuominen et al., 2014; White, Kirwan, Lai, Walton, & Ross, 2013).  However, with this rapid growth in usage, education on how to use social media in a professional and appropriate manner has not progressed.  Research suggested the policies in place are ineffective in ensuring students are demonstrating professional presence online (Booth, 2015; Prescott, Wilson, & Becket, 2013), which indicated a need for more research on what online professionalism should look like, what students were posting online, what they perceived as appropriate posting compared to what faculty perceived as appropriate online posting.

Background

The Saskatchewan Collaborative Bachelor of Science in Nursing (SCBScN) program student handbook states “absolutely NO pictures can be taken at any time during any setting” (Saskatchewan Polytechnic & University of Regina, 2016, p. 35).  Although this policy is readily accessible to students, it doesn’t seem to be well known knowledge that this policy exists.  Additionally, there is a lack of awareness of how faculty and students are currently using social media.  The way students and faculty utilize social media is dependent on their awareness of the policy, their comfort with social media and their understanding of professional presence online.  After further examination provincially and nationally, we noted a lack of online accessibility to nursing institutions’ policies surrounding social media and what professional presence looks like online.  In addition, policies may be vague, inadequate or simply not being enforced (Booth, 2015; Prescott et al., 2013).  Social media “technologies have already created risks of highly visible unprofessionalism within diverse health care professions” (Marnocha, Marnocha, & Pillow, 2015, p. 119).  What is evident from this is more education is required to ensure social media is not being misused (Frazier, Culley, Hein, Williams, & Tayakoli, 2014; Nyangeni et al., 2015). But more importantly that social media is being used to its full potential “to enhance nursing students’ communication skills, professionalism, and grasp of policy and ethics in health care” (Marnocha et al., 2015, p. 119).  The overall goal of this research is to complete a mixed methods study.  The aim of this paper was to review the literature of nursing faculty and student perceptions of professional presence on social media.

Methodology

A review of the literature was conducted between November 2016 to January 2017.  CINAHL, MEDLINE (OVID), ERIC, PsycINFO and Scopus were searched for relevant studies using the following MeSH heading and keywords:

1. Nursing faculty or nursing students (nurs* instructor(s), or nurs* professor(s), or nurs* teacher*, or nurs* educators, or nurs* sessionals
2. Social Media (or Twitter, or Facebook, or Linkedin, or Instagram, or Snapchat, or YouTube)
3. Perceptions (or Percept*, or aware*, or understand*, or attitudes, or beliefs, or knowledge)
4. Professional presence

Several articles were found based on this strategy and were selected based on the following inclusion/exclusion criteria.  The search of the literature was limited to peer-reviewed journal articles from any country, published in the English language from 2007-2017.  Qualitative, quantitative, or mixed methods studies were included if the articles included any of the keywords in the title or abstract.

As a team, the four researchers screened articles that met the inclusion criteria through a review of title and abstract and further if they were focused on nursing education.  The articles were divided between the four researchers for a full critique and determination of whether they met the inclusion criteria.  If there was a question about whether an article met inclusion criteria, the other three members of the research team would review the article and decide as a group whether or not to include the article.  The team met to categorize the final list of articles into student perceptions, faculty perceptions, and online professional presence.

Findings

The literature review was divided into the three main sections, student perceptions, faculty perceptions and professional presence.  The student perspectives were generally focused on the potential social media had for teaching and learning opportunities for nursing education, but lacked guidelines on how to reach this potential, and how social media was being misused. Faculty perspectives were often assessed in concert with student perspectives of social media use with an academic versus social focus.  Professional presence examined the literature for both faculty and student presence online and possible consequences of unprofessional behaviours in online communications, particularly in programs with social media policies.

Student Perceptions

Social media has been seen as a platform to increase student understanding of what is being taught and have a positive impact on student engagement (Chromey, Duchsherer, Pruett, & Vareberg, 2016; Jacquemin et al., 2014; Tuominen et al., 2014).  This enhanced student engagement could lead to “increased concept retention, course enjoyment, and student achievement” (Jacquemin et al., 2014).  Social media also allows students to autonomously control and direct their learning, which reinforces self-regulation of learning (Tower, Latimer, & Hewitt, 2014).

Young adults, a category which most students fall into, “are considered to be digital natives, and new technologies are a normal part of their lives” (Tuominen et al., 2014, p. 1). Social media use is substantially higher in students than it is in faculty.  A study done by Jacquemin, Smelser, and Bernot (2014) showed 55% of undergraduates used three or more social media sites, compared to only 12% of faculty reporting the use of three or more social media sites.  This difference in usage can be attributed to the generational age gap (Jacquemin et al., 2014; Prescott et al., 2013; Tuominen et al., 2014; White et al., 2013).

Over 75% of faculty do not use social media in the classroom (Jacquemin et al., 2014). This can be attributed to lack of familiarity, and feeling unsure or reluctant (Booth, 2015; Tuominen et al., 2014).  Another study revealed that “both students and educators are struggling to integrate this new technology into our existing practices of teaching and learning” (White et al., 2013, p. 7).  “Currently educators are still unsure of the importance and best practices related to the use of social technologies by students, or how to address the unique opportunities and challenges” (Booth, 2015).  What was evident, like most skills in nursing practice, online professionalism, like in-person professionalism must be taught.  Students require more understanding of the implications of their online behaviour, and how their posts reflect their education institution, professional responsibilities, and future employment opportunities (Booth, 2015; Prescott et al., 2013).

Josefsson, Hratinski, Pargman and Pargman (2016) identified higher education as being teacher centered compared to social media being user generated content.  Educational institutions are using online learning management systems like Blackboard and Moodle (Barlow et al., 2015).  Students indicated social media was more convenient than traditional web platforms being used (Jacquemin et al., 2014).  “Unlike other traditional educational technologies that are vetted and controlled by an educational institution (e.g., learning management system, institutional email), educators typically have little formal control over students’ access and use” (Booth, 2015, p. 322).  Another issue that is frequently overlooked is that everything posted and published is public and permanent (Josefsson, et al, 2016).  Online environments foster a false sense of intimacy and privacy (Fenwick, 2014).

Students described censoring or removing material, untagging themselves in posts by others, and having altered privacy settings for various reasons (White et al., 2013).  These reasons included risk of viewing by potential employers (52%) and advice from peers (30%), whereas advice from instructors was the reason in only 17% of cases.  With advice from faculty being ranked the lowest in this study it is evident that more education on this is needed for both students and faculty.  An additional issue that arises is the lack of familiarity with existing guidelines (43%) with only 15% agreeing that the guidelines were adequate (White et al., 2013).  Not only does this show the lack of accessible guidelines, but a lack of appropriate guidelines as well.

Caution must be taken in the use of social media around patient privacy and confidentiality, as well as ensuring blurring of professional and personal boundaries does not occur (Chromey et al., 2016; Nyangeni et al., 2015; Tower et al., 2014; White et al., 2013). While social media has a number of benefits it is important to also recognize the risks and potential damage to nurse integrity, relationships and employment if social media is being misused (Nyangeni et al., 2015).  One group of authors stated that nursing students were online whether that was desired or not, and “they are not aware of any universally acceptable description of responsible use of social media” (Nyangeni et al., 2015, p. 5).  A study done by White et al, (2013) also emphasized that “so far there is no generally accepted policy for students of the health professions,” which is something that needs to change.  It is clear “that educators need to do more to assist students in managing their online, as well as offline, personas and provide students with awareness of their online activity” (Prescott et al., 2013, p. 9).  “It is vital that both students and faculty become familiar and proficient with these sorts of social technologies in order to generate deeper insights into both functional and safe ways to embed these communication tools within practice” (Booth, 2015, p. 326).

Nursing education should not miss an opportunity to shape how social communication comes to life (Booth, 2015).  Educational institutions need to provide students with adequate guidance on what professionalism looks like online (Prescott et al., 2013). In efforts to guide social media usage, educational institutions have created policies, but the questions remain whether and how the policing and enforcement of these policies occurs. Policies can be seen as ineffectual and non-productive (Booth, 2015).  For those who take an interest in online professionalism “the most important way forward may not be how to protect and regulate students’ online behavior…Instead, we might consider more critically and imaginatively, with students, how social media works in and through their engagements with it” (Fenwick, 2014, p. 674).  Education on what policies are out there is required, along with the development of more appropriate policies. In the technological age, nursing students may one day become nursing faculty members so it is key to start education about professionalism online.

Faculty Perceptions 

This section summarizes the research on faculty perceptions of social media use in nursing programs. Only four research articles were found that assessed perceptions of nursing faculty or administration and this was often done concurrently with student assessments (Frazier et al., 2014; Killam, Carter & Graham, 2013; Marnocha et al., 2015; Smith & Lambert, 2014).  In general, the research described faculty or student perceptions of the appropriateness of posts and interactions online (Frazier et al., 2014; Marnocha et al., 2015), the social versus academic issues of using social media for learning (Frazier et al., 2014; Killam, et al., 2013; Marnocha et al., 2015; Smith & Lambert, 2014), whether social media increased engagement (Killam, et al., 2013; Smith & Lambert, 2014), the blurred boundaries of personal and professional identities (Killam, et al., 2013; Marnocha et al., 2015; Smith & Lambert, 2014), the awareness of social media policies in schools of nursing and how to enact them (Frazier et al., 2014; Marnocha et al., 2015), and whether policies could be used to educate faculty and students (Frazier et al., 2014; Killam, et al., 2013; Marnocha et al., 2015).

Two studies reported on inappropriate incidents, specifically in regard to faculty and administrator perceptions (Frazier et al., 2014; Marnocha et al., 2015).  Frazier, Culley, Hein, Williams, and Tayakoli (2014) found 27% of faculty and 71% of students used social media.  Survey results revealed that the majority of both groups agreed it was unprofessional to “friend” or interact with patients or post about clinical even if the patient identifying information was not used.  However, strikingly, over 60% of both students and faculty felt that as long as HIPAA wasn’t violated, posting was not the school’s business. Similar cyberprofessionalism concerns, as understood by administrators of nursing schools, was assessed in a mixed methods study in the USA (Marnocha et al., 2015).  The quantitative portion of this study collected data on unprofessional online student content and administrator perceptions of these incidents, while the qualitative portion asked each respondent for a narrative remembrance of an incident at their own school and at one other school.  Quantitative data returned by 293 schools, a 26% response rate, described the most reported incidents included negative comments or profanity, breached patient confidentiality or discriminatory language, or inappropriateness such as intoxication or sexually suggestive behaviours.  The main concern was the connection of these incidents to either the school or the clinical site.  The majority of programs did not have a committee to deal with online professionalism, however over half did have policies in place though a full third felt the policies were ineffective.  This may be reflected in the disciplinary responses to incidents which were most frequently an informal warning followed by a range of actions from remedial assignments to dismissal.  This study’s results were reported from nursing administration enacting policy in response to unprofessional reports most often from other students.

While this literature search did not focus on the use of social media as a teaching strategy or a learning management platform, these topics arose in all four papers regarding how social media use in the classroom begins to blur the line between social and academic use.  In their systematic review of social media platforms in health education (Smith & Lambert, 2014), it was noted this conflict created a barrier because Facebook and Twitter are considered social environments.  Faculty, therefore, were seen as blurring their relationships with students.  This highlights a difference in how social media is perceived to be used by students and faculty; students for social networking and faculty for professional development (Frazier et al., 2014).  A pedagogical dilemma then exists for creative educators because as Killam, Carter and Graham (2013) stated that if

professors feel like they can’t connect with their students on Facebook because of a set of guidelines then we’re going to lose out and how can we grow as a profession if we’re not evolving with what the times are? (p. 15)

Faculty were described as role models and moderators who were required to monitor conduct and facilitate academic rather than social activities (Smith & Lambert, 2014).  Faculty were encouraged to reflect on fostering learning in a risky environment (Killam et al., 2013) and use the social media platform with discernment considering the fact that it is a tool; how people use the tool does not impact professionalism, but the actions in relation to others impacts professionalism in academia.

Killam et al. (2013) also speak to the use of social media to engage students and enhance learning.  Their mixed methods exploratory descriptive study of perceptions of online professional learning revealed the challenge for faculty of being engaging all the time because of the distraction of unprofessional content.  Suggestions made included nursing and education faculty to take responsibility by monitoring posts and being ahead of the students in their delivery of education over social media platforms, as well as restrictions for use.  The authors’ constructivist approach acknowledged that learning is contextual and therefore a sense of community is created by building networks and practicing ethical netiquette.  Learning was enhanced when students could be more deeply engaged in topics such as becoming more aware of experts or social concerns of the profession (Smith & Lambert, 2014).

The concern of blurring boundaries arose again in response to effecting engagement (Smith & Lambert, 2014).  Two perspectives were acknowledged, one in the practice setting and one in education.  In the study by Frazier et al. (2015) of the use of social media in nursing education, both faculty and students agreed that registered nurses have a higher standard to uphold as professionals when interacting with patients.  In relation to the findings faculty felt it was unacceptable to “friend” patients or post information related to clinical or work.  These same concepts are transferable to the education setting where concerns exist with “friending” students (Smith & Lambert, 2014).  Crossing personal and professional boundaries as educators of nursing sends the perception that faculty can “spy” on students (Smith & Lambert, 2014) or have favourites (Killam et al., 2013).

These concerns seemed somewhat minimized in all four studies as the focus was on student lack of professionalism.  However, Frazier et al. (2014) discussed the need for social media policy for school of nursing liability protection which would encompass students and faculty.  One of the questions in the Frazier et al. (2014) survey was whether social media netiquette was taught and a discrepancy arose that students perceived it was not.  When asked whether social media policies were needed, faculty and students agreed they were required, however, faculty also desired policy statements specific to negative comments of faculty or courses.  This related to the findings of Marnocha et al. (2015) that cyberbullying is prevalent in nursing schools.

The theoretical application for Frazier et al. (2014) was Kohlberg’s (1977) stages of moral development.  Of the six stages, Frazier et al. (2014) commented that nursing students were functioning at stage four, the law and order stage and having a policy to follow fulfills the need for boundaries. While faculty may resent the limits, policy may be necessary.  This led to the discussion that faculty perceived, and have unrealistic expectations that, students are functioning at Kohlberg’s stage five (right action is societally determined) or stage six (right is determined by one’s conscience).  The question, then, is whether students are developmentally ready morally to decide and act beyond stage four.  The issue is whether faculty can use policy as an ethical and moral teaching tool (Frazier et al., 2014).  With the realization that cyberbullying exists (Marnocha et al. 2015), there is a requirement for education on reporting such behaviour and maintaining not only professional standards but organizational policies and restrictions (Killam et al., 2013).  Frazier et al. (2014) stated that ethical education must be at the student moral development level. Modelling professionalism was advocated by Killam et al. (2013) as “you can tell people what to do but you cannot control poor judgment” (p. 13).  Therefore, collaborative and inquiry based strategies are a constructivist approach to support modelled professionalism by faculty.

Online Professional Presence 

This section will focus on online professional presence with regards to literature found in professions such as medicine, pharmacy, and nursing in particular.  Professionalism is an important component of education in the healthcare field (Fenwick, 2014).  Online professionalism is a relatively new topic due to the fairly recent increase in social media use. One of the challenges that has been encountered in this literature review is the lack of research available on online professional presence in nursing, in Canadian nursing programs.  With the dearth of information available a clear definition of online professionalism has not been found.  This is problematic since professional programs, not just nursing, are faced with the increased use of social media among students and faculty (Marnocha et al., 2015) and students should be able to have a clear understanding of this concept.  Thus having a clear understanding of how professional presence online is defined would be beneficial for the students’ professional presence and reputation in the online community and for securing future employment (Alexander, 2016).

The use of new terms such as cyberprofessionalism (Marnocha, et al., 2015) and e-professionalism (Fenwick, 2014) have been used to describe the professional behaviours of online activity, however, there was no clear definition of these terms.  The literature does contain examples of unprofessional online behaviour.  For example, Barlow et al., (2015) defined unprofessional online content as “online depiction of illegal activity, overt intoxication or illicit drug use, or the posting of patient information.” (p. 1.e2).  This study, was an online survey of 880 medical students from 21 medical schools in Australia (Barlow et al., 2015).  Students reported seeing unprofessional content on other students’ accounts and 34.7% self-reported posting unprofessional content.  Marnocha et al., (2015) conducted a survey of deans or directors of nursing schools (n = 293) in the United States regarding incidents of unprofessional conduct posted online by their nursing students.  Respondents were asked to identify whether unprofessional online content from six specific descriptions including: the use of profanity or discriminatory language, depiction of intoxication or sexual suggestiveness, patient confidentiality breaches, or negative comments about patients, peers, work, or profession had occurred at their school.  Online unprofessional conduct was reported by 77% of the respondents (Marnocha et al., 2015).  The most common types of unprofessional posts were; negative comments about the patients, peers, their work environment, or the profession, profane and discriminatory language, and breaches of patient confidentiality.  Less commonly reported were incidents of intoxication and sexually suggestive posts.  As nursing students are in the healthcare field, it is not surprising that the nursing deans and directors surveyed were most concerned with posts containing confidential patient information.  Further, the nursing deans and directors surveyed were also concerned with the posts that were derogatory to the educational institution and the profession.  Preventing derogatory comments about others and the educational institutions helps to mold and strengthen the nursing students’ professional identities as well as inform their civility towards others (Marnocha et al., 2015).

Guidance regarding professional presence

A small amount of the literature has reported that nursing schools have developed policies that specifically cover online content (Marnocha et al., 2015).  Moreover, handling unprofessional postings in these institutions was done more effectively than in schools without such policies (Marnocha et al., 2015).  Unfortunately, students who were aware of online policies and guidelines, were still reporting viewing or personally posting content that would be considered unprofessional (Barlow et al., 2015).  The fact that unprofessional content was still posted online, even in the event that there may be consequences, might relate to the assumption that students were unsure whether they should be held to a higher standard and that they believed what was posted on their personal social media accounts should be separate from their professional identity. Prescott, Wilson, and Becket (2013) conducted a survey of 595 students in pharmacy (n = 91), social work (n= 166), and nursing (n = 338), in the United Kingdom.  The results of the survey led the authors to conclude that university students in professional programs need a better understanding of the implications of their behaviours, particularly their online activity.

In addition to educational institutions creating policies and guidelines, some professional organizations have also developed guidelines for online communication.  For example, Marnocha et al. (2015) included guidelines developed by the American Nurses Association, the National Council of State Boards of Nursing, National Student Nurses Association, the American College of Physicians, and Federation of State Medical Boards.  Prescott et al. (2013) listed some of the United Kingdom guidelines.  The Canadian Nurses Association (2012) presented an ethical decision making tool in 2012 which focuses on the ethical challenges of online posts made in private social media platforms.  The Canadian Nurses Protective Society (2012) also published information on social media.  This publication informs nurses of privacy, permanency, and risk management strategies when using social media.  However, most students in professional programs are not always aware of their professional body guidelines or their own school’s policies and guidelines.  As such, it should be up to educators to guide and instruct the students on the expected behaviours (Prescott et al., 2013).

Consequences of unprofessional online presence

Nursing literature has a shortage of information on social media use and professional presence.  One of the gaps in the nursing literature was the perceptions of faculty members and nursing students about the meaning of professional presence.  In comparison, there are several studies that discuss what the consequences are for professionals conducting online activities in an unprofessional manner (Alexander, 2016; Marnocha et al., 2015; Nyangeni et al., 2015; Prescott et al., 2013).  This was a common occurrence in the other healthcare and professional program literature (Barlow et al., 2015; Kedrowicz, Royal, and Flammer (2016)).  Furthermore, the consequences of unprofessional online postings are usually imposed by the professional associations and or educational institutions (Barlow, et al., 2015), with little consistency across the different organizations.  Violations of the Healthcare Insurance Portability and Accountability Act (HIPPA), including demeaning or confidential patient information, and information about peers, educators, clinical sites, or the profession are all considered unprofessional conduct (Marnocha et al., 2015) and are considered the most serious infarction.  Prescott et al. (2013) emphasized the propensity of the literature from most professional programs to be focused on the consequences of unprofessional online conduct, including expulsion from school, job loss, and questioning of fitness to practice. Thus, these potentially severe consequences warrant clear dissemination of professional presence guidelines including potential consequences of not doing so to students and professionals (Marnocha et al., 2015).

Role confusion: Personal versus professional

Another challenge that emerged from the review of the literature on professional presence in the online community was role clarity among the students of professional programs.  Some students have difficulty knowing what professional communication looks like while other students can articulate professional communication.  For instance, undergraduate nursing students in a South African study had difficulty delineating between what should be considered private personal communications and what should be considered professional communication when using social media (Nyangeni et al., 2015).  On the other hand, the study conducted by Josefsson et al. (2016) found that students in a social media technologies graduate level course could identify three distinct types of roles for social media use, private, student, and professional.  The private role was for communicating with friends and family, the student role was utilized while doing academic work on social media sites, whereas the professional role was recognized when social media was used as a tool for career building.  According to Josefsson et al. (2015), potential employers and professional connections could be made when their social media was used professionally, however it would depend on the social media platform that was being utilized.

There has been some discussion about blurred boundaries when it comes to posts online in social media networks.  Some of the concerns students mentioned were regarding the right to have private lives when in professional jobs or education programs.  For instance, nursing students believed that their posts to Facebook (Prescott, et al., 2013) and other social media sites (Nyangeni, et al., 2015) should be considered separate from their academic life. Kedrowicz, Royal, and Flammer (2016) discussed the professional online impression management in a study on doctor of veterinary medicine students (n = 140).  The purpose of their study was to guide the development of education around professional identity in the social sphere.  According to Kedrowicz et al. (2016), the public holds veterinary medicine doctors and by extension the students of veterinary medicine, to a higher standard.  These standards are likely transferable to most professionals in the healthcare field and similarly transferable to nursing (Alexander, 2016).  As Alexander (2016) indicated, “it is difficult, if not impossible, to step outside your identity as a nurse” (p. 262).  With this statement in mind, nursing students should be informed of the potential benefits and consequences of online postings.  Things to consider, according to Alexander (2016), are online profile photos and the content that has been posted and/or promoted.  Having poor personal presentation online could lead potential employers or patients to make judgments about personality, skills and expertise (Alexander, 2016).

In summary, the lack of information in the literature about online professionalism and how one would know how to communicate online in a professional manner is indicative of the need for further studies.  Educators of students in professional programs, such as nursing, are challenged with teaching about professionalism and role modeling a professional manner in several areas.  Nursing educators teach students in the classroom, clinical settings, and simulation laboratories.  In all of these settings it is expected students will present themselves in a professional manner.  The students are also expected to conduct themselves in a professional manner outside of the academic setting, however it is difficult to know if that is occurring, unless it is posted online for all to see.  Other professions have examined professional presence, including pharmacy, medicine, and veterinary medicine and it is necessary to see if students of nursing are comparable to other healthcare professionals.

Discussion

All sections of the literature review revealed a concern with differing perspectives for both faculty and students about presence on social media.  Differing perspectives were thought to be grounded in the amount of time spent or comfort with its use (Jaquemin et al., 2014) and the perception of control over its use by educational institution members (Booth, 2015).  The perception of control or the perception of right to have control, may be the crux of the issue for professional presence in social media. On social media platforms, profiles are built with choice; the picture conveying personality, a description of the individual, and connection points to others through likes and favorites.  Whether used for teaching or learning, social media for academia created a blurring of boundaries.

Nursing faculty indicated they use social media to engage students more in content and process as the faculty believed that social media would help to increase knowledge retention, satisfaction with courses and encourage self-directed learning in nursing students (Jacquemin et al., 2014; Tower et al., 2014).  However, the paradox was students’ perceived faculty use of social media was an invasion on the social environment that sites like Facebook or Snapchat provided (Smith & Lambert, 2014).  The students’ perception was that faculty blurred the divide between academia and social environments and students expressed concerns that faculty were stepping into a private realm rather than promoting professional development (Frazier et al., 2014).  For students, confusion then remained how social media was to be used, privately or professionally (Josefsson et al., 2016; Nyangeni, et al., 2015).  This sentiment was echoed in concerns from faculty and administrators that posting of unprofessional content continued, requiring policies and disciplinary committees (Marnocha et al., 2015; Prescott et al., 2013).  The question to be answered is whether faculty created this blurring of boundaries or provided an opportunity for learning how to separate personal and professional identities.

Nyangeni et al. (2015) suggested that it should be clearly stated that role modeling is needed.  “Educational institutions need to be proactive by implementing social media policies and ensuring effective and timely handling of student-posted unprofessional content” (Marnocha et al., 2015).  Marnocha et al. (2015) reported that students who are aware of the policies are still both viewing and posting content that would not be considered appropriate, so although there are some policies and some education happening regarding social media use there seems to be a barrier in these translating into nursing students’ practice.  Nyangeni et al. (2015) discovered that medical students do not associate their social networking with their current and future career, so perhaps nursing students are also misinterpreting the severity of unprofessional behavior online. As the increase in social media use is relatively new, it is possible that educational institutions missed the opportunity to be proactive in creating policy.  What is evident in the research is that dealing with unprofessional posting as it happens was not an effective means of teaching about online professional presence.  Additionally, there appeared to be missed teaching opportunities for both faculty and students.  Now more than ever there is a need for educational institutions to form committees to create solutions, and proactively ensure that professional presence online is occurs.  Killiam et al. (2013) explained that students and faculty both felt registered nurses uphold a higher standard of professionalism, but if it is not being taught in curriculum what is there to prove students are being properly educated about online professionalism and ethical netiquette?

Professional presence online compared to professionalism in-person requires further examination.  Students of professional programs require ethical, moral, etiquette and netiquette training while in their programs.  Frazier et al. (2014) found students were unaware of the National Council of State Boards of Nursing’s social media guide and believed that teaching these principles needed to be completed while the students were in the correct developmental stage.  By doing so, this may help students garner the netiquette, or online etiquette, skills needed to exhibit cyberprofessionalism.  Unfortunately, incivility in nursing has long been an issue in face to face interactions and is now crossing over into cyber streams, such as social media, which sometimes mixes back into the face to face interactions.  For example, Marnocha et al., (2015) found that 11% of the respondents reported incidents of cyberbullying.  One such incident that was reported was of an exchange between two students that had originated on social media and then continued in the classroom, causing a disruption for all present.  By educating about and reinforcing the professionalism in communication, in the online communities as well as in person, perhaps the use of derogatory comments about peers, coworkers, patients, and educational institutions will drastically decrease.  The result would lead to the molding and strengthening of the nursing students’ professional identities and inform their civility towards others (Marnocha et al., 2015).  Future research is needed that examines cyberbullying among and towards nursing students, faculty, and practicing nurses and what ramifications this unprofessional conduct has on nurses and the nursing profession.

Many nursing students and nursing faculty were either not aware of guidelines with regards to social media or there are no existing or clear guidelines or education surrounding how to use social media in a professional manner (Barlow et al., 2015).  There are consequences for nurses when they do not use social media professionally (Alexander, 2016; Marnocha et al., 2015; Nyangeni et al., 2015) so where can nurses find information on professional social media use and can and should that information be included in undergraduate education to better prepare nursing students for entering the profession?  The Canadian Nurses Association (2012) provided ethical examples and discussion points, but no clear guidelines from the perspective of a national professional association. Some provincial nursing bodies do give clearer social media guidelines and policies (Nurses Association of New Brunswick, 2012; Registered Nurses Association of Ontario, n.d.).  Nursing schools and nurse educators should integrate social media education into their undergraduate nursing and continuing education curricula (Marnocha et al., 2015).  Nurses have a responsibility to ensure they understand their employer’s policy regarding social media use, however it is clear human resource departments needs to allocate some supportive education surrounding professional use of social media for their nurse employees.

Conclusion

Online professionalism is becoming a matter of great concern for nursing programs. The current nursing literature is lacking information on Canadian nursing student and faculty use and perception of online professionalism on social media.  Furthermore, the paucity of appropriate social media guidelines and policies for nursing is concerning.  It is important that more research be conducted in this area so educational institutions can properly prepare future nurses.  Nursing students need to be well equipped for their role as a professional nurse, not only in their face to face practice, but also in their online communications.  However, as social media platforms change and access between patients and healthcare providers becomes more fluid, the nature of indiscretion and how it is handled must change.  Future research should focus on professionalism in nursing in online communications with ways to increase awareness and development of appropriate social media guidelines and policies.

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AUTHOR BIOS

Natasha Hubbard Murdoch RN BSN MN PhD(c) is a mixed methods educational researcher with a focus on interprofessional education. Innovative approaches to pre-qualifying experiences for students focus on role clarification and teamwork and are based in face-to-face problem based learning, a diverse array of online platforms, blended learning, and simulation.

Angela Ahlquist RN BScN MA is faculty with the SCBScN program at Saskatchewan Polytechnic. Angela’s master’s thesis focused on new parents’ perceptions of infant sleep problems. Angela is interested in all aspects of social media application in health including patient and healthcare provider perceptions of bullying.

Pamela Farthing RN BA MSc is Research Chair in Diabetes Care at Saskatchewan Polytechnic.  Pamela’s research experience spans respiratory epidemiology, diabetes, nursing, and rural health. Pamela’s interest in social media arose from her experiences in online education and her work on provincial and national nursing informatics organizations.

Justine Mennie RN BScN is a new graduate of the SCBScN program practicing in a rural prairie setting. During her tenure as a student on council, Justine focused on social media policy in the educational and health settings and helped drive the development of this research.

Acknowledgements

This research was supported in part by funding from the Institute of Nursing Scholarship, School of Nursing and the Office of Applied Research, Saskatchewan Polytechnic.

 

 

 

 

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