by Sigrid Stjernswärd, PhD

Associate Professor, Health-promoting Complex Interventions, Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden

Frode F. Jacobsen, PhD

Professor, Centre for Care Research, Western Norway, Western Norway University of Applied Services, Bergen, Norway

Stinne Glasdam, PhD

Associate Professor, Integrative Health Research, Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.

Citation: Stjernswärd, S., Jacobsen, F. & Glasdam, S. (2023). Scandinavian nurses’ use of social media to position themselves as nurses and the nursing profession during the COVID-19 pandemic – a Berger and Luckmann inspired qualitative study. Canadian Journal of Nursing Informatics, 18(2).  https://cjni.net/journal/?p=11570

Abstract

Based on a study of nurses’ social media uses during the pandemic, this article aims to illuminate how nurses used social media to position themselves as nurses and safeguard the nursing profession. Thirty semi-structured interviews were conducted with nurses in the three Scandinavian countries. Data were thematically analysed, with theoretical inspiration from Berger and Luckmann (1966). The findings revealed that nurses used social media as a showcase to illuminate their working conditions and to support their unions’ struggle. However, nurses were also cautious regarding social media uses. Conclusively, nurses used social media as a mouthpiece to reach an audience, which could include colleagues, the general public, and possibly a wider audience, while balancing their professional role and associated ethics, so as not to cross the line of internalised values pertaining to the nursing profession. This motivates further studies on nurses’ professional uses of social media.

Keywords: Berger and Luckmann, COVID–19, Interview study, Nurses, Nursing profession, Scandinavian, Social media, Working conditions.

Background

This study focuses on nurses and their use of social media during the COVID-19 pandemic to highlight the nursing profession. The COVID-19 pandemic has contributed to illuminating societies’ possibilities to deliver healthcare services to their citizens in the face of a global crisis. Healthcare professionals’ working conditions have come to the fore, for example health hazards for nurses pertaining to COVID-19 related work tasks, including emotional distress, depression, burnout, ethical stress, and COVID-19 infections (Nagel et al., 2022). Before the pandemic, the World Health Organization (WHO, 2018) estimated that about nine million nurses and midwives will be needed by 2030. However, an increased turnover seems to have followed due to bad working conditions, burnout, and fear of COVID-19 among nurses during the COVID-19 pandemic (Berlin et al., 2022; Fronda & Labrague, 2022).

The COVID-19 pandemic has contributed to putting nurses’ roles and working conditions in the limelight (Anders, 2021; Bergman et al., 2021; Halcomb et al., 2020). The mass media predominantly seem to present nurses in three ways, namely 1) nurses as selfless, sacrificing, and outstanding moral subjects practising on the front-line under unfair conditions; 2) nurses as model citizens, being compliant, hardworking, and obedient subjects; and 3) hero worship as a fitting reward for nurses who were unappreciated pre-pandemic, with heroism reconfiguring nursing work from the ordinary and mundane to the impactful and exciting (Mohammed et al., 2021). With social media, information travels fast, with users having the option to be prosumers, meaning that they can be both consumers and producers of information (Goodyear et al., 2021). This means that individual citizens, including nurses, can choose to publish publicly accessible material through social media platforms, thereby potentially affecting consumers’ view on, e.g., nurses and nursing through their postings. O’Leary et al. (2021), for instance, showed that nurses were active on social media platforms such as Twitter during the COVID-19 pandemic. Besides sharing knowledge, nurses were keen on advocating for improvements needed to address COVID-19 and used social media to reach out to politicians and healthcare leaders. Network analyses nevertheless showed that nurses primarily interact with their own professional community, limiting their influence in a broader context (O’Leary et al., 2021).

The last decades have witnessed a fast-developing digitalisation of society, including health and healthcare services. It affects possibilities for citizens to inform themselves and for individual citizens, patients, and healthcare professionals to work together for prevention, diagnostics, treatment, and rehabilitation, since many people carry minicomputers in their pockets in the form of smartphones. In some respects, the pandemic has contributed to accelerate this digitalisation, paving the way for creative uses of social media to address COVID-19 related challenges. Social media were often used by individual citizens, professional groups including nurses, organisations, and governments to cope with the crisis inflicted on society (Gladchenko, 2022; Rajan et al., 2022).

A recent study demonstrated that nurses’ use of social media functioned as a socialisation tool for establishing new COVID-19 routines in clinical practice and as ways to have collegial support and supervision, but also in the education of nursing students during the pandemic (Glasdam et al., 2022a). Furthermore, virtual meeting places (such as MS Teams) supported collective understandings of the COVID-19 situation and related knowledge amongst nurses, with the pandemic bringing to the fore the already imperative issue of e-professionalism regarding nurses’ clinical practice (Mosalanejad et al., 2021; Rukavina et al., 2021). Examples of social media uses supporting knowledge development include gaining and sharing information about COVID-19 procedures through social media, watching instructive YouTube videos about uses of protective gear, and using social media to influence the population to adopt so-called correct COVID-19 behaviour (Glasdam et al., 2022a; 2022b). Such innovations have the potential to support healthcare delivery. Nevertheless, risks are present and must be taken into consideration, for instance related to safety, inequality, confidentiality, and legal issues (Moutasem et al., 2021; Naeem & Ozuem, 2021). Such developments have also led to blurred boundaries in terms of private and professional spheres, highlighting issues related to nursing and e-professionalism (Glasdam et al., 2022a; Rukavina et al., 2021). Further, this illuminates some challenges relating to ethics, regulations, work routines, and more. A deeper understanding of nurses’ use of social media can therefore be of interest, as it may shed light on how such uses potentially contribute to constructing nurses’ own and social media users’ views of nurses and nursing. This article aims to illuminate how nurses used social media to position themselves as nurses and portray the nursing profession during the COVID-19 pandemic.

Method

The current study was based on individual semi-structured interviews with thirty nurses in Denmark, Norway, and Sweden. The empirical material was analysed using a thematic analysis, inspired by Braun and Clarke (2006) and theoretically inspired by Berger and Luckmann (1966), see also (Glasdam et al., 2022a). To enhance the study’s quality and transparency, the Standards for Reporting Qualitative Research (SRQR) checklist was used (O’Brien et al, 2014).

Theoretical framework

Berger and Luckmann’s (1966) theory of reality as a social construction was chosen as a theoretical framework. This theoretical perspective could help to shed light on how usual systems, organisations, and individuals (re)act in a global crisis situation such as the COVID-19 pandemic, when routine actions are more or less dissolved and potentially replaced by new actions. Daily structure gives everyday life meaning because it helps individuals apprehend everyday life as normal and self-evident, with individuals’ understandings of reality being formed by the society they live in (Berger & Luckmann, 1966). When disrupted, as seen during the COVID-19 pandemic, the meaning of everyday life needs to be restored through cultural processes of meaning-making. According to Berger and Luckmann (1966), ’society’ can be understood in terms of an ongoing dialectical process composed of the three movements of externalisation, objectivation, and internalisation. Humans continuously externalise their views and assumptions by expressing their sense of reality through communication with others. By processes of confirmation and dis-confirmation as to what is reality, a sense of shared reality results in objectivation, i.e., presenting a view of the world as an objective reality to members of a society, groups, or institutions. Hence, objectification implies that mutually interacting people confirm a certain understanding of reality to each other, which will appear to them as if it were an objective reality.

Socialisation leads to people internalising this reality as individuals are brought to participate in the social institutional structure, i.e., in its objective reality (Berger & Luckmann, 1966). Socialisation refers to the comprehensive and sustained governance that leads individuals into the objective world of society/sub-universes, with primary socialisation occurring as a child. Secondary socialisation includes the acquisition of role-specific knowledge and happens through the internalisation of group or institutionally based sub-universes, such as interest groups and healthcare institutions. Institutions confront individuals with seemingly undeniable facts, external to the individual and persistent in their shaping of experience of reality. All institutions have a motivating and controlling body of knowledge, which defines and constructs institutionally appropriate rules of conduct, representing a body of generally valid truths about reality employed in the sanctioning of deviance. Individuals pick up institutionally appropriate rules of conduct and the dynamics of institutionalised conduct and roles to be played through socialisation and internalisation (Berger & Luckmann, 1966). Individuals’ specific societal context influences their understandings of reality and knowledge, also applying to nurses during the pandemic, with individuals externalising their own understanding of reality in communication with others. Individuals thereby embody institutions through constructed roles and associated rules of conduct, through which they participate in a social world that becomes subjectively real to them. Through habitualisation and social interaction, institutionalised roles are fortified.

The existence of sub-universes, however, creates a tension between the subuniverses’ insiders and outsiders. Insiders must be kept in and outsiders need to be kept outside and accept the sub-universe as legitimate. Procedures of intimidation (e.g., propaganda) bring about legitimation, which serves to construct and integrate meaning attached to institutional processes, that is, objectifying meaning. Legitimation entails cognitive and normative elements, both ‘knowledge’ and ‘values’, telling individuals how they should act and how things are to be understood (Berger & Luckmann 1966). Compliance with socially defined role standards is not optional and non-compliance leads to sanctions. Individuals’ understanding of everyday life can however be threatened if the reality of everyday life becomes problematic and the integration of what the individuals perceive as normal and self-evident no longer seems true, which for instance can happen for nurses in relation to crises such as the COVID-19 pandemic (Mohammed et al., 2021). As human activity is subject to habitualisation, with repeated actions becoming a pattern (Berger & Luckmann, 1966), crises such as the pandemic can be viewed as a situation that profoundly changes everyday life as previously known to most individuals, including nurses.

Participants

The participants were recruited using convenience sampling (Patton, 2015) and included nurses, who worked during the COVID-19 pandemic, regardless of age, gender, and length of professional nursing experience. There were no explicit exclusion criteria. The participants were recruited through social media posts, personal contacts, and snowballing, where participants pointed to other potential interviewees (Leighton et al., 2021). Interested nurses communicated with named contact persons in their specific country. Ten nurses from each of the three Scandinavian countries were interviewed. They worked in hospitals, nursing homes and home-based care services and mentioned private and/or professional (non) use of social media platforms in relation to COVID-19 (see Table 1). The empirical material was not fine-grained enough to make deeper analyses of the different uses of the named platforms.

Table 1: Characteristic of the nurses included in the study

Interviewing process

A semi-structured interview guide was constructed and translated into the three Scandinavian languages, facilitating a homogeneous and dependable data collection while remaining responsive to the individual participants’ needs (McIntosh & Morse, 2015). The interview guide was developed in a consensual process between seven researchers in Denmark, Norway, and Sweden from the fields of nursing and media/communication, respectively. The authors had multiple occasions to discuss their respective knowledge and pre-understandings about nursing, social media, and the COVID-19 pandemic, thereby promoting self-reflexivity.

The guide covered the following themes: sociodemographic data; general use of social media; and private and professional uses of social media related to COVID-19. Participants were asked to describe what type of information they read/shared, on which platforms, for which uses, etc. Social media were defined as digital platforms for the distribution of user generated content, such as Twitter, Facebook, LinkedIn, etc. All seven researchers carried out one pilot interview each, which were all included for analysis. Participants easily grasped the interview questions; thus, the interview guide was not modified. The seven involved researchers performed three to seven interviews each (April-August 2021) via a digital audio-video platform (Zoom), using the same interview guide. All participants and researchers were unknown to each other prior to the interview. The interviews were audio-recorded on external Dictaphones, lasting 21-89 minutes each (average 51 minutes). 

Analytic strategy 

The latent, thematic analysis was methodically inspired by Braun and Clarke (2006) and theoretically inspired by Berger and Luckmann (1966). Firstly, all interviews were transcribed verbatim, whereafter all researchers read the aggregated empirical material several times for familiarisation with its content. All researchers were able to read and understand the aggregated empirical material, as the three Scandinavian languages are based on a historical language community (Lund, 2006). Thereafter, the transcribed interview contents were manually reorganised one interview at a time, using a common matrix developed in consensus by all seven researchers, with no software. Eventually, the current article’s authors coded and reorganised the entire empirical material in accordance with the article’s aim. For this process, analytical questions theoretically inspired by Berger and Luckmann’s (1966) theory of reality as a social construction were used to break down and reduce the amount of the empirical material. The analysis’ focus was not to compare nurses across countries or different work settings, implying that the empirical material was analysed as an entity across the Scandinavian context. The analytical questions focused on what nurses expressed about their uses of social media to reconstruct their position as nurses and the nursing profession during the pandemic:

• How did nurses’ use of social media challenge and/or support the existing social order and reality of nurses’ position and the nursing profession, internally and externally?

• How did social media uses support the externalisation, internalisation, and habitualisation of professional work prerequisites and conditions amongst nurses during the pandemic?

Themes were constructed based on the coded material and were then reviewed and further developed in a dialectic and consensual analysis process amongst the authors, with the study’s aim and analytical questions in mind. Initially, the researchers carried out the described steps separately, then co-jointly. Through this analytical process, two themes with two sub-themes, respectively, were refined, defined, and named (Braun & Clarke, 2006), see Table 2.

Table 2: Themes and sub-themes

Ethical considerations

The study was ethically approved in Norway (no. 343272 and 492729) and followed the Helsinki Declaration principles (World Medical Association, 2013). Ethical approval was not necessary in Sweden or Denmark. Personal data was handled in accordance with the EU General Data Protection Regulation (GDPR) 2016/679 (European Union, 2016).

Findings

Showcasing working conditions

An opportunity to highlight pros and cons

The pandemic was an opportunity for nurses to rethink, reconstruct, and highlight critical working conditions, and to showcase this internally and externally to different parties, thereby positioning themselves as nurses within their profession in healthcare and society. While some nurses chose to use social media to externalise their working conditions, others were more restrictive, as will be seen below. Nurses used social media to make their voice heard in society and to communicate their experiences of their working conditions during the COVID-19 pandemic to each other, representing ways to externalise their working conditions. The pandemic made the need for nurses’ functions and efforts in society clear to the general population, including politicians and decision-makers, thereby aiding nurses in highlighting their position in society and potentially generating recognition amongst nurses with similar experiences. Such engagement potentially supported nurses’ professional identity, roles, and collegial unity. Nurses described that some social media posts highlighted nurses’ forced move to specific COVID-19 units against their will. Through such social media contributions, nurses created noise internally and a counter-movement related to the organisation of the healthcare system and nurses’ roles within this system, and externally in society in general. Nurses externalised their insider experiences of professional conditions, with the potential to disturb the prevailing social order and reality of the healthcare system in which they were working.

My post about a forced relocation to a COVID-19 section. It went crazy, with over 5,000 shares over the weekend. I was flooded with telephone calls by television and radio channels and different newspapers […] It was based on my own personal situation, but I also tried to lift it as a more general criticism […] I felt insecure and lacked skills. I questioned whether it could have been avoided? […] The Danish Nurses Organisation had (in vain) fought for insanely many months to get such a contingency supplement.

(DK1)

Social media channels were also used to inform the public about professional/clinical conditions in general, with focus on how the pandemic affected nurses’ working conditions, and, by extension, the care that could be provided to patients.

You try to share for an enhanced spread, to make people understand how it has been and is in intensive care [..] When our doctor made a description of what our reality looks like, with the politicians’ image not matching our reality. We’ve tried to spread it, so the public will see how it is.

(S4)

Other social media posts illuminated working conditions related to the pandemic, which nurses experienced as burdensome, such as the wearing of facemasks and protective equipment that created problems and a stressful bustle.

The frontline nurses (in trade union affairs) choose to go on social media, (and they) will talk to a journalist, or whomever it may be. They share different things, such as their working conditions and how to wear masks, how marked their faces are, how to dress and undress in a COVID-19 section 20 times a day, and how one has to wait until it’s one’s turn to get out.

(DK6)

Moreover, some insider nurses reflected on the exhibition of poor working conditions posted on social media. These nurses reported the presence of both scarce and good resources and conditions to handle the pandemic within their organisation, and outpatient care at hospitals, referring to conditions that were not as visible in the media as more dramatic events (e.g. high workload, spread of the virus). Examples included the temporarily diminished workload in departments not focusing specifically on COVID-19 infected patients. This image contradicted and nuanced more dramatic depictions of the healthcare system, showing that different settings were affected by the pandemic to varying degrees.

There has been a lot of focus on hospitals. We really had a great time during the pandemic, we had what we needed (in terms of safety equipment). Some wards have been busy, but often (the pandemic) resulted in fewer patients for outpatient teams. We’ve had some periods, e.g., in March last year (2020), when we didn’t really know what to do (few patients). This didn’t show in the media.

(N9)

However, nurses also reported advantages related to not following social media feeds too closely, to avoid increased COVID-19 related stress. Social media posts could for instance contribute to the castigation of healthcare professionals/organisations that were deemed to deviate from set COVID-19 management rules. Healthcare organisations could be put under hard pressure through the media, with nurses being sought out by journalists and being stigmatised in the general population. For instance, nurses were at times depicted and viewed as causing further spread of COVID-19. In that way, some nurses defended the healthcare system’s practices and the professionals’ competencies by justifying the prevailing conditions during the pandemic.

We had been infected (at the nursing home). People died. There was a lot of rioting outside by journalists and stuff. And my neighbours walked in a circle around me. There was lots of chaos, so I think I was happily unaware of what was written on both Facebook and other platforms. […] We worked our fingers to the bone to keep the infection away, that was the truth.

(N5)

Other nurses were afraid of being branded as incompetent by outsiders who did not belong to the healthcare system if they did not succeed in pandemic related tasks. Therefore, those nurses revealed nothing on social media.

We’ve actually been a bit afraid of doing something wrong, to be accused of something afterwards in social media. We had an outbreak at our place. […] It should have come out in the media, but […] nobody wanted to be a spokesperson for the ward.

(N8)

Benchmarking and updating competence and security issues

The COVID-19 pandemic could be regarded as a collective crisis of reality where the virus as a threat to people’s lives was perceived as an overhanging risk. Nurses used social media information as arguments for implementing changes in their practice, in that way potentially affecting nurses’ working conditions and practices while using social media as a leverage for this. An example includes posts on the use of protective equipment, and when there were disagreements about guidelines or face masks. Social media revealed that the new social order in relation to correct COVID-19 behaviour was uncertain, open for interpretation, and thus also for negotiation among decision makers within healthcare. Facebook, for instance, was used as a channel for critical reflections on protective equipment that nurses were offered and required to use.

(Facebook group) is called: “I’m a nurse” […]. There are some (nurses) who write questions, and then there are 142 comments […] (We) found some scientific articles (about face masks) […]  (I) confronted my manager with (these facts). She took the question further to a corona group in the municipality. Then, we got other kinds of masks.

(DK3)

Furthermore, social media forums for professionals were used to share clinical experiences related to the handling of COVID-19 infected patients, thus becoming a guide for the clinical management of infections, and leading to the implementation and internalisation of new clinical routines and safety margins in the handling of patients. Social media use thus potentially influenced nursing practices.

‘This is not a scientific forum (Facebook forum for healthcare professionals), all members must be conscious that this is a damage control group, because there is no other place to share such information. Everything that is written here needs to be considered critically.’ But it was really good because there were lots of experience exchanges […] There was no evidence for this either, but since so many said it, it seems to be the case (healthcare professionals noticed that COVID-19 infected patients’ oxygen concentration decreased rapidly while walking even if not when sitting down). We started implementing this (a so-called ‘POX walk’, i.e., a 20 metres walk while measuring patients’ oxygen levels) as a safety margin.

(S3)

Nurses’ use of social media also highlighted how the reality in healthcare was subject to societal economic considerations, which from nurses’ perspective seemed to have a higher priority than nurses’ safety and health. Reading social media posts aroused an ‘inner rebel’ in some nurses who otherwise supported the healthcare system’s reality and order. Information from social media could thus lead to the questioning of nurses’ working conditions and clinical reality.

I read on Facebook about those masks, how safe are they? Do we really have to put on a PF-FFP3 mask every time we go to a patient? Suddenly, there was talk about: We must not wear them; only when the patient receives some form of oxygen treatment, because they are too expensive. It was difficult not to get – perhaps because one was already frustrated – an impression that this related to finances more than my security.

(DK1)

An extension of union struggles – or the silence of the Samaritans

A call for better salaries

The pandemic gave rise to a critique of nurses’ salaries and demands for higher salaries. Nurses from Norway and Denmark participated in legal strikes during the pandemic. Social media were thus used to spread voices and messages contrary to the institutions’ established regulations and working contracts, thereby potentially undermining socialisation efforts and roles in line with the institutions’ traditional order. This included professional hierarchies and related rules of the game. Such posts thus contributed to the externalisation of negatively experienced working conditions and, potentially, to the subversion of a prevailing social order within healthcare, although nothing can be said about such posts’ actual effects.

Although I’d not written anything about it (about nurses getting gingerbread as a compensation for extra COVID-19 related efforts), there were many (posts) about this. If I saw some postings with [..] good arguments as to why it was wide off the mark, I reposted them (on Facebook/Instagram) [….] My posts on Facebook have been a lot about salaries and civil service reforms. I’m also an employee representative, so I’ve also posted stories about our rights and salary.

(DK1)

Lack of acknowledgement from employers, e.g., in the form of absent salary compensations, testified about nurses’ relatively low position within healthcare. Social media posts represented nurses’ different views on salaries and strikes, pointing to both the orthodox nurse supporting the existing order and the rebellious nurse, challenging the order of the healthcare system and their acknowledgement in society. However, the rebellious nurses challenged the order in different ways, revealing disagreements within the rebel group. This could simultaneously be seen as an asymmetrical rebel company with internal insider battles within healthcare.

I also don’t mind posting a slightly controversial post [..] I think I’ve stepped on some nurses’ toes in my private sphere. There’s been a long, long debate about whether nurses should go on strike or not. [..] I think I got 11 likes, and there are not very many of them who are nurses [….] and I still have a reasonably large professional circle […] It’s very interesting that you can read Facebook that way.

(DK4)

Well, I think it’s been kind of positive, because whatever way it is, we as nurses think that we get paid too little, the workplace climate is bad. […] I think politicians need an eye opener and this is what one had hoped for a bit, but it won’t be like that. […] we got 3000 extra crowns once and then we get an extra week of holidays during the summer, that’s what we get.

(S8)

Nurses’ use of social media as a political mouthpiece ranged from the very active and outgoing rebel to the one passively reading and silently accepting both the existing order and others’ attempts to change this order.

The challenge is that you always have to think about what you say, because there’s a culture of silence in healthcare and the media, so you can’t write just anything. […] You can’t say how it really is. You shall just be grateful and keep working, but not say anything at all about what isn’t good. […] I’ve also shared things, which I think are important, and I’ve written things on Facebook. I stand for that, but you must be careful. There’s chatter, of course, that the trade union will also silence the shop stewards. […] I don’t know if it’s because you don’t want to show how it really is. […] The whistleblowers have a hard time.

(S9)

Nurses reported on social media initiatives that were meant to support them in their professional roles. The image of nurses as the good Samaritan could be conveyed by others through initiatives in social media praising nurses’ work, such as Facebook groups inviting people to applaud nurses at a specific time every day. Nurses at times appreciated such initiatives, but also gently derided them. Although well-meant, nurses perceived that such efforts did not seem to result in, for instance, increased salaries.

All the posts about all those that clapped their hands in the evenings for healthcare personnel. I had kind of mixed feelings about this, partly because it was a bit silly but also nice. What else can you do to show your appreciation?

(S7)

Nurses’ societal importance in focus

Social media were seen as a channel to attract focus on the nursing profession per se, with some nurses calling for more trade union activities in social media. Some nurses expected the trade union to use social media in a socialisation platform to promote the profession, inviting experienced and forthcoming nurses, and a wider audience into the nurse profession’s reality.

The advantage of social media is that you can really get some attention paid to a topic. Some visual content is totally cool. At the last employee representative meeting I attended, I suggested to our district chairman that the Danish Nursing Organisation should become stronger on social media. Where are you on Instagram?

(DK1)

Nurses also forwarded the trade unions’ postings that aligned with their message, and thereby used the trade unions’ position as a lever to give the contents credibility and power. This thus shed light on the different institutions’ diverging interests, the healthcare system, the politicians, and the trade unions as nurses’ representatives. Nurses used social media to dismantle existing structures and to support their own case through the trade unions’ messages.

The Danish Nurses’ Council made the posting (Trade union-launched slogan: “Now, we will take care of you when you get sick, then you must abide by the rules”) [..] It was not a completely out-of-the-blue-message to diffuse. I think it also gives the message a little more weight when people can see where it’s from (Danish Nurses’ Council).

(DK3)

Other social media posts pointed at nurses’ professional role as exposed and busy, with nurses leaving their workplaces and the profession, thereby externalising the social reality of the profession as experienced by nurses. This could be seen as a call for more nurses in the profession and for strategies to recruit and maintain nurses in healthcare, with the pandemic highlighting the critical need for nurses in society.

Nurses are in the (pandemic’s) centre. It’s clear that you take the opportunity to get the spotlight on yourself, and nurses are of course worth it. […] So it’s really a good opportunity to actually use social media, but then it’s probably my personality that makes me not want to jump on the bandwagon.

(S7)

Nurses used social media to follow and/or share their opinions on the healthcare system’s current status and to highlight changes that they deemed necessary to uphold adequate care and retain nurses in their workplaces and the nursing profession. They offered an insider view of the healthcare system’s conditions, basically demanding a change of the rules of the game to uphold the system’s healthcare function and nurses’ motivation to stay in the profession.

One shall follow the recommendations that Sweden’s Public Health Agency demands. I’ve done that and I think everybody shall do it […] to hinder the virus’ spread and relieve healthcare […]. I’ve also shared posts (including my own comments) […] The healthcare system needs to be refurbished. […] (if not) there won’t be anyone who wants to work with this […] We’re on our knees.

(S9)

Discussion

COVID-19 generated a global crisis, which some nurses grasped as an occasion to exhibit their professional working conditions, thereby externalising the conditions of their professional sub-universe through social media. This externalisation both enhanced their own collective meaning-making and potentially engaged a wider public in discussing nurses’ working conditions. The findings show that nurses used the pandemic to promote demands for trade union policy improvements regarding salaries and working conditions. Nurses used social media as a mouthpiece to reach out to the general public, politicians, and employers, thereby externalising their work conditions. Kubisa (2016) argued that healthcare professionals face the dilemma of how to protest without harming patients and, simultaneously, capturing public attention. Nurses in clinical work perceive protest decisions as dramatic (Kubisa, 2016) and may have the ambition to organise protests with minimum negative impact on patients’ situation and professional care and treatment activities. This is in line with the picture of nurses as selfless (Kubisa, 2016) and as good Samaritans (Ahn, 2021; Glasdam et al., 2021), and thus with internalised roles that are potentially in agreement with such perceptions. Nurses’ willingness to take care of patients e.g., during strikes undermines their bargaining position (Kubisa, 2016).

It seems as if the pandemic has highlighted the necessity and importance of nurses’ roles in the healthcare system and in the general population, including politicians and decision-makers. The current findings pointed to the fact that some nurses use the pandemic as a steppingstone to challenge the political system, while others tacitly applaud the rebels’ activities, and others distance themselves from the rebels’ activities, trying to maintain the current order. From a Berger and Luckmann (1966) perspective, this could be seen as a struggle to keep the insiders in, i.e., the ones sticking to institutionalised roles and rules, and the outsiders, e.g., ‘rebels’, out through attempts at upholding the existing order. It could also be seen as attempts at dismantling the prevailing working conditions, through attempts at overthrowing the existing rules and thereby creating a somewhat altered shared reality, where social media play an increasing role in the externalisation of, e.g., working conditions and professional roles, and the objectivation of this reality. The literature indicates that nurses’ at times precarious working conditions and employment realities may represent a threat to their health and quality of life, including low salaries, strenuous working hours, and high exposure to risk (Llop-Gironés et al, 2021), especially since there is a global shortage of nurses (Buchan & Aiken, 2008; WHO 2018).

Scandinavian nurses have been organising trade unions since 1899 in Denmark, 1910 in Sweden and 1912 in Norway, fighting for good working conditions and increased salaries. Professionalisation is related to both the service task and image building regarding autonomy, granted through public recognition (Forsyth & Danisiewicz, 1985), serving to justify the institutional order and objectify meaning (Berger & Luckmann, 1966). The pandemic seems to have functioned as a take-off for many nurses to fight for the recognition of their role and profession in the population and within healthcare, and to challenge their salaries’ and working conditions’ status.

Further, the findings show that nurses use social media as consumers and producers of information. They consume and produce value in social media for self-consumption or consumption by others, with or without implicit or explicit incentives from organisations involved in the exchange, and with potential benefits on individual, organisational, and societal levels (Lang et al., 2020). In the current findings, nurses are keen on using the pandemic and social media to showcase professional requirements and working conditions, with hopes for improvements in terms of e.g., salary and working conditions on individual and organisational levels. Attracting and retaining nurses in the profession can affect whole societies. The Scandinavian welfare state, for instance, is dependent on public work forces such as nurses, since all citizens are entitled to free health and social services, financed by general taxes (Dahlborg et al., 2020).

Nurses in the current study both consume and share others’ and ‘self-made’ information through social media, although nothing can be said about the posts’ potential effects and recipients. Little distinction has been made in the findings relating to the used platforms, which requires further study. Furthermore, the current findings are based on a limited sample, only giving a glimpse into possible social media uses, with a variety of levels of engagement with social media amongst nurses. Nurses also problematise social media uses, showing a ‘high professional morale’ (Glasdam et al., 2022a). This echoes findings on e-professionalism, focusing on attitudes and behaviours that reflect professionalism through digital media (Mosalanejad et al., 2021; Ryan et al., 2019; Wang et al., 2019). Perceptions of e-professionalism can nevertheless vary depending on personal, public, and professional values, intents, and attitudes, with different platforms and levels of privacy being seen as more or less acceptable for sharing different types of posts (Ryan et al., 2019).

Previous studies also showed that social media can be a source of information, misinformation, and disinformation (Glasdam & Stjernswärd, 2020; Hollowood & Monstrous, 2020), a tool to promote the nursing profession (Glasdam et al., 2022b) and to advocate for professional improvements (O’Leary et al., 2021). O’Leary et al.’s (2021) study showed how nurses’ power to influence in a broader societal context is questioned if the profession only communicates internally. The pandemic related healthcare crisis nonetheless contributed to illuminate both new and existing problems that mirror nurses’ clinical reality. The current findings show that social media postings contributed to shed light on nurses’ experienced clinical reality to a wider audience. Nonetheless, different approaches to social media use were seen, with nurses showing an awareness of their professional role versus their private persona, which reflected ideas on e-professionalism (Rukavina et al., 2021).

Study Limitations

This study has strengths and limitations. The snowballing recruitment procedure tends to recruit homogenous samples, which can restrict the diversity of expressed viewpoints and experiences. Recruiting through social media may limit the recruitment of participants to those with an active online presence (Leighton et al., 2021). Thus, the use of both social media and personal contacts for recruitment can be seen as a strength. The sample was varied, with more or less active participants regarding social media use. Further, participants came from a range of different healthcare organisations, encompassing diverse wards/care organisations, while simultaneously only including a restricted number of nurses from the individual, specific wards/care organisations. From a philosophical perspective, saturation is impossible since an interview is a moving target conditional on new questions and new responses occurring throughout the interview (Guest et al., 2006).

The study generated rich data from three Scandinavian countries, which may partly speak for the findings’ transferability. The analysis illuminated heterogeneity, tensions, and a richness of experiences and social media uses, which can be further explored in future studies focusing larger samples and samples focusing on specific types of healthcare organisations/wards and social media platforms. All authors were involved in the analysis process, including a continuous movement between the transcribed empirical data and the proceeding analysis when constructing themes, strengthening the study’s trustworthiness. Quotes were used to highlight the participants’ voices, to illustrate the findings, and for transparency regarding the authors’ interpretation of empirical data. The analysis process was supported by the chosen theoretical lens, lifting it to a theoretical level and reducing the influence of the researchers’ pre-understandings on the analysis. Nonetheless, the choice of analytical frame also influenced the questions posed to the material, and thereby its interpretation and the construction of themes. The data collection was performed during the first 15-18 months after the pandemic was declared, contextualising the findings to that specific time lapse.

Conclusion

Nurses grasped the global crisis generated by COVID-19 as an occasion to exhibit professional requirements and working conditions, using social media as a tool to showcase the nursing profession. Some nurses used the pandemic to showcase and argue for better working conditions and increased salaries, highlighting the importance of nurses’ position and work in society. Other nurses tacitly applauded the rebels’ activities, and others again distanced themselves from the rebels’ activities, trying to maintain the current order in healthcare. Using the pandemic as a starting point for promoting demands for trade union policy improvements regarding salaries and working conditions, some nurses used social media to reach an audience, which could include colleagues and the general public.

The current findings also showed that nurses used social media as prosumers, i.e., as both consumers and producers of information, for self-consumption and potential consumption by others, and with potential effects on individual, group, and/or societal levels, although nothing could be said about such potential effects in the current study. Nonetheless, nurses reflected upon their private versus professional role in social media and the current study indicates that nurses can use social media to position themselves and the nursing profession, with a varied audience as recipients, also potentially enhancing their own collective meaning-making relating to their profession. Further, the findings showed a variety of social media uses, with different levels of engagement by nurses with social media. This points to the value of further studies to explore uses in more depth and the potential effects of such uses on content producers and consumers. The current findings were based on a sample of nurses from the three Scandinavian countries and from a variety of healthcare organisations. Further studies from other countries and additional care contexts could be done to expand on the current findings.

Author Biographies

Sigrid Stjernswärd, PhD

Stjernswärd is Associate professor at the Department of Health Sciences, Lund University in Sweden, where she teaches at the bachelor, master, and doctoral level. Her research interests are primarily: mental health and psychosocial interventions, trauma, family support, e-health, mindfulness and compassion, social media and COVID-19, and interdisciplinary research endeavours. 

ORCID: https://orcid.org/0000-0002-7152-9206

Frode F. Jacobsen, PhD

Jacobsen serves as Research Director of the Centre for Care Research – Western Norway and has been Professor at Western Norway University of Applied Sciences since 2008, and Professor II at VID Specialised University, Norway, since 2006. He has a doctoral degree in social anthropology, pre- and paraclinical medical studies, and is educated as a nurse. His research interests include culture and health systems in various contexts and countries, and older adults’ care.

ORCID:  https://orcid.org/0000-0002-9395-2574

Stinne Glasdam, PhD

Glsdam is Associate professor at Department of Health Sciences, Lund University and teaches at the bachelor, master, and doctoral level. Her research interests are primarily sociological medicine within the areas of: oncology, gerontology, antimicrobial resistance, COVID-19, media, relatives, and professions.

ORCID: https://orcid.org/0000-0002-0893-3054

Acknowledgements

Thanks to Lisbeth Hybholt (Senior researcher, Psychiatry Region Zealand Denmark), Anette Grønning (Associate professor, University of Southern Denmark), Helena Sandberg (Associate professor, Lund University) and Bente Kalsnes (Associate professor, Kristiania University College) for being part of designing the current study, conducting 15 of the 30 interviews, and doing initial analysis of the entire empirical material. Also, thanks to Anette Grønning for founding transcription of ten interviews. A special thanks to Lisbeth Hybholt for active writing of drafts of the current article. Thanks to all participating nurses.

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