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