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Online social networking sites are a popular way to share interests, build and maintain relationships and stay more connected to the world. Tools that were not available a few years ago are now used on a daily basis. Social networking has been likened to a digital tattoo. Both Universities and Healthcare Institutions have concerns about the potential implications that students, educators and practitioners may face when using the media. The main concerns are related to patient protection by both qualified and student healthcare workers. This article outlines the guidelines put in place to avoid any mistakes made on SNS and how to maintain an e-professional aura whilst using SNS. Examples of good and bad social networking by students and practitioners are given. How the implementation of recently introduced guidelines impacts on the use of SNS in dentistry requires further research.
Clinical Relevance: Social networking has become part of everyday life and yet it can create problems for dental healthcare professionals as they attempt to accommodate both personal and professional ‘aura’ in the medium.
Article
Social networking sites (SNS) such as Facebook, Twitter, Myspace, LinkedIn, etc are integrated into everyday life.1 Part of their appeal is that they are both intriguing and addictive because users have the power to influence their personal connections and relationships with other people. They can then watch connections take place between others and also become any character they wish by simply creating a profile. The versatility extends to the ability to create multiple identities online, within a few minutes.2 Not only can SNS users access unlimited information on the internet, but they can also produce similar material themselves which can be shared globally with people in an instant.3 However, the drawback is that, once it is posted, it is often not possible to retract it. Some commentators have likened this to digital tattoos. In this analogy, SNS may hold intimate comments, be intriguing to view but sometimes lead to serious mistakes which, like a tattoo, cannot be removed.4
Mobile computing devices, such as smartphones and iPads, allow communication and access to SNS anywhere at any time.5 These tools and devices allow instant communication, removing previous natural barriers like distance.6 The medium is changing rapidly and SNS have had to become mobile-friendly following competition from innovative mobile apps. Instant messaging features, such as the app ‘Watsapp’, have forced SNS to provide users with the same mobile-friendly tools.
The increased use of SNS by students has encouraged educational authorities to look at ways to link the medium with learning and teaching and therefore tap into the advantages of improved communication.7 Whilst dental education has successfully implemented electronic learning in a blended style within the dental curriculum, mobile learning is now being introduced and evaluated.8,5 The challenge for educators is the best way to incorporate educational content into the use of the medium.9
The use of SNS may have potential drawbacks which relate to what information is placed online. Health professionals have a duty, not only to themselves but also to patients, to maintain a professional profile when discussing material. The ability for information to be moved around quickly and to be sent out from the immediate circle of communication could lead to inappropriate material being posted. Comments or pictures can quickly be taken out of context and put both users and organizations into difficult and sometimes embarrassing situations. Therefore, at the same time as the SNS are used, specific guidelines are required to enable users to share information in the correct manner.10
The aim of this paper is to highlight the importance of maintaining an e-professional aura whilst online.
The objectives to achieve this aim will be by outlining examples of guidelines for dentists as health professionals when using SNS, the role of social networking within dental undergraduate education specifically, the appropriateness of SNS in dental education and the future of social networking in dentistry.
Social media guidelines
Within the United Kingdom, the General Dental Council (GDC) standards handbook for dental students and practitioners now includes guidelines for SNS. The guidelines have clear set boundaries and promote cautiousness when professionals/dental students are communicating outside normal work hours via SNS.11
Guidelines are provided for SNS specifically for health professionals/students. Excerpts from those guidelines are outlined in Table 1 and are taken from four of the main healthcare related authorities:
General Dental Council 11Guidance on using Social Media
Ensure that information posted about patients is anonymous and the patient cannot identify or be identified. Do not discuss dental treatments and care with patients on SNS.
The relationship with patients must be maintained with appropriate boundaries. Friend requests on SNS by patients should be thought about carefully.
Your online image can influence your professional life. Any photo/media posted online could potentially impact your profession and the profession of others.
When offline or online, behave professionally and ‘presume everything you share online will be there permanently’. Manage privacy settings accordingly.
British Medical Association 12Using Social Media: practical and ethical guidance for doctors and medical students
‘Doctors and students responsibility to protect patient confidentiality’. Guidelines for patient if any medical cases are to be discussed or shared on SNS.
Material posted on personal profiles with friends could be shared and viewed by anyone. Maintain a boundary between professional and personal life as this is often ‘blurred’ by SNS. Friend requests should be carefully considered.
Personal and profession comments online may result in defamation which could lead to legal action by organizations/companies etc. Anonymous profile posts can be traced back to the author.
Material posted on SNS could affect the public confidence in the medical profession and, although it is not illegal, doctors and medical students are expected to behave professionally at all times and respect the profession.
Nursery and Midwifery Council13Social networking sites
Students/nurses/midwives may jeopardize or risk registration if they share confidential material and information on SNS or post inappropriate comments. Mobile phones should not be used in the workplace.
Do not pursue a relationship with a patient even if he/she is out of your care and any friend requests on SNS such as Facebook should be ignored.
Avoid defamatory comments or activities on SNS about or associated with patients/colleagues/organizations that could affect their reputation.
Privacy settings should be adjusted accordingly. Behave responsibly and professionally and do not distribute sexually explicit material on SNS.
Health and Care Professions Council14Focus on standards – Social networking sites
Actions will be taken against a registrant who has put confidential information about a patient on SNS. Always act in the best interest of patients and respect confidentiality
Registrants are free to use SNS as part of their everyday life but within the set standards.
Defamatory comments that could harm reputations and activity on SNS should be avoided against patients, colleagues and organizations.
Behave with ‘honesty and integrity’ and ensure that any activity on SNS does not damage public confidence in the health profession.
The guidance is similar, although there are differences between the organizations/authorities on how to adhere to these SNS standards. The grey area is in the area of ‘Maintaining boundaries’, where accepting a friend request from patients ranges from ‘thought about carefully’11 to ‘should be ignored’.13 All of the guidelines highlight maintaining patient confidentiality and behaving professionally. Information posted, discussed or mentioned should not allow patients to identify themselves or others. The guidelines have taken into account the main social networking sites, although the medium is rapidly changing and newer sites/apps, which reportedly remove pictures and text within seconds of being sent, provide difficulty in interpretation of these guidelines.
Education and SNS
Maintaining boundaries
Educators may be uncomfortable maintaining an online profile on a SNS and consider it as an intrusion of privacy. They may find it difficult to maintain a professional and private relationship.15 Furthermore, such insecurities are real barriers and prevent professionals and educators from utilizing the benefits of SNS. This will create a divide between enthusiastic young students, who appear to have little or no concerns, and adult educators who will not share their viewpoint.16 There is an increased awareness and promotion of SNS within education, with faculty members and practitioners starting to become confident in the use of SNS for their workplace. With experience they are also able to maintain an ‘e-professional aura’ online.2 This does require careful management and self-surveillance whilst on SNS. One tutor reports that she feels her students also need to follow guidelines and what better example but to show them how she herself behaves online. It was reported how she upholds the boundary between her professional and personal life. Subjects that are not discussed online include ‘partying and dating’, citing these as good examples of how to maintain the boundaries with her students.2
As the new General Dental Council standards have taken effect in September 2013,11 the changes in the use of SNS has not been evaluated and whether this will address issues like privacy, plagiarism and relationships online between patients/students and dentists/tutors is yet to be evaluated.
SNS as a learning tool
It has been argued that the internet will shape the way academic material is taught and learnt.17 The situated learning theory explains how students learn through social interaction and social world participation18 and is relevant in the use of social networking in education.19 Students who have a good relationship through collaboration within their classrooms are highly motivated in achieving their academic goals compared to those who did not co-operate with other students or do not take part in social interaction.20 Classroom community is a crucial part of student education and SNS helps students maintain a social bond between each other, which in turn helps their education.21 Hung and Yuen,19 when investigating SNS in the classroom, found that students appreciated the concept of being able to share anything with fellow students (photo, videos, etc) and the use of SNS saved them the effort of gathering information for their course themselves. Peer support is highly valued in education and this takes place with the use of SNS. The disadvantages identified include time management, recognizing the worth of academic knowledge in the learning community and technical problems associated with the use of mobile devices.22
E-professionalism
The use of SNS could lead to misconceptions about particular professions based on the online activity of students. For example, medical and public health students felt that they may be misjudged through stereotypes of their professional areas which were outdated or due to unfamiliarity of their roles.18 Interestingly, the dental student in the study had no concerns about others' portrayal of her profession, but was aware that misjudgements can take place online when a situation is not face to face. Another study found that students were well aware of the damages that SNS can do to their academic and professional life and the majority of students agreed that guidelines were a necessity to help use Facebook, so that it benefits their education.23
There is evidence which shows that students acknowledge and are able to identify poor use of SNS, but would appreciate guidance at their level of understanding with practical examples. This includes recognizing behaviour such as use of drugs/alcohol, sexual content/nudity, criticizing others, disclosing patient/client information and criminal discussions, as very unprofessional.23 This may be obvious, but for some students practical examples are needed.
Poor use of SNS
With any internet platform, there is always evidence of misbehaviour. For example, in 2009, a paramedic was sacked for posting pictures of a patient's skull with nails on it on Facebook. It was reported to the Health and Care Professions Council that posting such images was ‘part of an activity that many staff undertook at the time’.24 This misunderstanding is often quoted as an excuse when healthcare professionals have misused SNS significantly. Another example was a patient who sued a hospital after she found that her anaesthesiologist doctor drew a moustache on her face and allowed another staff member to take pictures during an operation. She felt violated at this clear breach of privacy. The hospital has now stated that they have now begun to teach staff about patient privacy and how to behave in operation rooms.25 This is common sense but surprisingly such incidents do occur.23 Unprofessional behaviour may also include sexual/personal content. For example, a nurse was suspended for having a relationship with a ‘vulnerable’ patient, by arranging a date with her via Facebook. A report, highlighting the misuse of SNS, explains how a doctor obtained the phone number of an 18-year-old patient from her medical records and started sending ‘flirtatious’ text messages. This behaviour resulted in a six-month ban.26 Such cases emphasize the importance of guidelines for healthcare professionals and how students and trainees need to be aware of the consequences of such behaviour during their practising careers. Although there have been many cases which show how SNS can be a bad influence on healthcare professionals, there are few reports on the poor use of SNS by dental practitioners. The poor use of SNS is quickly highlighted by the press and, it could be argued, disproportionately to the amount of use of the medium. However, there should be zero tolerance of any unacceptable use when using social networking.
Good use of SNS
The advantages of SNS are that you can use the media to spread knowledge, update people about healthcare and distribute the latest news. A surgeon sending tweets live from an operating room, in an attempt to show the world how a tumour can be removed from a kidney, was cited as good use of SNS.27 Another good example is through websites dedicated to professionals, nurses, doctors, dentists, etc who can get help in promoting health delivery, education and delivery all over the world.28 The Google hangout panel had been used to discuss how health campaigns should be targeted towards men and women with appreciation of the differences between the sexes.29 An orthopaedic surgeon promoted a yearly fitness challenge motivating people to change their lifestyle.30 Another analogy for SNS is to use them as virtual shadows which record noteworthy moments and allow users to review their positive activities. This can then influence their future actions where they can change their current practices.4
The Dos and Don'ts
There are many good examples of how to adhere to good social networking practice and the main advice is to be sensible and not to compromise your professional work. Table 2 provides a quick guide to the Dos and Don'ts of social networking and many dentists may wish to adapt their own list not only to assist themselves but also other health professionals that they meet in their day-to-day life.31
Do
Don't
Be aware and alert online.Think about your goals, especially when posting online.
Be put off using SNS just because you are in the dental field. Social networking can be used to share experiences and advice so that others can beneit. When sharing dental-related information, make sure it is evidence-based.
Maintain e-professionalism by reflecting on your online presence and making sure that it is in keeping with your position as a health professional.
Think that you are invisible just because people cannot see you.
Think carefully as to which social media you are using and who will see your posts: protect your privacy.
Use aliases and always reveal your true name.
Follow GDC guidelines.
Use social networks to build or pursue improper relationships with patients.
Put patients' interests first.
Get over friendly with patients on SNS and think before you accept friend requests.
Conclusion
Social media sites have become embedded in popular culture and are a genuinely enjoyable experience for the majority of people. It is the responsibility of health professionals, including dentists, to adhere to their professional guidelines and manage their actions on SNS whilst keeping up an ‘e-professional aura’. There is little evidence on the effective use of SNS as an educational tool in dentistry. It has a so far untapped potential to provide improved communication for students and professionals to spread health-related information.
