Nurses, How to Become ‘Valuable Persons’ Using Social Media

The professional benefits and security issues for nurses using social networking tools are demonstrated and assessed in this article. The phenomena of web-based social networks offers the opportunity for nurses to educate and receive healthcare information faster than ever before, raise the public’s health awareness while maintaining security and confidentiality for themselves and their social network followers. Social networking websites, such as Facebook©, Twitter, Instagram, LinkedIn and Google+, are presented in the context of extending health information to consumers. By using keywords and hashtags, accessing information through social network websites is explained through a fictional scenario of how these mechanisms can effectively promote the discovery of quality health information without difficulty.


Introduction
The adjective 'valuable' has multiple meanings depending on the context of how it is used. It could describe one's sense of feelings toward another person or it could hint at one's level of monetary wealth. Today, with social technology proliferation, the phrase 'valuable person' is most likely being used to describe one's popularity in respect to their web-based social network. The electronic social network uses social media tools such as Facebook, and LinkedIn, to communicate. If one has a large online following through these tools (people linked to each other electronically through the web), or has multiple online Internet profiles, this person is 'connected,' and maybe a 'valuable person.' Their value may be established through a winning personality or because they openly share quality information desired and needed by others. The ease of connecting to people through the Internet offers new opportunities for sharing information and educating. Using these tools in the healthcare arena offers a new way to market a product and raise awareness on any aspect of health. As educators in healthcare, nurses have an opportunity to employ communication technologies that reach a broad audience of interested individuals. To become a 'valuable person' in today's digitally connected world, one has to seize the tools available to remain competitive and influential in the healthcare workforce. A nurse using social media in their profession has new and different kinds of opportunities to teach about health as well as a way to promote their profession.
It was forecasted that 2012 would be the year that mobile devices transformed information gathering and seeking in the healthcare field [1]. As with many 'forecasts' this has not come true. While mobile devices certainly made an impact in healthcare there still remains significant room for growth. Millions of healthcare professionals carry mobile devices such as smartphones and tablet computers and use them in novel ways to improve their engagement with patients, the quality of care they provide, and their access to information. These tools, mobile devices and social networking websites, are becoming a regular system for communication. They allow patients to make appointments online, provide access to forms for completion prior to an appointment, and offer the provider opportunities to freely publish quality evidence based health information.
The devices themselves are not purely causing communication processes to change but the convergence of telephone and software application (apps) technologies are. Beyond email, the software apps, commonly referred to as social media websites or social networking websites, that are assisting in changing our modes of communication are Facebook, Twitter, Instagram, Google+ and LinkedIn; to name only a few These are the biggest, i.e. most popular, social networking websites in the U.S. and many others are attempting to gain popularity. In October 2013, Facebook had over 1.26 billion users [2]. In 2012, it consumed 15% of the time a user spent online. Twitter consumed 96.5% of a users' time spent with a mobile device app, and has over 2 million active monthly users [3,4].
Other than simply connecting people to a real-time mish-mash of information, some social networking sites attempt to specialize in subject matter such as health, music, or eating. One way nurses can utilize social networking tools is by modeling what some athletes have done to promote healthcare. For instance, Olympic swimmer, Garrett.
Weber-Gale, utilizes his athletic fame and love of cooking to promote healthy living and eating habits for all of his website's viewers. Through the links provided off his website, viewers can access Weber-Gale's Twitter account and Facebook© page to keep in contact with his health updates [5].
To envision how healthcare practitioners, specifically nurses, can seize opportunities in the emerging area of mobile device technology and social networking, or to define allegorically, social information gathering tools, one needs to know exactly what social networks are and how they have evolved. Using technology to share health advice and facts with their followers can help complete this task. To illustrate how a nurse can use social networking tools, a brief fictional scenario is presented below and then referenced throughout the article. "Suzie, RN" is" a fictional registered nurse, who uses social networking sites to promote her workplace, profession, and advances in healthcare. Suzie is used in examples to show the difference between correct and incorrect usages of specific social media sites, and how consumers and nurses can benefit from using these communication tools. A description of what social networks are, how nurses and consumers can communicate through social networks, and a discussion on where these technologies could assist healthcare concludes this article.

Suzie, RN A Social Networking 'Valuable Person'
Suzie, RN, works in the Cardiac ICU at General Hospital. She runs two Facebook© profiles, a private group a public group, she tweets, has a LinkedIn profile, uses Google+, and keeps her Instagram updated. She has 150 friends in her private Facebook© group and over 600 in her public group. More than 400 people that she does not personally know follow her on Twitter, and she is currently connected to 6 different organizations on LinkedIn, plus 3 different Circles on Google +. She publically promotes the 'cool' aspects of her job and the innovative technology that she uses through pictures on Instagram. When Suzie realized she was gaining a public following she spoke with her employer's Social Networking Committee to let them know what she has been doing, how she was doing it and to inform them that she was following the policies and guidelines for professional use of social networking tools published by the American Nurses Association and her employer. She assured them that she has completed the institutional HIPAA educational module, was not and would not publicize any patient data, jeopardize patients' confidentiality or share information that was not to be shared [6,7].

Social networks defined
The terms 'social media websites' and 'social networking websites' are commonly used interchangeably. The way the communication tools are used helps to define if them as a social media website or social networking website. For instance, Twitter, used as a social media tool, can provide information to a person who follows General A+ Hospital's tweets; however, General A+ Hospital does not personally follow this individual on Twitter. If General A+ Hospital and the individual were to both follow each other, they would directly be connected in a social manner, thus using Twitter as a social networking tool. SNS (social networking sites (websites)), such as Twitter and Facebook, differ from face-to-face social networks in three ways; 1) the way information is obtained, 2) the size, and 3) if the 'following' is a personal relationship or not.

Obtaining information
A SNS either pushes information to you from your network or hosts information from a network to access any time. You can set your accounts to automatically push new information to you, not push to you or to keep the data available until accessed.
Poor communication, or even lack of communication, is undesirable due to the significance of keeping up-to-date with information that could possibly be vital for your interests or relevance to your profession and health. Joining social networking sites can restore this communication, as you become intact with your online followers, even if you are not directly contacting the people in your network. For instance, if a nurse were to post a video on his or her Facebook© profile or Twitter account, it could go viral within minutes. The option to "Share" or "Like" a posted video on Facebook would be present to every person in the nurse's virtual social circle. This could result in the video appearing on the top of the newsfeed for the virtual friends that the nurse, who originally posted the video, is acquainted. This can easily prompt anyone to take a moment to watch the video and maybe learn something new.

Network size
Non-virtual social networks consist on average of 150 people. This estimate has become known as Dunbar's Number. Virtual social networks tend to average 634 connections [8]. For example, Suzie, RN has both health consumers and patients in her virtual and non-virtual social networks. These individuals benefit by following this nurse who educates, informs, and shares health information [9].

An acquaintance or not
All the people in non-virtual social networks are actually known. Thus, social networking sites are our virtual collections of electronic persona profiles that connect to other profiles. We may or may not know the individuals behind the profiles yet we still share information with them. With electronic profiles we can chose to connect to the profile and share our information with the person or connect to them and not share information.
Depending on the type of SNS, the definition can be expanded to state that a SNS is a virtual collection of persona profiles with similar interests. This explanation would apply to the websites that focus only on specific subjects, such as health, eating, movies, etc.

Possible Uses of Social Networks by Nurses
Nurses can use SNS technology to reach out to patients and health consumers by sharing health information and health guidance from their professional field. At the same time, they will become more proficient with the current technologies and possibly improve the quality of their work through their access to information. In Facebook©, the valuable person, being a nurse, could have a Facebook© group, separate from a personal profile wall, just like Suzie in the above scenario. This separate group can be dedicated to consumers of health information. The group can be devoted to health and have a following of friends (virtual networks/electronic personas) that have an interest in what the nurse is sharing. Nurses can also establish a private group within Facebook© for colleagues where professional questions can be posed to their virtual peers. It is the responsibility of the individual who poses these questions to ensure that the user follows professional principles and the institution's policies. While this limits some medical knowledge from being shared to the social networking community, this method of peer networking can extend one's own personal gain of information, resources and consultation opportunities. The nurse could provide status updates that educate their 'friends' on health issues, health events, and published health news stories they find relevant for the group. Nurses can also share this information with their whole virtual network, through their own public walls. Like Facebook, Twitter is able to send a status update, or Tweet, to the individual's text message enabled mobile phone or any other Web connected device with a web browser. As a 'valuable person' on Twitter, the nurse Tweets, i.e. pushes out short clips of health information of interest to their followers in 140 characters or less. With Twitter, Suzie could push disease specific support messages, 'gems' of health advice, advertise a health event, or query to her followers. Support messages delivered in person or electronically via Tweets or status updates can make a positive impact on an individual's day. By using any type of social network system, nurses can update their status or send out tweets with kind messages directly to their subscribers where they have established a personal relationship, or to any patient. A genuine post from Suzie that says, "Keep fighting!" can make any one patient push negative thoughts to the side in that moment of receipt, and remain positive regaining some confidence in the midst of the seemingly endless fight for their health. Offering another form of care by pushing emotionally supportive messages via social networking sites can positively impact the way nurses are viewed, and bridge a gap in communication between healthcare professionals and health consumers.
By using a hashtag, #, in Tweets, e.g. "I think the #NHSbill is kind", the # to denote a keyword or important topic automatically creates a method for tweets to be searched and organized by fellow Twitter members. This provides an opportunity for the nurse to gain a following of individuals and recognition for their Tweets when keywords are searched. The use of hashtags also enables individuals to quickly connect to others to 'follow' for instantaneous information exchange. Building a social network of like-minded profiles could ultimately save time because only relevant data is being pushed to you. You do not have to sort through an endless list of irrelevant emails, nor through information in your newsfeed of where there is interest. This could make information gathering more efficient and relevant.
Google+ is another innovative way for nurses to become a valuable person by sharing their knowledge about events and current information in the healthcare field. Nurses can share these clips of health related information with the public or only with those in one of his/her "Circles". A circle on Google+ is a way of organizing friends and followers into groups of people, such as "Family", "Friends", or "Coworkers," etc. When using Google+, if Suzie, RN wanted to share a job event with her nursing coworkers she has the control of only of sharing this information with her coworker circle.
Facebook, Twitter and Google+ all provide the ability to recruit individuals for nurse led research studies. Presently this is the only freely available method to reach a large network of people that all have six degrees of separation. One simple wall posting in Facebook, tweet in Twitter or post shared on Google+ can spread endlessly as it goes from social network to social network through re-postings 'shared' by social network members. Being connected to Twitter, as well as Facebook© and Google+, increases the likelihood of knowing information well before anyone else. Because these social utilities described above spread information faster than any other current mechanism, a nurse blogger or a nurse using social networking sites may achieve that ever coveted 15 minutes of fame.
When posting information it is important to remember to write for the lowest literacy level to increase the likelihood that all readers will be able to read and understand the posting. The only health literacy survey in the U.S. found that most adults read at an intermediate level of ability for reading health information but with over 75 million with a basic and lower level of reading (U.S. Department of Education, 2003) one needs to remember to write for them. Suzie, RN always makes sure she uses simple words and short sentences. If she is referring to a website or recommending a website she always evaluates that webpage for its quality of information and audience. She does this by using the mnemonic SPAT (Site, Publisher, Audience, Timeliness). Suzie knows that by doing a quick review of a web page for these components if it is of good enough quality and literacy level for her to push on to her followers, being health consumers and/or patients. If she recognizes the site (URL) as a good source, and that there is an author or a company (publisher) taking credit for the information on the web page, she then looks to make sure there is a date on the webpage for when it was last updated or at least published. With those criterion met, she judges the page for its target audience to see if it is appropriate for her audience and that there is no bias [10,11].
While nurses may form personal and emotional relationships with their patients, it is not appropriate to become connected through social networking websites. Whether it is Facebook©, Twitter, Instagram, Google+, or LinkedIn, creating a connection through personal profiles could lead to disastrous outcomes. For example, a nurse posting pictures or statuses of a current situation may make a former patient feel uncomfortable or disappointed with the care that they received.
Because student nurses may not be officially recognized as hospital employees, it is important that students realize that their actions shared on a social networking websites have an impact on the thoughts of the 'follower,' or 'friend.' While nurses and student nurses are allowed to do as they please away from the hospital, they need to be taught that patients expect a high standard from them as well as the hospital. When, Suzie, RN, was a student nurse she heard of an interaction between a fellow student nurse and that student's patient. The patient has requested that the student "friend" her on Facebook ©. The student nurse did, right there in the hospital room through her mobile phone! While there are six noted principles under the ANA Social Networking Policy, the story Suzie, RN heard broke policy number 2: "Nurses must observe ethically prescribed professional patient-nurse boundaries." [6,7].

Job Postings and Workplace Promotions through Social Networking Sites
If one becomes a 'follower' of the right source for jobs, there may be an advantage by being a first responder as well as learning if you have an existing relationship with the person posting the position or know someone who does. Having virtual connections creates advantages for those using social networks, as opposed to those who do not. For instance, Suzie, RN Tweeted that there is an Informatics position open at the hospital where she works. It states, "Any Nursing Informatics gurus that want a position at #General Hospital of #Pittsburgh? Now hiring; be sure to apply! #nursing informatics #jobopening". A person using these keywords to search can then see this posting, and hopefully end up with a new job. Nurses, who are seeking employment opportunities, or research salary ranges and job expectations, could follow nurse bloggers or Twitter accounts, as helpful advice and insight may be tweeted.
If Suzie, RN were to decide to tweet a video to promote a workplace, she would use the keywords associated with her job to compel social networkers to "Retweet" the video. By using hashtags, Suzie could caption her video by saying: "Take a #tour of the newly constructed #PediatricsWing of the #General Hospital located in #Pittsburgh!" This video would then be available to anyone who types the hashtagged keywords into the search bar. If a Twitter user were to type into the search bar "Pittsburgh", this tweet would then be available to all those that searched this word. The hashtag technique is valuable during hospital events and fundraisers as nurses can inform the community they work for of health events where community members can participate.
LinkedIn.com is another Internet based social networking site targeted to the professional scene. It links career professionals to other professionals building a diverse social network. There is less socializing on LinkedIn.com since it is mainly used for professional networking. The site hosts resumes so virtual connections can readily see them to establish business opportunities. LinkedIn hosts job ads and shows the user who they may be linked to that knows someone connected to that company or open position. Using LinkedIn can benefit a nurse by making it easier to come in contact with employers and important contacts that have connections to job notices, or even offers. There have even been reports that law firms frequent LinkedIn to locate expert witnesses in subject specialties [12].

Pictures for Consumers
Using Twitter, Facebook© and Google+ to post pictures is another way Suzie, RN can educate her social network. Pictures are important since they satisfy another form of learning -visual. Sharing photos with consumers provides a glimpse of the type work being done by nurses. Suzie, RN may post a picture while volunteering in an area where a natural disaster has occurred, to offer her followers of an eyewitness account. She could also take a picture of the new Flu Mist and have a caption that says: "Who even likes needles? Flu Mist is awesome! #flumist #noneedles #GeneralHospital". This promotes the idea of the flu mist instead of a flu shot, which could influence more people to get the mist if they were hesitant about getting a shot, due to the needle factor. Patients and health consumers can both benefit greatly from this. For instance, if a female patient that Suzie, RN is working with one day dislikes being poked with needles, she could be following Suzie on Instagram, see the Flu Mist picture in the newsfeed, and decide to give that a 'shot'. Instagram is a social networking system, which shares photographs from those people that an individual decides to "follow". There is then a photo stream homepage in chronological order, displaying photographs with filters and captions. Photos of rashes could be shown and identified to broaden the exposure of rash varieties to consumers; especially mothers. Information such as this might enable the person to properly treat the rash, saving a trip to the hospital.
Posting photos that may include people is always of concern. If Suzie, RN posted a photo showing a person, then following the rules set by her employer, she had obtained consent to publically share the photo by the person pictured. Any user of social networking utilities must follow ethical guidelines for the information they share.
Using Instagram, a free application for mobile phone, assists Suzie, RN in quickly pushing photos to her social network. She often shares photos of her workplace. The novelty of Instagram is the optional filter effects that can be added to the snapped picture. Instagram automatically connects to her Facebook© page while at the same time providing space for captions and hashtags. Sharing photos confirms that something is real and creates positive emotional responses about the subject shown. They can also have the reverse effect, thus influencing positive healthy behavior. For example, sharing a photo of basal cell carcinoma may increase sales for sun block and long sleeve white t-shirts.
Posting pictures on social networking websites can potentially lead to a patient's personal information being shared with the public. Guidelines should be placed on what types of pictures can be posted. Ideally, shared photos should show no faces or personal information of patients. Suzie, RN knows that if she makes one mistake in her postings her career, and her image is at stake. Therefore, she reviews the guidebook the American Nurses Association published on social networking principles for nurses. (The American Nurses Association, 2013), It covers the code of ethics for nurses in regards to social networking and their standards of practice.

Security Issues/Recommendations
Nurses who use the Internet as a medium to communicate and connect with other healthcare professionals may be at risk of security breaches. Some security issues that can possibly occur by using Facebook©, Twitter, Instagram, Google+ and LinkedIn could be an anonymous person hacking into the groups regulated for certain people. This would violate everyone's confidentiality. On the flip side, an angry or frustrated nurse could spam their employer's Facebook© wall or a competing hospital's Facebook© wall. Establishing an organizational Social Network Committee is one option of limiting these security issues, as this committee can work together to provide guidelines to help eliminate and halt the spread of private information. Specific guidelines should be in place to ensure that a breach in the system or in any health information will not occur. Following strict information sharing guidelines can keep nurses and their workplaces out of lawsuits. With rapid changes in social technologies, these information sharing policies change constantly. Staying current and up-to-date with the policies can significantly help nurses not to release information or pictures that could negatively affect them, their workplaces or their employers. Knowing, following, committing to, and respecting the policies put in order is just as important for nurses as having actual policies and guidelines being set forth for them. Suzie, RN is very aware that anything that she is accountable for anything she posts, anywhere, electronically and/or in paper. Along with reviewing the ANA's book discussing the principles for social networking for nurses. Suzie, RN also stays current with the guidelines set from professional nursing associations such as the National Council of State Boards of Nursing (National Council of State Boards of Nursing, 2013) and the Dermatology Nurses' Association [6,7,13] The HIPAA Privacy Rule puts in place protection for and individual's personal health information. The covered entities that must follow the HIPAA policy includes health plans (HMOs, health insurance companies, government, etc.), health care providers, and health care clearing houses. (U.S. Department of Health and Human Services). This means that nurses are required to follow HIPAA. Due to HIPAA, patients and health consumers can expect that their medical records, conversations about care or treatment, billing and insurance information, and any other type of health information cannot be disclosed. Only if there is an emergency where disclosure of personal health information is vital for patient care may personal health information be shared [14][15][16].

Can these Technologies be Change Agents for Healthcare
Administratively, the use of SNS utilities enables a form of data collection that can be tracked and visualized. Within the clinical environment with a secure wireless device, nurses could pass patient information on to other nurses to give them a heads-up on the patients' condition and/or needs. This could reduce the number of steps a nurse takes to work, save time, and portray the image of an efficient working environment to the patient. This form of data transmission could transform nursing logs, and patients' charts and records. This type of information system should run on an Intranet with high security to protect everyone's privacy. All of the social networking websites, and the methods of using them in the healthcare environment, could improve the quality and type of work nurses do worldwide.
Social networking utilities and mobile devices are changing the way we communicate. If consumers were to become as open about their health status as they are with what they have eaten or where they have been, more accurate data for disease trending could be assessed and then forecasted [17].
Information from SNS could immediately initiate care that could curtail a health crisis. This reduces the cost of treating an illness, and lessens health practitioner workload. If a secure data transmission standard was created for only health data and only accessible to certified health care practitioners, such as the digital networks for the military in the 90's when only the civilians had only analog transmission, then health information could be more widely distributed and accessible to those 'in the need to know moment.' If nurses seize the available technologies and apply them to their work then they may do their jobs more effectively and enjoyably. By sharing quality health information that the general public can understand and find relative, Suzie, RN not only gains the respect of the public, she is promoting the image of the nursing profession. Everyone wants to be a 'valuable person' and there are options with knowledge of how achieve this status. Information can be viral, be an influencer, and be that a valuable person.