LEGAL ASPECTS OF NURSING: INTERNET SOCIAL NETWORKING AND NURSE ETHICS Introduction to Social Networking Once the domain of college students, Facebook has more than 200 million active users worldwide, and the fastest growing group of users is those ages 35 years and older. Traffic on Twitter, the astonishingly popular messaging service, doubled in March alone. Now millions of people "tweet," posting updates limited to 140 characters, similar to a text message on a cell phone. Even skeptics would have to concede that social networking on the Internet is more than just a fad. (Hensley, 2009). Communication technologies such as Facebook, YouTube, blogs and mobile phone cameras have made it increasingly common for nurses to share details of their working lives online. (Livsey, 2010). Consequences of Internet Social Network It was only a matter of time until specialized sites for nurses-such as Allnurses.com or NurseConnect.com, provided virtual watercoolers for swapping stories, gripes, and tips. (Hensley, 2009). The American Nurses Association (ANA) even gave students free access to their website, which includes access to NurseSpace, the ANA's new social network for nurses. (http://nursingworld.org/students: American Nurses Association, 2008). But is the phenomenon of value to nurses? Some think so. (Hensley, 2009). Online social networks can break down barriers that keep nurses apart. "Nursing can be very specialized," said Michael Lord, a critical care nurse in Philadelphia. "And our individual unit cultures can be quite different from the cultures of any of the specialties." He frequents Allnurses.com, Nurse-anesthesia.org, and sometimes nursing groups on Facebook. Lord enjoys bouncing ideas off nurses around the country, sometimes comparing his hospital's protocols with theirs. Beyond the exchange of facts, he said, online networking allows him to encourage and support newer, less experienced nurses and to find mentors of his own. (Hensley, 2009). Wendy Jones, who works as a surgical ICU nurse in Texarkana, Texas, doesn't use the specialized networks much. She's a fiend on Twitter, though, where she goes by "@nursewendy" and has more than 3,600 followers. Twitter, she said, attracts "smart people who actually have something to say," as compared with Facebook and MySpace. She's become friends with some physicians on Twitter, including a neurosurgeon, something that can be hard to do in person. "It's easier to feel on a par with them on Twitter than when you're in the hospital and they're giving orders," she said. (Hensley, 2009). Internet Social Network Disadvantages to the Nurse Not all nurses have the same experience as Michael Lord and Wendy Jones. The social network phenomenon can be disadvantageous to some nurses. This was realized by one nurse who was fired from her job after airing grievances on Facebook. It turned out that the nurse’s conduct was unprofessional, and the employer had the right to terminate her employment. An employer is justified in sanctioning nurses who air their grievances over

1

the Internet because this unprofessional behavior can undermine the institution's reputation. The Health Insurance Portability and Accountability Act allows an employer to fire an employee for violating privacy provisions that might occur during an employee's free time. (Facebook fracas, 2010). In another recent case, a Swedish nurse took pictures of operations with her mobile phone and posted them on her Facebook profile page. The fact that she did not intend to breach patient privacy was not accepted as an excuse. She was suspended and an inquiry was launched. (Livsey, 2010). Also, recently, there have been a couple of professional boundary issues reported by news media across the country. In Wisconsin a patient was brought into the emergency room where two nurses, independently, took cell phone photos of the patient's body part. One of the nurses allegedly posted it on her Facebook page. Needless to say, both nurses were fired from their positions and their future nursing careers look bleak. The FBI is investigating this case for HIPAA (Health Insurance Portability and Accountability Act) violations. (Spector, 2010). In Washington state two certified nursing assistants and a licensed practical nurse were fired from their positions for taking cell phone photos of nude nursing home residents, most of whom had dementia. While the employees have not been charged with a crime, they too will most likely not be hired to work in health care again. They have also put the nursing facility in jeopardy of losing their Medicare/Medicaid funding. (Spector, 2010). Boards of Nursing Intervention Boards of nursing (BONs) have asked the National Council of State Boards of Nursing (NCSBN) to develop more detailed language on boundary crossings and violations as they have received increasingly more complaints, particularly those related to cell phone cameras and use of the Internet. Therefore, NCSBN's Disciplinary Resource Committee has been working on model nurse practice act and administrative rule language related to questions of boundary violations and crossings. (Spector, 2010). NCSBN offers a free professional boundaries brochure, Professional Boundaries - A Nurse's Guide to the Importance of Appropriate Professional Boundaries, that is designed to help nursing students, educators, health care organizations, and the public understand and apply the concepts of professional boundaries between a nurse and a client. To download a free electronic copy, visit www.ncsbn.org/Professional_Boundaries_2007_Web. pdf. To order hard copies of this brochure, which are also free of charge, e-mail your contact information, as well as the quantity you would like to order, to [email protected]. (Spector, 2010).

Role of the Nurse Educator Educators need to be very clear with students about boundary violations on the Internet and with the use of cell phones, as well as boundary crossings and violations in general. People have become very free with disclosing personal details about themselves and others on the Internet. Likewise, intimate photos are uploaded on social networking sites on a daily basis. This has become second nature to many people today. Therefore, it is no wonder that nurses, particularly young nurses who have grown up with social media are crossing the line and posting details about patients, their work and even photos of their 2

patients. Most educators are stunned when they first hear about these violations, but it is happening, and the educators’ help is needed to put an end to it. Students need to know that they are putting their jobs and licenses at risk when they divulge information of any sort about their patients on the Internet. (Spector, 2010). Boundary issues should be brought up early in students' education program, and educators should encourage dialogue and reflections about boundary crossings and violations. Particularly in this Internet age, students need to be aware that divulging any information about their patients is not appropriate. (Spector, 2010). Nurse education providers and trust managers should remind students and staff of guidelines relating to communication technologies and review their guidance annually. (Livsey, 2010). The Interface between Personal Health Records and Social Networking Social networking is central to many personal health records applications. It involves the explicit modeling of connections between people, forming a complex network of relations, which in turn enables and facilitates collaborations. For example, it enables users to see what their peers or others with a predefined relationship (“friends”, “colleagues”, “fellow patients” etc.) are doing; enables automated selection of “relevant” information (based on what peers are doing and reading on the Web); enables reputation and trust management, accountability and quality control, and fosters viral dissemination of information and applications (it is this “viral marketing” aspect that makes some personal health records applications so attractive to venture capitalists and public health practitioners alike). In one case, the Court upheld the constitutionality of a statute that restrict the sale of physicians' prescribing data for commercial marketing purposes. (Grande and Asch, 2009). The ruling is a reminder that when physicians care for patients, they leave behind electronic tracks that allow others to observe their clinical decisions and that these observations can be deployed in the service of both commercial and social goals. The case at hand focused on the use of electronic prescription records from retail pharmacies to profile physicians' prescribing habits. In the hands of pharmaceutical detailers, these data became powerful tools for directing and tailoring marketing efforts to individual prescribers on the basis of their current and historical prescribing behavior; they provided sales representatives with greater knowledge of and influence over individual physicians. (Grande and Asch, 2009). But physicians also leave other electronic tracks, the number and clarity of which have increased in pace with the diffusion of information technology throughout the health care system. Before that case, nearly all discussions about restricting access to health information concerned patients' privacy. (Grande and Asch, 2009). Now, trafficking in health information might be evaluated by more comprehensive tests that concern not just the sensitivity of the information but its use. For example, there is widespread agreement that physicianspecific data now available will be an important tool for improving the quality and value of care, and those uses should be promoted and expanded. (Grande and Asch, 2009). Conflict has emerged over uses focused on marketing and selling commercial products. Identifying appropriate restrictions on the use of such information for marketing purposes and facilitating its use for improving health care are conceptually and procedurally challenging. (Grande and Asch, 2009).

3

The Power of Social Networking in Health Informatics Moreover, social networking is a potentially powerful tool to engage users, in that it provides “social” incentives to enter, update, and manage personal information. Teenagers spend hours keeping their Facebook profile current, constantly updating their status. (Eysenbach, 2008). Imagine the same generation of users turning their attention and energy to similar tools for health. Will social networking be the killer application that gets people interested in personal health records, motivates users to take responsibility for their health and health information, and more importantly—retain their interest over time? (Eysenbach, 2008). The social networking idea, which involves modeling relationships between actors, is a relatively new idea in health informatics. For example, what is traditionally “modeled” in electronic health records is usually medical information (symptoms, diagnosis, therapy), but not relationships between people. (Eysenbach, 2008). True, in most electronic health records we usually have some database fields for storing the name of the family physician, the attending physician, closest relatives and emergency contacts, and perhaps a narrative free text social anamnesis, but none of the existing health record systems support the explicit modeling of the patients’ or health professionals’ complex social network. When we combine social networking approaches with emerging technologies such as Personal Health Records, a new class of applications emerges. (Eysenbach, 2008). The Web and related technologies have changed attitudes and the culture in health care. The Internet has been a tool for users and citizens to get more involved and empowered. Personal Health Records application tools take this to a new level, as the philosophy of end-user participation and engagement is exemplified. (Eysenbach, 2008). Application tools like wikis, illustrates that the “participation” theme relevant for user groups, such as scientists or health professionals, can be adopted for tasks like scholarly communication. Another application platform provides unique opportunities to address directly the concerns of patients relating to patient data use, and to facilitate obtaining informed consent for patient participation and data use in research studies in an ethical manner. This aspect of social networking via personal health records application is significant, because most patients do not want “the obtaining of consent to participate in a research study to detract from the reason for their appointment. (Eysenbach, 2008). Healthcare Privacy Issues in Internet Social Networking The emergence of social networking platforms and applications such as Facebook or PatientsLikeMe, potentially combined with personal health records, which allow users to share parts of their electronic health record with other users - create new levels of patient participation, as well as unique and unprecedented opportunities for engaging patients in their health, health care, and health research, and for connecting patients with informal and formal caregivers, health professionals, and researchers. However, it also creates complex privacy issues. For example, consumers - perceiving information they post or disclose on the Internet as ephemeral—may be unaware of the fact that web-information is often permanently archived and may be accessible long-term (e.g., by future

4

employers). Another issue is the concerns of patients relating to patient participation and data use in research studies, and the facilitation of obtaining informed consent in an ethical manner. Little is known about the actual consumer awareness of these privacy and “persistence” issues, in particular when it comes to young participating users. (Eysenbach, 2008). Ethical Considerations for the Nurse Autonomy and Informed Consent Informed consent involves the ability of persons to choose what they want to happen to them to the best of their capabilities. There are three necessary elements for informed consent: (a) information to ensure an understanding of what is involved in the research, which includes disclosure of possible risks involved, (b) comprehension of the information that is presented, and (c) voluntariness where there is no coercion and/or undue influence to participate. A research participant’s autonomy is diminished without adequate informed consent. (McCleary, 2007). Online research has the same issues as traditional research in the areas of informed consent and autonomy. However, because researcher and participant are not face to face, consent issues on the Internet are more complex and include: (a) Is informed consent required?; (b) How can it be obtained?; and (c) How can it be validated? (McCleary, 2007). The first question requires distinguishing between the public and the private domains. Postings on discussion boards, listservs, or chat rooms are available to anyone who chooses to access that particular site. Those who participate in that online group are usually aware of the public nature of their postings via warnings from the server agency. IRB’s may use this argument and may not require informed consent. However, those participating in forums which focus on sensitive topics may have an expectation of anonymity and privacy and suffer greater costs if these are violated. For example, perceived anonymity is often mentioned as an attractive feature of “cybersex” activities. If there is an expectation of privacy due to a particular site’s posted membership policies or the sensitivity of the group’s topic(s), this may be a reason for an IRB to require informed consent. (McCleary, 2007). If a discussion group participant reads his or her words in a published article, or if that group can be identified from quotes used without permission, there is a risk of harm, especially when the forum involves a sensitive topic such as HIV or mental illness. A researcher’s presence can damage the trust formed in a group and actually contribute to the forum’s demise. Online group members may not be comfortable knowing that a researcher is lurking in their group and may have responses such as feeling intruded upon, feeling as if the researcher is being voyeuristic, and that their online environment is no longer safe. (McCleary, 2007). Finally, if a researcher joins a discussion group to mine data, and does not meet the posted profile of users of the group, this is an act of deception and violates the autonomy and dignity of persons in that group. From the utilitarian perspective, this must be considered among the costs of the research. From the deontological and an ethics of care perspective, it might be argued that such deception is not acceptable. The responsible conduct of research goes beyond these perspectives and needs to be considered when deciding methodology. (McCleary, 2007).

5

Online surveys also present issues related to informed consent, as well as anonymity and confidentiality. As noted in the Online surveys have a number of ways they can deal with informed consent. However, there is no way to tell for sure whether survey respondents read and understand the online consent, use the resource referrals provided if there is a problem, or actually meet the study criteria. Some researchers provide a code to those who want to participate through a different medium such as e-mail, and are better able to obtain informed consent prior to respondents taking the survey. (McCleary, 2007). Ways to ensure that research subjects are protected include: (a) using an informed consent prior to collecting data; (b) getting permission to enter the group from the site administrator and/or participants; (c) being vigilant of possible issues and intervening (e.g., referral to resources such as an agency, organization, or Web site) as soon as possible; (d) getting consent from the poster to use quotes; (e) removing all possible identifiers, such as the communication’s headers and signatures, names, and pseudonyms; (f) making no reference to the type of communication, the location or type of forum; and (g) storing data in a safe manner. (McCleary, 2007). Blog Cautiously Nursing blogs are risky. If the author can be easily identified then it may be possible to identify the patients being described. One blog, 'Geeknurse' in the US, was recently shut down for this reason. (Livsey, 2010). Healthcare professional bloggers including nurses may encounter experiences that they are uncertain about how to handle. For instance, patients responding nurses’ blogs. One psychiatric intern said, “Less than a month into my intern year, I inexplicably received an email from someone from out of state who divulged that he had been treated for mental illness in the past. He had not been my patient; he was just pleased with the mental health care he had received. Unsure of what to do, I replied with a simple one-line e-mail, and thanked him for reading the blog. My response seemed to give him the green light to leave frequent comments on my blog posts. He e-mailed me again a few months later, asking for book recommendations, and he became angry when I did not reply immediately. I eventually turned on the option to approve or reject comments before they are posted. This greatly offended my blog reader who posted angry comments on my blog entries, which were followed by apologetic comments pleading with me to contact him and to reassure him that it was okay for him to read my blog. This experience was certainly frustrating and a bit frightening. I continued my blog throughout my intern year because my schedule was too hectic to keep up with all my friends. My blog was a great way to update friends and family about my life without having to send regular mass e-mails. At first it was fun to have strangers read and comment on my blog, but my experience with the patient from out of state was disquieting and I started to wonder what might occur if one of my own patients found my blog.” (Perez-Garcia, 2010). Judging from the intern’s experience, it appears that blogging may not be the most appropriate way to display personal information, unless the blogger has the ability to restrict visitors from viewing or entering the discussion. Also, if the nurse has a blog in which he or she discusses his/her working life, he/she must not include any details of patients that would enable readers to identify them. The nurse must be particularly careful if he/she uses their real name. (Livsey, 2010).

6

Maintain Patient Privacy If a nurse takes photos of patients, or writes a blog that mentions patients he or she has treated, he or she risk breaching patient privacy. (Livsey, 2010). In children's nursing, where nurses form close relationships with young patients, it is easy to take a snap on a mobile phone to capture a happy moment without gaining parental consent. But this could be in breach of the “nurses’ code of conduct”. (Livsey, 2010). Nurses need to be aware of the ways in which technology can endanger patient privacy. (Livsey, 2010). The nurse need to adhere to the basic rules for maintaining patient confidentiality during use of the social network:  Never photograph or video a patient without consent, or parental consent in the case of a child.  Never post photos or videos of patients online without their consent.  Do not post images of patient hospital numbers or notes. (Livsey, 2010).  Ensure that no patient could be identified from your profile on networking sites such as Facebook. (Livsey, 2010). Few nurses would deliberately compromise patient privacy. But it is easy to break the rules unthinkingly. (Livsey, 2010). Recommendations for the Job Seeker The customs and laws that regulate hiring also provide employers with rights. It remains largely true that in the United States, being considered for a job is more of a privilege than a right. The employment-at-will concept reminds us that a job belongs to an employer, and it remains the employer's discretion as to who may occupy that position. The observations offered in this article do not fundamentally alter this reality. Managers still possess considerable latitude in determining what type of employee will best represent the organization. Most managers making hiring decisions represent a generation with a distinctly different set of expectations regarding acceptable public personas. These expectations are probably at odds with how many young people live their lives, both online and offline. The generational divide exemplified by using social networking information will probably dwindle over the years, until such time that it is inevitably replaced by a new technology or new social reality. Until then, however, caution is perhaps the best ally, particularly in a tough labor market. Be attentive to what your online profile says about you; focus on presenting the identity of someone that would make an excellent employee. (Smitha & Kidder, 2010). Employer Risks vs. Benefits Companies are struggling to balance the benefits and risks of letting workers roam online realms such as Facebook and Twitter. Half of companies have not set out a specific policy for workers' online social networking activities, according to the report from two professional groups, the Health Care Compliance Association and the Society of Corporate Compliance and Ethics. Although many organizations lack social networking policies, one-quarter of the nearly 800 compliance and ethics professionals surveyed said their organization has had to discipline an employee for activities on Face-book, Twitter or Linkedln. (Frauenheim, 2009). Social networking sites pose risks such as employee disclosures of confidential information, exposure to computer viruses and postings that

7

can damage a firm's reputation. Social networking can help firms in ways including viral marketing. And companies can discourage employees from positive social networking activities by the use of dra-conian policies. (Frauenheim, 2009). There are uncertainties among employers as to what the limits are in employer monitoring. The social networking field has exploded. Half of Facebook's active users log on to the site in any given day, and more than 35 million users update their status daily. (Frauenheim, 2009). Companies, though, are in the dark about much of this activity. Many companies do not have an active monitoring system for checking employee activity on social networking sites. (Frauenheim, 2009). A related topic is the potential for leaks of sensitive data through e-mails. This can include intentional and inadvertent zapping of information such as customer or employee financial data. More and more companies are trying to stop such leaks with sophisticated software. These tools, known as data-loss protection applications, can flag suspect messages, such as ones with large attachments or particular key words. (Frauenheim, 2009). Another factor is the economic downturn, during which employers have terminated many workers. Companies have to be wary of sabotage by disgruntled ex-workers or the prospect of former employees providing intellectual property to competitors. (Frauenheim, 2009). Employers are taking increased steps to protect their data. However, some employers go too far in their monitoring by improperly getting passwords to employees' personal Gmail or Yahoo e-mail accounts and snooping in them. (Frauenheim, 2009). Companies should set clear policies on Internet use and employee privacy. Policies are needed in an era when so much intellectual property is in electronic form. However, the intersection of data protection, employee freedoms and social media is a gray one. (Frauenheim, 2009). Developing Company Policies Social networking is now so commonplace and its implications sufficiently significant that more formalized approaches are warranted. (Smitha & Kidder, 2010). No doubt, the Age of Information makes for interesting new territory for the compliance officer. (Harned, 2009). It is in most companies’ interests to establish policies and guidelines about what constitutes appropriate and inappropriate use of social networking information. (Smitha & Kidder, 2010). How do you monitor what employees are doing? Who does the investigating? How might their activity affect the corporate brand? What can the company do about it? How do you balance employees’ right to privacy with the company's interests? What is it appropriate to expect in terms of off-hours behavior? (Harned, 2009). You probably already have Internet usage policies in place at your office. Technology has changed rapidly, so now's a good time to revisit those policies to make sure that they are current. (Harned, 2009). EEO policies and codes of conduct are good places to begin a review of necessary changes. (Smitha & Kidder, 2010). First of all, you don't want to be Big Brother, and you would probably be unsuccessful if you tried. The Web is too dynamic to have total control over, or even awareness of, everything your employees do online. More importantly, you shouldn't be policing the private lives of employees. Don't base your decisions about all employees based on the potential for harm by the very lowest common denominator. (Harned, 2009).

8

It is reasonable and fair to use some basic tools, such as "search spiders," to see what's being said about your company. But the intent should be to know what's going on in the Net as it relates to your company, not to keep tabs on the private lives and thoughts of those who work with you. Be reasonable, presume that employees will be reasonable as well; deal with aberrant behavior as such. (Harned, 2009). Make sure that your Internet policy is consistent with your company's values, in addition to being relevant to the evolving challenges and complexity of today's global village. Address how certain behaviors might affect your company and its brand, other employees, customers, and other stakeholders including shareholders. (Harned, 2009). Whenever a decision or action has the potential to affect others, it involves ethics. Take the time to consider the ethical dimension of Internet behavior, and encourage employees to do the same. Certainly, there are people who don't care about the harm they may do to others, but they are the exception rather than the rule. More bad choices are made out of thoughtlessness than malice, and this is particularly true of Web behavior. It seems too anonymous. It's so easy to dissociate actions from consequences, and to think that poor choices made online are victimless crimes. (Harned, 2009). Have clear standards and communicate your expectations to employees. Take the time to think through and articulate your standards for online behavior. Then, clearly and plainly explain to employees which parts of their out-of-work behavior fall within the parameters of their obligations as an employee of your company. This realm includes obvious problems (shooting a video in their uniform or at their workplace) as well as issues that might be subtler, such as discussing a patient without using the name but including other identifiable details. (Harned, 2009). Recognize that the same standard may not be appropriate for all employees. The higher you go up the food chain, the less private your personal time becomes. Encourage employees, especially those who are new to management, to consider how their outside endeavors affect the company as a whole. (Harned, 2009). Care enough to make it a training and supervisory priority. Consider the amount of harm that a single viral video can do to your company. Rather than dealing with the problem after the fact, invest in preventive education. Teach employees to think about how their online behaviors will affect others, including your company. Encourage supervisors to have conversations with their reports about what you do and don't consider appropriate. (Harned, 2009). As a company, model the high ethical standards in online behavior that you want your employees to live by. Be transparent and above-board, and make sure that all areas of your company adhere to those principles. Avoid questionable behaviors, such as paid online "reviews" and spying on competitors; you wouldn't dumpster-dive at their plant, so don't allow deceptive posts in message boards or the like. (Harned, 2009). Finally, if employees do step over the line, enforce the consequences that you've communicated. Document what action you've taken. And, as candidly as is appropriate, use cases as jumping off points for discussion and education. (Harned, 2009).

9

Recommendations for Job Hirers Firms should take advantage of the opportunity to enhance their organizational identity through the use of communication technologies, such as Facebook. Creating and maintaining a positive organizational image is critical for maximizing a company's advantages. An individual's work role is one of the central sources of identity in our society, so an organization's social identity can and should be used as a recruiting and retention tool. (Smitha & Kidder, 2010). Next, organizations should emphasize that use of communication technologies, such as Facebook information in the selection process, must have a clear purpose and be job related. Because there is a strong likelihood of encountering extraneous information related to protected class status, there are two types of risk exposures when managers "troll" social networking sites. The first risk is the potential for EEO violations. The second risk involves the challenging issue of seeking a good fit between the candidate and the organization's culture. Certainly, one of the strong appeals toward using communication technologies, such as Facebook, is that managers can obtain a richer picture of candidates' backgrounds and interests. Organizations must address the following question: How far and under what circumstances should hiring managers consider a candidate's preferred movies, novels, and pastimes as determinants of ability and willingness to do the job? Particular caution must be paid to avoiding discrimination on the basis of legal off-the-job activities such as drinking, smoking, political expression, and the like. As with other job selection tools, the burden to prove this relatedness rests with the employer. Third, social networking information may not always be truthful; in fact, it is the nature of the media that some posted information is deliberately deceptive and, in some cases, may not be the responsibility of a particular user. It is imperative that informational integrity be assessed, especially regarding material that may potentially be disqualifying. We believe a fair policy would require managers to undertake reasonable efforts to validate any damaging information culled from a candidate's Facebook site. At the very least, this might entail asking candidates themselves to affirm the authenticity of this information. (Smitha & Kidder, 2010). Also, when a candidate's profile is set to "private" and is not publicly available, that no one, including current employees and business partners, should be pressured to provide their "friend" privileges for that candidate to the employer. Nor should organizations attempt to gain access to a job applicant's Facebook site without permission. The laws about privacy on the Web are constantly evolving, and are likely to be stricter in the future. (Smitha & Kidder, 2010).

10

Internet Social Networking and Nurse Ethics References

Grande, David, MD., MPA, & Asch, David A., MD, MBA. (2009). Commercial versus Social Goals of Tracking What Doctors Do. The New England Journal of Medicine. Vol. 360. pp. 747-749.

Eysenbach, Gunther, MD, MPH. (2008). Medicine 2.0: Participation, Apomediation, and Openness. Journal of Medical Internet Research. Vol. 10. No. 3. Retrieved September 1, 2010 from http://www.jmir.org/2008/3/e22/

"Facebook fracas." (2010, January). Nursing Vol. 40. No. 1. pp. 10. Retrieved February 7, 2011 from General OneFile via http://find.galegroup.com.ezproxy.fiu.edu/gps/infomark.do?&contentSet=IACDocuments&type=retrieve&tabID=T002&prodId=IPS&docId=A218558883&source=gal e&srcprod=ITOF&userGroupName=flstuniv&version=1.0

Frauenheim Ed. (2009). Social Media, E-Mail Remain Challenging for Employers. Workforce Management. Vol. 88. No. 13. pp. 4.

Harned, Patricia. (2009, June). Enforcing Employee Ethics in Online Networks Era. Compliance Week. Vol. 6. No. 65. pp. 63, 76. Retrieved February 8, 2011 from http://search.proquest.com.ezproxy.fiu.edu/docview/216716101?accountid=10901

11

Hensley, Scott. (2009). Social Networking on the Internet. American Journal of Nursing. Volume 109. Issue 7. pp. 20. Retrieved September 1, 2010 from http://journals.lww.com/ajnonline/Fulltext/2009/07000/Social_Networking_on_the_Inter net.18.aspx

http://nursingworld.org/students: American Nurses Association. (2008, March-April). Nursing Education Perspectives. Vol. 29. No. 2. pp. 113. Retrieved February 7, 2011 from Academic OneFile via http://find.galegroup.com.ezproxy.fiu.edu/gtx/infomark.do?&contentSet=IACDocuments&type=retrieve&tabID=T002&prodId=AONE&docId=A177991451&source= gale&srcprod=AONE&userGroupName=flstuniv&version=1.0

Livsey, Trish. (2008, December 2010). "Post-it pitfalls: new technology makes it easy to breach patient privacy unwittingly." Nursing Standard. Vol. 23. No. 14. pp. 26+. Retrieved February 7, 2011 from General OneFile via http://find.galegroup.com.ezproxy.fiu.edu/gps/infomark.do?&contentSet=IACDocuments&type=retrieve&tabID=T002&prodId=IPS&docId=A191816954&source=gal e&srcprod=ITOF&userGroupName=flstuniv&version=1.0

McCleary, Roseanna. (2007). Ethical Issues in Online Social Work Research. Journal of Social Work Values & Ethics. . Vol. 4, No. 1. Retrieved September 1, 2010 from http://www.socialworker.com/jswve/content/view/46/50/

12

Perez-Garcia, Gonzalo J. (2010). Challenges faced by psychiatrists in the Internet age. (Resident’s Corner). Psychiatric Times. Vol. 27. No. 4. Pp. 8.

Smitha, William P. & Kidder, Deborah L. (2010). You've been tagged! (Then again, maybe not): Employers and Facebook. Business Horizons. Vol. 53. No. 5. pp. 491-9. Retrieved February 7, 2011 from http://vnweb.hwwilsonweb.com.ezproxy.fiu.edu/hww/results/results_single_fulltext.jhtml ;hwwilsonid=LAGXLLKW21HAVQA3DIOSFF4ADUNGIIV0

Spector, Nancy, PhD, RN. (2010, July). "Boundary violations via the internet." Texas Board of Nursing Bulletin. Vol. 41. No. 3. pp. 6. Retrieved February 7, 2011 from Academic OneFile via http://find.galegroup.com.ezproxy.fiu.edu/gtx/infomark.do?&contentSet=IACDocuments&type=retrieve&tabID=T002&prodId=AONE&docId=A232888965&source= gale&srcprod=AONE&userGroupName=flstuniv&version=1.0

13

Internet Social Networking and Nurse Ethics Quiz 1. Facebook has more than 200 million active users worldwide.

a. True b. False

2. Twitter is a popular messaging service, similar to a text message on a cell phone.

a. True b. False

3. Social networking sites for nurses are:

a. Allnurses.com b. NurseConnect.com c. Nurse-anesthesia.org

4. Online nurse social networks can help to:

a. Break down barriers that keep nurses apart b. Support new, less experienced nurses c. Find nurse mentors d. Feel on par with twittering physicians e. All of the above

14

5. Social networking involves:

a. Forming a complex network of relations b. Enabling and facilitating collaborations c. Enabling users to see what their peers, friends, relatives, colleagues, fellow patients are doing d. Viral marketing e. All of the above

6. Viral marketing aspect of social networking makes some personal health records applications attractive to venture capitalists and sales representatives.

a. True b. False

7. When physicians care for patients, they leave behind electronic tracks that allow others to observe their clinical decisions, and that these observations can be deployed in the service of both commercial and social goal.

a. True b. False

8. Application of information technology to medicine threatens to undermine the ethical foundation of quality healthcare.

a. True b. False

15

9. Informed Consent involves:

a. Coercion b. Undue influence c. The ability of persons to choose what they want to happen to them to the best of their capabilities d. Withholding information

10. Postings on discussion boards, list servers, or chat rooms are available to anyone who chooses to access that particular site.

a. True b. False

11..IRB may not require informed consent if those who participate in that online group are aware of the nature of their postings via warning from the server agency.

a. True b. False

12. A reason for an IRB to require consent is:

a. There is no expectation of privacy b. There is an expectation of privacy due to a particular site’s posted membership or the sensitivity of the group’s topic c. Participants are not aware of that their sensitive discussions are disclosed d. There is a warning from the server agency

16

13. If a discussion group participant reads his or her words in a published article, or if that group can be identified from quotes used without permission:

a. Sensitive quotes used is always ok b. Anyone is free to publish any article with sensitive words without permission c. There is no risk of harm d. There is a risk of harm

14. Ways to ensure that research subjects are protected include:

a. Getting permission to enter the group from the site participants b. Getting consent from the poster to use quotes c. Using an informed consent prior to collecting data d. Removing all possible identifiers e. All of the above

15. It is possible for the health care provider to unknowingly offend a blogger who is a former or current patient.

a. True b. False

16. Activities by employees on social networking sites can pose risks such as:

a. Disclosure of confidential information b. Exposure to computer viruses c. Postings that can damage a firm’s reputation d. All of the above

17

17. Some organizations’ compliance or ethics department/personnel has a social networking policy or active monitoring system.

a. True b. False

18. Data-loss protection applications software can decrease potential leaks of sensitive data through emails.

a. True b. False

18

Internet Social Networking and Nurse Ethics

Blank Answer Sheet

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

19

Internet Social Networking and Nurse Ethics

Answers to Quiz

1. A 2. A 3. E 4. E 5. E 6. A 7. A 8. A 9. C 10. A 11. A 12. B 13. D 14. E 15. A 16. D 17. A 18. A

20