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Ethical Decision-Making Among Nurses Participating in Social Media: A Grounded Theory Study

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Social Media Usage Among Nurses: Perceptions and Practices

Affiliation.

1 Author Affiliations: Faculty Attending Physicians (Drs Lefebvre, Glass, Husain, Pariyadath, Cline, and Stopyra), Nurses (Mss McKinney and Roberson), and Medical Student (Mr McLean), Medical University of South Carolina, Charleston, South Carolina; and Attending Physician (Dr Franasiak), Mid Ohio Emergency Services, Columbus, Ohio.
PMID: 32049701
DOI: 10.1097/NNA.0000000000000857

Objective: This study aims to examine the existing perceptions and social media practices of nurses in a large academic medical center.

Background: Limited data are available about the perceptions and social media practices among healthcare providers. An understanding of the social networking landscape within the nursing profession is necessary to inform policy and develop effective guidelines.

Methods: This was a single-center prospective observational study involving nurses at a large academic medical center. Nurses completed an anonymous questionnaire regarding their personal use and perceptions of social media in the context of clinical medicine.

Results: A total of 397 nurses participated in the study survey. Overall, 87% of participants reported using a general social media account currently. Increasing age was associated with decreasing frequency of social media use.

Conclusion: Social media usage is common among nurses. Social media perceptions and practices among nurses vary considerably. Well-informed policy and targeted education are needed to guide social media use among healthcare workers.

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How nurses can use social media to their advantage

Reinbeck, Donna PhD, RN, NEA-BC; Antonacci, Jaclyn MA

Donna Reinbeck is an assistant professor at the Medical University of South Carolina in Charleston, S.C., and Jaclyn Antonacci is a social media coordinator at William Paterson University in Wayne, N.J.

The authors have disclosed no financial relationships related to this article.

nursing research articles on social media

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Open Access

Peer-reviewed

Research Article

Nurses’ use of social media during the COVID-19 pandemic—A scoping review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration

Affiliation Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden

Roles Conceptualization, Formal analysis, Investigation, Methodology

Affiliations Media and Communication Studies, School of Health and Welfare, Halmstad University, Halmstad, Sweden, Department of Communication and Media, Faculty of Social Sciences, Lund University, Lund, Sweden

Roles Conceptualization, Formal analysis, Methodology

* E-mail: [email protected]

Affiliations Centre for Care Research Western Norway, Western Norway University of Applied Services Bergen, Bergen, Norway, VID Specialized University, Stavanger, Norway

Affiliation Media Studies, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark

Affiliation Centre for Relationships and De-escalation, Mental Health Services Region Zealand, Slagelse, Denmark

Stinne Glasdam,
Helena Sandberg,
Sigrid Stjernswärd,
Frode F. Jacobsen,
Anette H. Grønning,
Lisbeth Hybholt

Published: February 18, 2022
https://doi.org/10.1371/journal.pone.0263502
Reader Comments

During the COVID-19 pandemic, nurses stand in an unknown situation while facing continuous news feeds. Social media is a ubiquitous tool to gain and share reliable knowledge and experiences regarding COVID-19. The article aims to explore how nurses use social media in relation to the COVID-19 pandemic.

A scoping review inspired by Arksey and O’Mally was conducted by searches in Medline, CINAHL, Academic Search Complete and Web of Sciences. Empirical research studies investigating nurses’ use of social media in relation to COVID-19 were included. Exclusion criteria were: Literature reviews, articles in languages other than English, articles about E-health, and articles investigating healthcare professionals without specification of nurses included. Articles, published in January-November 2020, were included and analysed through a thematic analysis. The PRISMA-ScR checklist was used.

Most of the eleven included studies were cross-sectional surveys, conducted in developing countries, and had neither social media nor nurses as their main focus of interest. Three themes were identified: ‘Social media as a knowledge node’, ‘Social media functioned as profession-promoting channels’ and ‘Social media as a disciplinary tool’. Nurses used social media as channels to gain and share information about COVID-19, and to support each other by highlighting the need for training and changes in delivery of care and redeployment. Further, social media functioned as profession-promoting channels partly sharing heroic self-representations and acknowledgment of frontline persons in the pandemic, partly by displaying critical working conditions. Finally, nurses used social media to educate people to perform the ‘right ‘COVID-19’ behaviours in society.

This review provided snapshots of nurses’ uses of social media from various regions in the world, but revealed a need for studies from further countries and continents. The study calls for further multi-methodological and in depth qualitative research, including theoretically framed studies, with a specific focus on the uses of social media among nurses during the pandemic.

Citation: Glasdam S, Sandberg H, Stjernswärd S, Jacobsen FF, Grønning AH, Hybholt L (2022) Nurses’ use of social media during the COVID-19 pandemic—A scoping review. PLoS ONE 17(2): e0263502. https://doi.org/10.1371/journal.pone.0263502

Editor: Anat Gesser-Edelsburg, University of Haifa, ISRAEL

Received: May 11, 2021; Accepted: January 20, 2022; Published: February 18, 2022

Copyright: © 2022 Glasdam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files. The relevant studies and search criteria are included in the manuscript.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

There is a global shortage of healthcare professionals, in particular nurses [ 1 , 2 ]. The World Health Organization (WHO) [ 2 ] estimates that the world will need an additional 9 million nurses and midwives by 2030, and Scheffler and Arnold [ 3 ] project a shortage of nearly 2.5 million nurses across 23 OECD countries in 2030. Several studies show that perceived staffing adequacy, both in numbers and qualifications, is of major importance for nurses to leave or stay at a workplace [ 4 , 5 ]. Today, nurses’ work situation is affected by the current coronavirus SARS-CoV-2 and COVID-19 outbreak in multiple ways, with an increased workload, safety issues, novel and constantly updated work routines, an unpredictable future, feelings of worry and insecurity, and more [ 6 – 8 ].

Nurses’ feelings of worry and insecurity can be linked to the overwhelming crisis situation caused by the COVID-9 pandemic [ 9 ], as it is important for healthcare professionals to be well prepared to take care of patients with COVID-19 [ 10 , 11 ]. Care provision is a considerable mental and emotional challenge during a pandemic, which when combined with exhaustion may result in nurses being infected, dying, getting burned-out and/or leaving their jobs [ 12 – 15 ]. Nurses’ commitment to caring for their patients is hence often detrimental to their own mental and physical wellbeing [ 8 , 13 , 16 ]. The negative impact of COVID-19 outbreaks on health professionals’ mental health is confirmed by further studies, e.g. through the nurses’ repeated and prolonged exposure to stressors due to direct exposure to infectious diseases [ 11 , 17 – 19 ]. Also, insomnia and sleep disorders are shown among healthcare professionals during the pandemic [ 8 ].

During the current pandemic, nurses stand on precarious ground, in an unknown situation and with continuous news feeds [ 6 ]. It is important and challenging for nurses to be up to date with reliable knowledge and share experiences with each other to handle this new situation. Social media has become a ubiquitous tool for an increasing number of people in multiple areas of daily life. Social media enables private and professional uses, functioning as a source of e.g. news and information, entertainment, opinion making, networking, and connectivity, as well as identity construction [ 20 – 23 ], also for healthcare professionals with clinical positions [ 24 – 26 ]. Social media can be defined as internet-based applications for user-generated content production, sharing and communication where individuals and groups create user-specific profiles for a site or app designed and maintained by a social media service [ 27 , 28 ]. Social media is an umbrella term covering technologies, services, platforms and channels. Social media technologies allow users to co-create, distribute and share information at different levels of participation, facilitating ‘prosumption’, understood as the blurring of production and consumption, of information in contrast to only consuming e.g. COVID-19 information online [ 29 – 31 ]. Social media services further facilitate the development of social networks online by connecting a profile with those of other individuals and/or groups [ 32 ]. Examples of social media platforms include Twitter, Facebook, Instagram, LinkedIn, YouTube, and Clubhouse, etc. Social media channels can be sources of all kinds of information [ 33 , 34 ]. They offer moments of entertainment, encouragement, and relaxation during the day. It is unknown how, for what purposes, and to what extent nurses use social media for knowledge search, knowledge production and knowledge sharing, as well as for the exchange of experiences and emotions related to the direct work with patients during this pandemic. A crisis like the current one with COVID-19 strongly affects the nurses’ work situation, including the physical, mental and social work environment. There are enhanced stress and suffering in patients and their families, challenging safety and ethical issues, novel and constantly updated work routines, and an unpredictable future with subsequent feelings of worry and insecurity, to name a few aspects [ 6 , 7 ]. This may lead to serious consequences on sustainability of nurses’ work life. An understanding of whether and how nurses relate to the vast amount of information pervading the multitude of popular social media platforms may help us understand if and how nurses navigate and make use of social media in their professional role and whether such use can be an empowering or disempowering factor. News travels fast and on a global scale through social media [ 35 ], contributing to a rapid spread of all kinds of information to wide audiences. As social media can be a source of both emotional turmoil [ 21 ] and emotional support [ 36 ], it is of particular importance to explore its potential uses in the current COVID-19 pandemic. Therefore, this scoping review aims to explore how nurses use social media in relation to the COVID-19 pandemic.

A scoping review inspired by Arksey and O’Mally [ 37 ] was conducted in November 2020—January 2021. Scoping reviews are useful for examining emerging evidence. This approach seemed relevant as the literature in this field was characterised by studies with a wide range of designs and the research question became relatively broad [ 37 ]. The method of this scoping review will be presented below in five stages, inspired by Arksey and O’Mally [ 37 ]: 1) Identifying the research question, 2) identifying relevant studies, 3) study selection, 4) charting the data and 5) analytical strategy. The Prisma-ScR checklist was used for reporting this review [ 38 ], see S1 Checklist . The review was not registered and a protocol was not prepared.

Identifying the research question

Overall, we identified two research questions: 1) What is the scope of the empirical research on how nurses use social media in relation to the COVID-19 pandemic? and 2) How are the nurses’ uses of social media described?

Identifying relevant studies

The two broad research questions aim at examining the extent, range and nature of relevant research activity and to identify types of available evidence of relevance to the topic of this article. The method of scoping review is considered an apt method for achieving these aims. A systematic literature search was conducted in four databases: CINAHL, Medline, Academic Search Complete (EBSCO) and the Web of Science citation database. We chose these databases as they provide the opportunity to find articles that have been published in both the health and media fields. In each of the three selected databases, the search strategy consisted of a building block search carried out according to the population, exposure and outcome (PEO) model [ 39 ]; 1) Population: nurses, 2) Exposure: Social media, and 3) Outcome/Theme: COVID-19, see ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0263502.t001

Each block included a variation of relevant search terms. The search was limited to articles written in English and published from 1st January 2020 - 7th November 2020, closely related to the onset of the COVID-19 pandemic and beyond. Table 2 shows the full electronic search strategy used to identify studies with all search terms and limits for all three databases.

https://doi.org/10.1371/journal.pone.0263502.t002

The 738 identified studies were transferred to COVIDENCE.org for the following screening process. We supplemented the building block with a citation pearl search in the Web of Science citation database of the included articles to be able to find relevant studies outside the three databases. We did not include grey literature defined as all kinds of materials produced by governments, academics, business and industry, which is not controlled by commercial publishers [ 40 ] as the focus was on peer reviewed research articles within the topic.

Study selection

The first and last authors (SG & LH) of the current article separately screened the article titles, abstracts and full texts using COVIDENCE.org with the following criteria: empirical research studies investigating nurses’ use of social media in relation to COVID-19. Inclusion criteria: All articles investigating or presenting results on how nurses used social media during the COVID-19 pandemic were included, as for example investigations on COVID-19 knowledge among nurses and social media as a source of knowledge. The following articles were excluded: Literature reviews, articles in languages other than English, articles about E-health, and articles investigating healthcare professionals without specification of nurses included. In case of disagreement in the screening process, the two authors discussed the inclusion/exclusion until agreement was reached. The review included nine articles. Further, two articles were included after the citation pearl search in Web of Science. The study selection process is summarised in the PRISMA flow chart [ 41 ], see Fig 1 .

https://doi.org/10.1371/journal.pone.0263502.g001

Charting the data

The third author (SS) completed the review’s data extraction and coding stages. A structured data extraction spreadsheet was created to extract data from the included studies based on the Cochrane Consumers and Communication Review Groups data extraction template [ 42 ]. The following information was extracted from the articles: 1) Authors, 2) Country, 3) Journal, 4) Impact factor (extracted from journal website), 5) Study period, 6) Study design, 7) Sample size, 8) Target group and context, 9) Theory, 10) Results, and 11) Limitations. A selection of the data is presented in Table 2 . The theories, results and limitations are presented and discussed in the body of the text in the Results section and in the thematic analysis that follows. The extracted data was checked for accuracy and further discussed by two of the authors (HS & SS). The validation of the extracted data could be described as an iterative process in which comparisons were made repeatedly between the extracted data and the original articles. In case there were discrepancies or important nuances missing in the table, the data was further discussed and, if necessary, complemented until a consensus was reached among the authors. In line with Arksey and O’Mally [ 37 ], the current scoping review does not include a quality assessment of the studies. Two of the authors (HS & SS) nonetheless charted the studies’ strengths and limitations as reported by the respective articles’ authors. This process was first done independently, then jointly, and potential discrepancies were again resolved through in depth discussions until a mutual agreement was reached.

Analytical strategy

The analysis was a collating and summarising of the relevant results. As in scoping reviews in general, the analysis aimed to create an overview or map of the types of evidence and knowledge in a given field [ 43 , 44 ]. Levac and colleagues [ 45 ] recommended three distinct steps in the analytical phase of a scoping review: 1) analysing the data including a descriptive numerical summary analysis and a qualitative thematic analysis, 2) reporting the outcome articulated through themes referring to research questions of the study, and 3) applying meaning to the results relating to the overall aim of the study. In this study, the descriptive summary analysis is the results of the data charting, and Evans [ 46 ] inspired the qualitative thematic analysis. The descriptive summary analysis was presented as ‘Characteristics of the studies’ in the result section. Regarding the thematic analysis, first, the articles were read and re-read to develop a sense of the studies as a whole. Second, differences between the studies’ key findings related to the research questions and the aim of the study were compared and contrasted, and three themes were identified by grouping and categorising the findings into areas of similarity. Third, the themes were re-examined to interpret the content of each theme, and to identify consistencies and incongruities. Fourth, the themes described, consisting of ‘Social media as knowledge nodes’, ‘Social media as profession-promotion’ and ‘Social media as a disciplinary tool’.

This section will start with the characteristics of the included studies in the form of a descriptive summary analysis. Next, the themes will be presented.

Characteristics of the studies

A schematic overview of the included studies is presented in Table 3 .

https://doi.org/10.1371/journal.pone.0263502.t003

All the studies were carried out in the first six months of 2020, in a diversity of countries representing multiple regions such as Africa, Asia, the Middle East, South America, and Europe. The studies took place in Brazil, Ethiopia, India (2), Libya, Pakistan (2), Qatar, Saudi Arabia, the United Kingdom, and Vietnam. Most studies were published in journals with a focus on developing countries, infectious diseases, tropical medicine, clinical care, or health professions. The journals’ impact factor (IF) ranged from 0.5–2.5 (some with no impact reported).

The studies’ research areas and aims consisted of evaluations of risk perception, attitudes, knowledge and preparedness related to COVID-19 [ 47 , 49 , 51 – 56 ] and explorations of social media posts [ 48 , 50 ], including policies, and both social media and traditional printed news media and magazines [ 57 ].

Nine out of eleven studies were descriptive cross-sectional surveys (n = 9; seven online, one paper-based, one unclear). A majority targeted healthcare professionals (n = 9) and/or media content such as social media posts (n = 3) [ 48 , 50 , 57 ], and policy documents and news coverage (n = 1) [ 57 ]. Data was collected through the means of validated and non-validated questionnaires, the sampling of (social) media posts and policies, and interviews.

The population studied, i.e. the samples and platforms (e.g. social media posts) in the studies consisted of healthcare professionals including nurses, physicians, paramedical staff, pharmacists, physiotherapists, and other clinical and administrative staff from a variety of healthcare related contexts [ 47 , 49 , 51 – 56 ], members of the general public [ 53 ], social media posts from platforms such as Twitter, YouTube, Instagram, LinkedIn, Reddit and Facebook [ 48 , 50 , 57 ], and policies and media (social media, traditional media) [ 57 ].

Social media did not come through as the major object of study in most studies. Only one article used social media in the title [ 48 ]. Only one article had social media as one out of several keywords [ 48 ] and another had ‘communications media’ as a keyword [ 50 ]. All articles mention social media in their abstracts, either in terms of a distribution channel, social media as data collection method or as an object of study (a variable), e.g. general uses of social media, social media as a source of information, user generated content on social media, or nurses’ uses of social media to express themselves. Forte and Pires’ [ 50 ] study illustrated a clear bottom-up perspective with social media as a medium for self-expression and interaction, in comparison to most of the other studies, which had a top-down perspective on communication where social media was treated as a tool for transmission or distribution of information. Three of the articles [ 48 , 50 , 57 ] expressed a more nuanced understanding of social media. All but the three former articles focused on determining, assessing, or evaluating knowledge, attitudes, perceptions, and/or preventive practices and preparedness where nurses’ use of social media appeared as a sub-element (one out of many explanatory or independent variables to explain attitudes or behaviour) in the study, exemplified by titles such as: “ Assessment of knowledge , attitude and practice regarding COVID-19…” [ 56 ] and “Factors determining the knowledge and prevention practice of healthcare workers towards COVID-19… . ” [ 47 ].

Most studies did not refer to any theories. Three of the articles referred to theoretical frameworks [ 47 , 50 , 57 ], but the theories did not reappear or drive the result analysis nor the discussion. The use of the theories was thus shrouded in obscurity. Key concepts such as knowledge, attitudes, risk, perceptions, media use, preparedness etc., were often taken for granted and consequently not properly defined or discussed in detail. The descriptions of the survey instruments (the questionnaires) were in some cases poor (e.g. [ 49 , 55 ]) lacking in detail and transparency, with scarce information of items (variables) and questions asked, making it difficult to not only interpret the results but also to assess their significance. Two studies included the full questionnaire as appendix [ 53 , 56 ], and one referred to supplementary material to be retrieved through an URL-link [ 47 ]. There was generally a lack of reflection about the study’s methods and brief comments on the limitations. One study does not report any limitations [ 54 ]. All other studies report a varied number of limitations. The cross-sectional studies for instance reported limitations pertaining to the samples’ characteristics and size and thus representativity, to the chosen distribution method, which may prevent e.g. people without Internet access from participating, to single/limited study contexts, and e.g. contexts with limited number of known/detected COVID-19 infection, and to risk of bias pertaining to (lack of) social media access. Further, no causal inferences can be made due to the studies’ design. Further reported limitations were associated with the studies’ time frame and with weaknesses in the design of the measurement instruments and operationalisation of the study objects, such as limited numbers of survey items related to the measured concepts. The non-cross-sectional studies [ 48 , 48 , 57 ] also reported a number of limitations. El Awaisi [ 48 ] for instance reported a limited knowledge of the samples’ sociodemographic characteristics, limited representativity, risk of bias related to study time frame and data collection period, and encoding bias.

Social media as knowledge nodes

The results revealed a variety in the healthcare professionals’ use of social media in relation to COVID-19 [ 47 , 49 , 51 , 52 , 54 – 57 ]. Some studies found that social media was predominant over other sources of information [ 49 , 52 , 55 , 56 ]. Huynh and colleagues [ 52 ] found that 91.1% of healthcare professionals, including nurses, in Vietnam used social media to inform themselves about COVID-19, compared to the Ministry of Health Website (82.6%), television (79.2%), and friends and relatives (43.4%). Among healthcare professionals, including nurses, Salman and colleagues [ 55 ] also found that social media was the major source (65%) of information in Pakistan, followed by television/radio (24%), friends/family/relatives (7.7%), and newspapers (1.9%). In the study by Sharma and colleagues [ 56 ], the most common source of information about COVID-19 among healthcare professionals, including nurses, was the internet (79.3%) followed by social media (69.5%), television (61%) newspapers (59.8%), government sources (58.5%), friends and family (32.9%), and radio (17.1%). According to the studies by Elhadi and colleagues [ 49 ] and Sharma and colleagues [ 56 ], 65,1% and 70% of healthcare professionals, including nurses, in Libya and India, respectively, used social media as a source of information. The study of Qadah et al. [ 54 ] found that 39.8% of the healthcare professionals in Saudi Arabia had heard about COVID-19 through social media.

Overall, social media functioned as channels where healthcare professionals, including nurses, gained information about COVID-19 [ 47 , 49 – 52 , 54 – 57 ]. However, in the study of Paul and colleagues [ 53 ] only 8% of the healthcare professionals, including nurses, in India relied on social media for information related to COVID‑19. These findings were in contrast to Asemahagn [ 47 ] that found that healthcare professionals in Ethiopia who used social media as information sources were 2.5 times more knowledgeable compared to healthcare professionals who did not access information using social media. Several studies showed that a major part of the healthcare professions had relatively good COVID-19 related knowledge [ 51 , 52 , 55 ]. Nevertheless, Elhadi and colleagues [ 49 ] found that the majority of healthcare professionals, including nurses, reported an inadequate level of knowledge on COVID-19.

Vindrola-Padros and colleagues [ 57 ] found that social media were used by nurses and other healthcare professionals in the United Kingdom to share inconsistencies in COVID-19 advice and in that way sharpened attention to possible issues in the management of COVID-19. Healthcare professionals used social media to support each other through the need for training and changes in delivery of care and redeployment, e.g. by weekly chats via Twitter around specific hashtags with discussions of new COVID-19 procedures in healthcare, sharing of educational/training guidelines, etc. [ 57 ].

Social media as profession-promotion

Social media became channels for heroic self-representations and acknowledgment of frontline persons, also nurses, in the pandemic [ 48 , 50 , 57 ]. El-Awaisi and colleagues [ 48 ] showed that the word ‘heroes’ was commonly used in posts on social media. The posts were used as reminders that many healthcare, non-healthcare professionals and volunteers risked their lives and worked around the clock to ensure the safety of COVID-19 ill patients [ 48 ] Forte and Pires [ 50 ] showed that nurses in Brazil appreciated being honoured and being called heroes, and Vindrola-Padros and colleagues [ 57 ] showed that nurses were proud of their jobs and often called on the need to be adaptable, resilient, and flexible through their heroic posts.

Some posts on social media also pointed to acknowledging and recognising overlooked health professions other than nurses and doctors, such as speech therapists and physician assistants for their efforts during the pandemic [ 48 ]. Vindrola-Padros and colleagues [ 57 ] found that solidarity between colleagues expressed through social media platforms generated positive emotions. In that sense, social media functioned as channels for fights and consolidations of healthcare professions in the medical profession’s hierarchy.

Studies also showed that social media posts were used to display critical working conditions such as ‘worked around the clock’ [ 48 ] and needs of personal protective equipment [ 50 ]. Forte and Pires [ 50 ] also showed that nurses replied to other people’s publications calling nursing professionals heroes, with appeals referring to a workday with precarious working conditions, absence of a decent salary floor and special retirement plan.

Social media as a disciplinary tool

Nurses used social media to raise awareness among people to the ‘right ‘COVID-19’ behaviours [ 50 ]. Forte and Pires [ 50 ] showed how nurses made appeals about staying at home during the quarantine period as stipulated by the state and municipal governments. The nurses also used social media posts to sensitise and educate people to remain in their homes, wash their hands correctly, use 70% alcohol for antisepsis, and apply ‘cough etiquette’ as preventive efforts to minimise the spread of COVID-19 [ 50 ].

This discussion focuses on three main findings. First, we discuss how social media serves as knowledge nodes for nurses. Second, we discuss how social media is used for profession-promoting purposes. Third, we discuss how nurses use social media to discipline the general public and foster appropriate COVID-19 hygiene and behaviour. Finally, we discuss the strengths and limitations of the scoping review.

The results show that social media serves as knowledge nodes for nurses, mostly in the form of a short statement that nurses gain information about COVID-19 via social media. One article shows that nurses also used social media to support each other through highlighting the need for training and changes in delivery of care and redeployment [ 57 ]. The latter is in line with Cheng et al.’s [ 58 ] study on peer support and crisis intervention for interdisciplinary teams with nurses utilising an application on smartphones. While social media used for peer-to-peer communication is mentioned, social media used for direct contact with patients and their families is thematically absent in the current review. As online patient-provider, communication may offer a new option for the delivery of affordable health services in a timely manner [ 59 ], this could represent an opportunity for nurses to take into account in the development of their professional practice, not the least in times of crisis such as the current COVID-19 pandemic. During the COVID-19 pandemic, studies show how different medical teams use social media (e.g. WhatsApp and Facebook Messenger) to make timely diagnosis of severe cases for prompt medical attention and to prevent the spread of disease by advocating social distancing and masking [ 60 , 61 , 70 ]. Several included studies in current review found that nurses got valuable knowledge through social media [ 47 , 51 , 52 , 55 ], but one study found that only 8% of the healthcare professionals in India relied on social media for information related to COVID‑19 [ 53 ]. Studies about ethical concerns and power, when using social media suggest that nurses might find it problematic to follow, post, read and trust content on social media [ 62 , 63 ]. Kuma et al. [ 64 ] show that prior positive experiences with social media, e.g. Facebook groups, might significantly influence the trust in such online groups.

Further, the results revealed that social media were used as channels for professional promotion, where both self-representations and a fight for awareness of nurses’ importance, knowledge, competence, work ethics and working conditions were central issues, both in relation to the COVID-19 pandemic and in general. This seems to differ somehow from literature with focus on physicians’ or pharmacists’ uses of social media. Studies reported that most physicians increased their use of social media during the pandemic, with social media being the most important source of COVID-19 information [ 65 , 66 ]. In addition, pharmacists used and actively encouraged their colleagues to use social media [ 67 ]. One study analysing over 10.000 tweets from physicians, concluded that more than 50% of the tweets related to actions, recommendations and concerns about possible misinformation related to COVID-19. Concerns about the healthcare system and working conditions were an actual issue, however, much further down on the list of important topics from the position of physicians [ 68 ]. The most prominent topic for the pharmacists studied appeared to be counteracting misinformation, while the theme of working conditions and the need for and plight of this professional group were not mentioned at all. By contrast, the current review stresses the vital importance for nurses, pointing out that they, during the pandemic, put their health and very lives at risk, work more hours and longer work-shifts than strictly obliged to, and suffer from lack of protective measures and gears. Moreover, nurses present themselves, regardless of the COVID-19 pandemic, as a profession with lack of a decent pay and pension plan. Mohammed et al. [ 69 ] show that the hero discourse in social media portray nurses as selfless, sacrificing, and outstanding moral subjects for practicing on the front-line under uncertain conditions. In addition, the hero discourse points to nurses as ‘model citizens’, portraying nurses as compliant, hardworking, and obedient subjects opposite to individuals and groups ignoring the medico-political recommendations regarding COVID-19. Moreover, the hero discourse is a tribute to nurses, reconfiguring nursing from mundane and ordinary to an exciting and impactful work [ 69 ]. The present pandemic provided nurses as professionals with a unique opportunity to use social media to demonstrate their indispensability, willingness to devote themselves to work for the common good and to accept sacrifices using, both putting themselves forward as heroes and pointing out that others outside the nursing profession acknowledge them as heroes. Social media platforms hence seem to be a place for nurses to strengthen their own professional self-conception and identity, voice concerns and share experiences of suffering, build strong professional collegial solidarity, and to position themselves in the medical professions hierarchy. Why studies on nurses seem to differ regarding social media and prominent topics is a question that probably has more than one answer. The nurses’ use of social media could reflect real differences in working conditions compared to professions like physicians and pharmacists. The nurses included in the current review’s studies could possibly represent jurisdictions where nurses experience particularly challenging working conditions, and in that way, social media functions as an extended mouthpiece for nurses [ 33 ]. Another explanation could be that nurses are more willing to share experiences, also painful, with colleagues and to build collegial solidarity as a way to cope with the situation [ 70 ]. The pandemic per se offers nurses personal and professional growth opportunities, also through social media uses [ 71 ].

Furthermore, the results showed how social media functioned as a disciplining tool where nurses used social media to raise awareness among other people regarding the right ‘COVID-19- behaviour’. This is in line with other studies showing that social media is used by both professionals and laymen to spread facts for educational purposes and raise awareness about the situation’s gravity [ 72 , 73 ]. Timotijevic [ 74 ] shows that the COVID-19 pandemic illustrates the complex interaction between political judgement, ideological orientations of governments, and medical expert advice forming this medico-political discourse. Nurses are regarded as medical experts in relation to COVID-19, which makes their voice particularly legitimate for people who support the medical discourse on COVID-19 and the need for the ‘new normal’ of behaviours [ 33 ]. However, what is understood as (true) information, misinformation or disinformation is dependent on the viewpoint of the information consumers and influences potentially affecting their perspectives [ 33 ]. In a crisis such as the COVID-19 pandemic, people are more likely to follow an official announcement, or order, than in so-called ordinary social situations [ 75 ], where the nurses’ voices in social media are a prolonged voice of the official guidelines regarding COVID-19. Healthcare professionals’, including nurses, use of social media can contribute to rapid dissemination by providing people with the latest medico-political knowledge and useful practices for handling COVID-19 [ 76 ]. In that way, social media functions as a channel to both raise people in the right COVID-19 spirit and consolidate the medico-political understanding of (true) information and (true) knowledge [ 33 ].

Scoping reviews are especially relevant for mapping research areas such as nurses’ use of social media, with emerging evidence and a lack of randomised controlled trials, as studies with a range of study designs can be included in the mapping [ 45 ]. This review revealed a paucity of methodologically strong studies, a lack of studies with social media as their main focus of interest, and further the studies were limited to specific regions of the world. Limitations in the included studies were the lack of theoretical frameworks and clear definitions of main concepts, and limited descriptions of data collection instruments, e.g. questions asked. Several of the studies suffer from deficiencies of various kinds, which makes it difficult to compare the results across the studies. It can explain the findings’ variety in the thematic analysis. Further, the current review cannot describe how and whether the nurses assess the gained information’s reliability, trustworthiness and usefulness. Furthermore, in several of the reviewed studies, it is difficult to separate nurses from healthcare professionals in general, which causes a risk that the focus on nurses specifically in the current review is blurred by other healthcare professions’ use of social media. In a scoping review, an optional element is a consulting exercise to inform and validate the findings, e.g. the consultants may provide additional references [ 37 ], which the current review did not comply with. A strength in the current study consists of the authors’ collaboration throughout the review, with a representation of senior researchers with different expertise areas.

The current study provided some knowledge about nurses’ use of social media, although this did not come across as the main focus of the reviewed articles. The results showed that several healthcare professionals, including nurses, in the included studies used social media as channels to gain information about COVID-19 in relation to the pandemic. However, only few studies explored the healthcare professionals’ assessment of reliability and quality of this information and how/if it helped nurses gain adequate knowledge about COVID-19, in contrast to studies on physicians’ and pharmacists’ use of social media where quality of information was a more explicitly expressed concern. Social media was also used by nurses to share inconsistencies in COVID-19 advice and in that way sharpened attention to possible issues in the management of COVID-19. Moreover, nurses used social media to support each other by highlighting the need for training and changes in delivery of care and redeployment. Social media functioned as profession-promoting channels for nurses by on one hand sharing heroic self-representations and acknowledgment of frontline persons in the pandemic. In that way, social media was used to express solidarity between colleagues in healthcare. On the other hand, social media was used to display critical working conditions, and challenged or opposed current healthcare management. Finally, the study showed that nurses used social media to raise awareness and educate people to perform the ‘right ‘COVID-19’ behaviours in society. The reviewed studies provide snapshots from various regions in the world that, to various degrees, were struck by the COVID-19 pandemic. The studies may be of great value in the specific local context for policy, practice and pandemic preparedness in the healthcare sector. As most of the reviewed studies did not have social media as their main focus of interest even though it was mentioned in the abstract, they could hardly be blamed for not making more out of it. This study calls for further multi-methodological and in depth qualitative research with a specific focus on the role and uses of social media among nurses and other health professionals during the COVID-19 pandemic. The quantitative surveys dominating the current review provide us with some pieces of information. Yet there is a huge research gap concerning contextualised, rich, and nuanced descriptions of how healthcare professionals use social media, make sense of the COVID-19 information they come across on social media platforms, how they engage with the content, develop professional standards, construct a professional identity and use social media for contestation and development of clinical practices. In the quest for such knowledge, existent social media research and theories should be made better use of, guiding the studies and providing analytical perspectives for fruitful analysis and a more critical understanding of social media in a health and nursing context. On a final note, we conclude that there is also a need for more studies from other regions of the world, e.g. Europe and the Nordic countries, characterised by a high degree of digitalisation of healthcare and healthcare organisations.

Supporting information

S1 checklist. preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) checklist section..

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J Med Internet Res
v.23(11); 2021 Nov

Dangers and Benefits of Social Media on E-Professionalism of Health Care Professionals: Scoping Review

Tea vukušić rukavina.

1 Andrija Stampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia

Joško Viskić

2 Department of Fixed Prosthodontics, School of Dental Medicine, University of Zagreb, Zagreb, Croatia

Lovela Machala Poplašen

Danko relić, marko marelić, drazen jokic.

3 Department of Orthodontics, School of Dental Medicine, University of Zagreb, Zagreb, Croatia

Kristijan Sedak

4 Department of Communication Sciences, Catholic University of Croatia, Zagreb, Croatia

Associated Data

Search strategy.

Summary of the reviewed studies (n=88).

List of the excluded studies and the reasons for exclusion.

Quality of the reviewed studies.

As we are witnessing the evolution of social media (SM) use worldwide among the general population, the popularity of SM has also been embraced by health care professionals (HCPs). In the context of SM evolution and exponential growth of users, this scoping review summarizes recent findings of the e-professionalism of HCPs.

The purpose of this scoping review is to characterize the recent original peer-reviewed research studies published between November 1, 2014, to December 31, 2020, on e-professionalism of HCPs; to assess the quality of the methodologies and approaches used; to explore the impact of SM on e-professionalism of HCPs; to recognize the benefits and dangers of SM; and to provide insights to guide future research in this area.

A search of the literature published from November 1, 2014, to December 31, 2020, was performed in January 2021 using 3 databases (PubMed, CINAHL, and Scopus). The searches were conducted using the following defined search terms: “professionalism” AND “social media” OR “social networks” OR “Internet” OR “Facebook” OR “Twitter” OR “Instagram” OR “TikTok.” The search strategy was limited to studies published in English. This scoping review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines.

Of the 1632 retrieved papers, a total of 88 studies were finally included in this review. Overall, the quality of the studies was satisfactory. Participants in the reviewed studies were from diverse health care professions. Medical health professionals were involved in about three-quarters of the studies. Three key benefits of SM on e-professionalism of HCPs were identified: (1) professional networking and collaboration, (2) professional education and training, and (3) patient education and health promotion. For the selected studies, there were five recognized dangers of SM on e-professionalism of HCPs: (1) loosening accountability, (2) compromising confidentiality, (3) blurred professional boundaries, (4) depiction of unprofessional behavior, and (5) legal issues and disciplinary consequences. This scoping review also recognizes recommendations for changes in educational curricula regarding e-professionalism as opportunities for improvement and barriers that influence HCPs use of SM in the context of e-professionalism.

Conclusions

Findings in the reviewed studies indicate the existence of both benefits and dangers of SM on e-professionalism of HCPs. Even though there are some barriers recognized, this review has highlighted existing recommendations for including e-professionalism in the educational curricula of HCPs. Based on all evidence provided, this review provided new insights and guides for future research on this area. There is a clear need for robust research to investigate new emerging SM platforms, the efficiency of guidelines and educational interventions, and the specifics of each profession regarding their SM potential and use.

Introduction

Global digital growth shows no sign of slowing, with a million new people worldwide coming online every day. This growth is clearly fueling social media (SM) use, as 45% of the world’s population are now SM users: a whopping 3.5 billion people [ 1 ]. The popularity and use of SM has increased substantially in the past few years, despite controversy around privacy, hacking, fake news, and all other negative aspects of online life [ 2 ].

Social media have been defined as “a group of online applications that allow for the creation and exchange of content generated by users” [ 3 ] and can be categorized into five groups: (1) collaborative projects (eg, Wikipedia), (2) blogs or microblogs (eg, Blogger or Twitter), (3) content communities (eg, YouTube), (4) social networking sites (SNSs; eg, Facebook), and (5) virtual gaming or social worlds (eg, Second Life) [ 4 ]. SNSs (eg, Facebook) are “applications that enable users to connect by creating personal information profiles, inviting friends and colleagues to have access to those profiles, and sending e-mails and instant messages between each other” [ 4 ]. There is a lot of mixing and confusion between the terms SM and SNSs with SM being a newer and a much broader term, encompassing SNSs.

As we are witnessing the evolution of SM use globally among the general population, popularity of SM has also been embraced by health care professionals (HCPs) [ 5 ]. It is further reflected as a considerable growth in the research about SM use in health and medicine [ 6 ], mainly focusing on the roles of SM or SNSs in linking patients and HCPs [ 7 - 9 ] or use of SM/SNSs for communication among HCPs [ 10 ].

Within these new platforms exists an unprecedented ability to expand access and communication, with the potential to revolutionize the way medical professionals interact with peers, patients, and the public. However, along with this expanded access lies the potential for inadvertent overlap between the physicians’ personal and professional lives. Boundary concerns are increasing with the blurring of personal and professional lines on SM [ 11 ]. Anything placed on the internet is essentially permanent, and our “digital footprint” stays forever documented in this virtual yet, for almost everyone, accessible world.

A definition for a new term “e-professionalism” was given by Cain and Romanelli [ 12 ] as “attitudes and behaviors (some of which may occur in private settings) reflecting traditional professionalism paradigms that are manifested through digital media.” The intersection between medical professionalism and SM has been termed also as online professionalism or digital professionalism [ 13 ].

Prior reviews have focused on the e-professionalism of medical students, residents, or physicians [ 14 ], or have presented a full spectrum of SM-related challenges and opportunities in the context of medical professionalism of diverse types of HCPs [ 15 , 16 ], but these studies were conducted almost 6 years ago. Within that time frame, the number of SM users (both HCPs and patients), SM influence on private and professional life, and new features within SM have increased substantially leaving scientific research struggling to keep up [ 17 - 19 ]. Since the end of November 2014, the number of Facebook users has doubled (from 1.35 billion to 2.7 billion) and the number of Instagram users almost quadrupled (from 300 million to 1.158 billion). New SM platforms like TikTok have gained popularity [ 20 ]. A gap has emerged in comprehensive understanding of the ways SM has influenced the medical field, especially professional behavior. With time being crucial in the context of SM evolution and exponential growth of users, this scoping review maps and summarizes recent findings and fills the knowledge gap about e-professionalism of HCPs.

The purpose of this scoping literature review was to characterize the recent original peer-reviewed research studies published between November 1, 2014, to December 31, 2020, on e-professionalism of HCPs; to assess quality of the methodologies and approaches used; to explore the impact of SM on e-professionalism of HCPs; to recognize benefits and dangers of SM; and to provide insights to guide future research in this area.

A Scoping Review

We performed a scoping review to explore the extent of the latest current evidence on e-professionalism of HCPs. The review questions were what are the reported outcomes of the benefits and dangers, and of SM on e-professionalism for HCPs, and what was the quality of methodologies and approaches used on the use of SM affecting e-professionalism of HCPs? The review subquestions were which knowledge gaps have been identified in studies and what are the recommendations for future research?

The scoping review method was chosen to map and summarize the evidence, and inform future research in the domain of e-professionalism of HCPs [ 21 - 23 ]. We performed a scoping review consistent with the guidance provided by the Joanna Briggs Institute Reviewer Manual [ 24 , 25 ]. The scoping review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines [ 26 ]. The protocol was registered on the Open Science Framework (registration DOI 10.17605/OSF.IO/YR8TW) [ 27 ] on April 9, 2021.

Search Strategy

A search of the literature was performed in January 2021 using 3 databases (PubMed, CINAHL [EBSCO], and Scopus). The searches were conducted for the period from November 1, 2014, to December 31, 2020, using the following defined search terms: “professionalism” (a Medical Subject Headings [MeSH] term) AND (“social media” [a MeSH term] OR “social networks” OR “Internet” [a MeSH term] OR “Facebook” OR “Twitter” OR “Instagram” OR “TikTok”) included in the title or abstract or keywords. The search strategy was limited to studies published in English.

The full search strategy is summarized in Multimedia Appendix 1 . A senior information specialist validated the search strategy. For a comprehensive assessment, we also searched the reference lists of all the included articles to identify other studies that may be relevant to our review.

Study Inclusion and Exclusion Criteria

Studies were included in this review if they were original research focused primarily on the use of SM among health professionals and studied the uses, benefits, or dangers of SM.

Studies were excluded from this review if they were not in English; were books, dissertations, reviews, reports, abstracts only, case studies, opinions, letters, commentaries, policies, guidelines, or recommendations; did not focus primarily on the use of SM among health professionals; did not study the uses, benefits, or dangers of SM among health professionals; did not study HCPs as a study population; described the use of SM primarily with a marketing or advertising focus; and were not available as full text in the final search.

Eligibility and Data Extraction

Following the search, all references captured by the search engine were uploaded to the reference management system Zotero (Corporation for Digital Scholarship). Duplicates were identified and removed. Initial screening of the studies, based on the information contained in the titles and abstracts, was undertaken independently by 2 reviewers (TVR and JV). The interrater reliability (IRR) between them was established. IRR to screen the papers was determined using the indices average pairwise percent agreement , Cohen kappa, and Krippendorff α (alpha) [ 28 ]. IRR was calculated with the ReCal (“Reliability Calculator”), an online utility that computes IRR coefficients [ 29 ]. To assess the eligibility of the papers, two researchers (TVR and JV) independently reviewed and evaluated the studies. Discrepancies were discussed with reference to the research objectives until consensus was reached on the inclusion for the analysis.

Data extraction was done in two passes. In the first pass, seven reviewers (TVR, JV, DR, LMP, DJ, KS, MM) extracted the data from included studies; in the second pass, two reviewers (TVR and JV) agreed on the extracted data. The following data were extracted: authors, year, country of origin, study objective and design, data analysis methods, study population, type of SM, key measures, conclusions/recommendations, and ethics statements.

Quality Evidence Assessment

The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies developed by the National Heart, Lung, and Blood Institute was used to evaluate the quality of the quantitative studies [ 30 ]. The Critical Appraisal Skills Programme appraisal tools were used to evaluate the quality of the qualitative and mixed methods reviewed studies [ 31 ]. Quality evidence assessment was performed by two reviewers (TVR and JV). If there was a discrepancy, a third reviewer was consulted (LMP).

Ethics Approval and Consent to Participate

This was a scoping review with no data collected from human participants. Ethical approval was not needed.

Figure 1 shows the PRISMA flowchart illustrating the searching process and how the studies were included in the review. The literature search retrieved 1632 papers, and after removing duplicates, 749 titles and abstracts were screened. The IRR between the two researchers (TVR and JV) who screened titles and abstracts was established. IRR values indicated high reliability (average pairwise percent agreement 89%, Cohen kappa 0.80, Krippendorff α=.83). Full texts of 126 papers were assessed for eligibility. We also searched the reference lists of the included articles and found another 10 relevant articles for inclusion. Thus, a total of 88 studies were finally included in this review. Details of the studies including year, country of origin, study objective and design, data analysis methods, study population, type of SM, key measures, conclusions/recommendations, and ethics statements are shown in Multimedia Appendix 2 . The studies (n=671) that were excluded are shown in Multimedia Appendix 3 , along with the reasons for their exclusion.

An external file that holds a picture, illustration, etc.
Object name is jmir_v23i11e25770_fig1.jpg

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart of the selection procedure. HCP: health care professional; SM: social media.

Characteristics of the Reviewed Studies

The studies were conducted in 40 countries, the majority being based in the United States (n=35), Canada (n=13), Australia (n=10), and the United Kingdom (n=10). Other countries with one or two studies were Brazil, China, Greece, Dominican Republic, Germany, Hong Kong, India, Ireland, Italy, Kingdom of Saudi Arabia, Mexico, New Zealand, Nigeria, Pakistan, Philippines, Singapore, South Africa, South Korea, Spain, Taiwan, Thailand, Turkey, and the United Arab Emirates ( Multimedia Appendix 2 ). A total of 8 studies were conducted in several countries simultaneously [ 32 - 39 ]. Participants in the reviewed studies were from diverse health care professions ( Table 1 ).

Types of health care professions included in the reviewed studies.

Health care profession		Studies (N=88), n

	Deans and directors	2
	Faculty	6
	Specialists	11
	Doctors (general)	8
	Residents	15
	Students	23

	Program directors	2
	Faculty	1
	Doctors (general)	1
	Students	5

	Deans and directors	1
	Faculty	2
	Nurses	3
	Students	8

	Pharmacists	2
	Students	4
Other health care professionals		4

a A study could include more than one type of health care professional.

b Other health care professionals are physiotherapists, physician assistant students, and osteopathic medicine students.

Medical health professionals were involved in about three-quarters of the studies. On several occasions, more than one health care profession was involved in the evaluated studies. Regarding the educational level of targeted HCPs, 35 studies investigated students [ 32 , 40 - 73 ]; 41 studies investigated residents or practicing HCPs [ 34 - 39 , 74 - 108 ]; 5 studies investigated deans or directors of programs [ 109 - 113 ]; and 7 studies investigated several educational levels of HCPs, students, residents, faculty members, or practicing HCPs [ 33 , 114 - 119 ].

Table 2 describes the types of SM/SNSs studied; the majority of the studies were unspecific, studying use of any type of SM or SNS. Only Facebook or “all SMs/SNSs with specific reference to Facebook” was analyzed in one-third of the studies ( Multimedia Appendix 2 ). Twitter [ 38 , 44 , 80 , 91 , 110 ], Instagram [ 101 ], and YouTube [ 37 ] were specifically targeted SM/SNSs in 7 studies.

Types of social media or social networking sites.

Social media/social networking site	Studies, n
Unspecific (any type of social media/social networking sites)	59
Facebook	21
All social media sites with specific reference to Facebook	1
All social media sites with specific reference to Facebook and Twitter	3
Instagram	1
Twitter	2
YouTube	1

Assessing the Quality of Studies

Overall, the quality of the studies was satisfactory. Most of the reviewed studies met the criteria in checklists ( Multimedia Appendix 4 ). All studies were exploratory in nature, and the findings were descriptive. Among 88 studies, 49 were quantitative [ 32 , 33 , 35 , 38 - 43 , 51 - 53 , 55 , 59 - 61 , 64 , 66 - 69 , 71 , 72 , 74 , 75 , 77 - 80 , 82 , 85 , 88 , 89 , 91 , 94 - 96 , 98 , 100 , 102 , 105 - 108 , 110 , 113 , 114 , 116 , 118 ], 12 were qualitative [ 34 , 36 , 44 , 45 , 49 , 57 , 73 , 76 , 92 , 93 , 101 , 104 ], and 27 used mixed methods [ 35 , 37 , 46 - 48 , 50 , 54 , 56 , 58 , 62 , 63 , 65 , 70 , 81 , 83 , 84 , 86 , 87 , 90 , 97 , 99 , 103 , 109 , 111 , 112 , 115 , 117 ]. Most studies used surveys (n=64) [ 32 , 33 , 35 , 38 - 43 , 47 , 48 , 51 - 55 , 57 , 59 - 62 , 64 - 72 , 74 , 75 , 77 - 82 , 85 , 88 , 89 , 91 , 94 - 98 , 100 , 102 , 103 , 106 - 119 ]. The questionnaires used in surveys were mostly developed by researchers. Of these survey studies, only about one-third had a response rate of 50% or greater, and 9 studies did not explicitly report a response rate [ 39 , 53 , 60 , 63 , 65 , 67 , 72 , 75 , 96 ]. In the mixed methods studies, dominantly, content or thematic analyses were used. A total of 11 studies conducted in-depth or semistructured interviews [ 34 , 36 , 44 , 49 , 58 , 65 , 73 , 76 , 97 , 104 , 117 ], and 6 studies used focus groups [ 45 , 49 , 58 , 70 , 112 , 117 ]. Most studies included (n=77) had clear ethical statements within the paper either stating ethical board approval or exemption, and 11 studies did not explicitly report an ethical statement [ 37 - 39 , 53 , 54 , 72 , 74 , 90 , 105 , 108 , 117 ].

SM Use Patterns Among Health Care Professionals

Studies that assessed SM use among different types of HCPs found high use among students, from 66.9% to 98.7% [ 40 , 43 , 50 , 51 , 60 , 61 , 64 - 66 , 68 - 70 , 102 ]; the highest with 98.7% using Facebook at least once a week was established among dental students. Lower rates of use were seen in practicing HCPs, physicians of different specialties, and program directors (PDs) or faculty, mostly ranging from 50% to 80% [ 35 , 39 , 74 , 80 , 83 , 85 , 86 , 88 , 89 , 91 , 96 , 105 , 106 , 108 , 110 , 113 , 114 ]. The exceptions were 3 studies: family medicine residents and physicians in Saudi Arabia where 95.4% of participants reported having an SM account and checking them at least once a day [ 79 ], 93.4% of medical doctors in a Singapore hospital [ 100 ], and 100% of Chinese registered nurses owned an SM account [ 107 ].

Several studies demonstrated a “generation gap” in SM use, where students are more likely than faculty to use SM [ 114 , 115 , 117 , 118 ]. A linear relationship between increasing age and decreasing SM use was also found among physicians of the same specialty or other HCPs [ 85 , 91 , 94 , 95 , 100 , 106 ].

Significant gender differences were established in several studies [ 71 , 79 , 91 , 95 , 105 , 107 ].

Irfan et al’s [ 79 ] study showed females using SM more for professional purposes, and Wang et al’s [ 107 ] study, where the study population was registered nurses, was similar. In Patel et al’s [ 91 ] study where a subgroup analysis on Twitter use for professional purposes revealed a significant gender difference: only one in four users was a female radiologist and only 14% of highly active users were female. Gender difference was established also in Gupta et al’s [ 62 ] content study of Facebook profiles (in favor of male medical students, ranging from 73.5% to 96.4%) [ 62 ], and 98.8% of all participants were males in a study about orthopedic surgeons [ 105 ].

Studies showed privacy settings deployment from 71% to 97% among HCPs [ 40 , 42 , 65 , 66 , 68 , 96 , 100 , 115 , 117 , 118 ]. Only 4 studies explicitly stated the percentage of students who had set their Facebook account on private: 37% of pharmacy students [ 40 ], 83.6% and 91% of dental students [ 64 , 65 ], and 71% of medical students [ 42 ]. More students than faculty used privacy features [ 115 , 118 ]. Results from a study among doctors in Singapore suggest that there is a knowledge deficit in terms of understanding of the privacy settings of SM accounts. From 30% to 55% of the respondents had an incorrect understanding of their SM account settings despite 95.5% claiming that they were aware that the institution had a SM policy [ 100 ]. Use of real names was investigated in 2 studies; in both, the vast majority of HCPs used their own names on Facebook [ 51 , 117 ], but on Twitter (45%) and Instagram (54%), far fewer dental students presented themselves with real names [ 51 ].

Studies also investigated the purpose of SM use, whether participants mixed professional and personal information and activities on SM sites (blended profiles) or adopted a separation strategy where professional information and activities were clearly separated from personal ones (dual citizenship) [ 34 , 39 , 69 , 78 , 79 , 91 , 96 , 97 , 106 ]. In Duke et al’s [ 115 ] study, significant differences were established between nursing students’ and faculties’ purpose of use, where almost twice as many students used SM for educational purposes than did faculty (58.5% vs 27.6%; P <.001), and almost 96% of students used SM to talk about academic-related problems compared to only 28% of faculty who did so ( P <.001). Irfan et al [ 79 ] investigated family medicine residents and physicians use of SM not only for personal purposes (76%) or professional reasons (26%); they have determined that participants also use SM for general education (46%) and in a smaller proportion (18.2%) for continuing medical education [ 79 ]. A study among South African nurses established that they experience difficulty in separating their professional and personal lives when using SM [ 73 ].

In terms of themes covered in the reviewed studies, we have focused on two major themes: benefits and dangers of SM on e-professionalism of HCPs. This scoping review also recognizes an evaluation of effects of existing approaches on promoting e-professionalism and barriers that influence HCPs use of SM in the context of e-professionalism.

Benefits of Social Media on E-Professionalism of Health Care Professionals

For the selected studies, there are three recognized benefits of SM on e-professionalism of HCPs: (1) professional networking and collaboration, (2) professional education and training, and (3) patient education and health promotion.

Professional Networking and Collaboration

The benefits of SM on e-professionalism of HCPs can be seen as improvements of established networks or possibilities for collaboration through SM sites [ 33 , 34 , 36 , 38 , 39 , 44 - 46 , 53 , 69 , 72 , 76 , 78 , 79 , 92 , 97 , 106 - 108 , 117 ]. Besides providing the opportunity for connecting with others and sharing experiences [ 38 , 39 , 46 , 53 , 69 , 72 , 78 , 106 - 108 ], SM have enabled the creation of communities for support. This enables students to help each other in studying and interacting with faculty who can provide advice, encouragement, and virtual mentorship [ 44 ]. Chretien et al [ 44 ] describe two roles that medical students use via SM, first, as access to information and, second, as a voice, a platform for advocacy, and an opportunity to state attitudes and opinions. SM is also where they gained control of their digital footprint and a sense of equalization within the medical hierarchy. SM provide for students, residents, and faculty a good discussion medium and an engaging way to get high-quality current information [ 79 , 117 ]. Professional networking and collaborations on SM enable the development and building of professional identities for health care professions [ 34 , 38 , 39 , 45 , 67 , 73 , 104 ]. Some studies emphasize SM benefits of peer-to-peer advising or learning, provision of emotional support, and identifying approaches through which physicians establish interpersonal trust on SM [ 36 , 45 , 92 ].

Professional Education and Training

Several studies have demonstrated students’ use of SM for acquiring knowledge, to gain access to information from experts with whom they otherwise would not be able to connect with, or for creating communities that can then be used as means for supportive, professional, and social learning [ 44 , 45 , 58 , 66 ].

A survey among US surgeons indicated that 70% of respondents believe SM benefits professional development, similar to findings among Chinese urologist where 52.7% believe that SM provides a platform for surgical or medical education [ 95 , 106 ].

Canadian urologists (59%) consider SM as a simple information repository that is likely to increase in the continuing professional development space [ 95 ]. About 80% of HCPs from Saudi Arabia agreed with the benefits of using SM in health care services and considered that the use of these technologies in the provision of health services improves their professional knowledge and that SM can be a useful tool by which physicians may promote their services [ 75 ].

In Duke et al’s [ 115 ] study, significant differences were established between nursing students’ and faculties’ purpose of use, where almost twice as many students used SM for educational purposes than did faculty (58.5% vs 27.6%; P <.001), and almost 96% of students used SM to talk about academic-related problems compared to only 28% of faculty who did so ( P <.001). Irfan et al [ 79 ] investigated family medicine residents’ and physicians’ use of SM for not only personal purposes (76.0%) or professional reasons (26.0%); they have determined that participants use SM also for general education (46.0%) and, in a smaller proportion, for continuing medical education (18.2%).

Patient Education and Health Promotion

Positive professional behaviors and attitudes regarding patient education and health promotion were also reported [ 34 , 37 , 75 , 97 , 106 ]. George et al [ 47 ] investigated US medical students’ attitudes about what positive role SM can play in improving communication with patients. A total of 44% of respondents stated they should and would react if a patient sought their medical advice via Facebook. Some students acknowledged the potential usefulness of SM in medical practice, patient education, health promotion, and interpersonal communication, if applied in a safe and responsible manner [ 47 ]. The thematic analysis of pharmacists’ semistructured interviews recognized addressing unprofessional posts made by peers as positive online behavior. Another positive professional activity was the use of SM to educate society in general about the role that pharmacists play in the health care system, their clinical roles, and how they can promote quality care for patients [ 34 ]. More than half of the HCPs in a cross-sectional study in Saudi Arabia agreed with the benefits of using SNSs in health care services as a suitable tool for patient education and raising public health awareness [ 75 ]. The results of the study among Saudi Arabian orthopedic surgeons showed that they are more likely to post online for the sake of sharing general medical knowledge as opposed to giving specific treatment advice. Most of them were open to the possibilities of using SM more with their patients for the sake of education, knowledge sharing, and improving patient outcomes [ 97 ]. In terms of communication with patients, in Long et al’s [ 106 ] study, the majority of urologists thought SM had improved efficiency in patient education (65.4%) and patient communication (55.1%).

Dangers of Social Media on E-Professionalism of Health Care Professionals

For the selected studies, there are five recognized dangers of SM on e-professionalism of HCPs: (1) loosening accountability, (2) compromising confidentiality, (3) blurred professional boundaries, (4) depiction of unprofessional behavior, and (5) legal issues.

Loosening Accountability

According to some studies in this review, loosening accountability can be seen as a danger to e-professionalism from two points of view: eroding public trust by providing poor quality of information on SM [ 39 , 106 , 117 ] and damaging to the professional image [ 43 , 45 , 51 , 56 , 57 , 59 , 64 , 66 , 68 , 70 , 73 , 102 , 106 , 112 ].

Potential damage to the professional image has been depicted by students as concerns about repercussions of their posts on career development or future employment, since employers are checking SM profiles of candidates [ 43 , 45 , 51 , 56 , 57 , 59 , 66 , 68 , 70 ].

Students are concerned about the extent of representation of the students’ character on SM; they edit profiles before interviews or career fairs [ 57 , 70 ] or intend to review or modify their profiles when they become qualified [ 45 , 51 ]. As students get closer to graduation, they are more concerned about future employment opportunities and their professional career. In addition, it has been reported that there is more awareness of online responsibilities as students progress through their program because employers can, and at times do, use SM profiles to make hiring decisions [ 56 ].

Three reviewed studies investigated PDs’ (medical and dental) attitudes about the use of SM for admission criteria [ 109 , 110 , 112 ]. In a study that evaluated how SM is being used in dental hygiene programs admissions and policy, only 4% of programs evaluated a potential student’s internet presence, mostly by searching on Facebook. Of those respondents that do not evaluate internet presence in applicants, more than half are not considering adding this to the admissions criteria (57.2%). Others are considering it (39.1%), and a small number (3.6%) plan to implement this in the future [ 109 ]. Use of SM is higher among medical PDs, and they more often view the online behavior of residency applicants, surgical residents, and faculty surgeons [ 110 ]. Among general surgery PDs, 18% reported visiting the SM profiles of medical students applying for surgical residency. Overall, 11% of PDs reported lowering the rank or completely removing a residency applicant from the rank order list because of online behavior [ 110 ].

Compromising Confidentiality

Being both an ethical and potentially legal issue, many of the studies have investigated attitudes toward compromising confidentiality, concerns that HCPs have about use of SM, patient privacy, and violations of Health Insurance Portability and Accountability Act (HIPAA) standards as a separate problem. Breaches of patient privacy was a concern for many different types of HCPs [ 34 , 43 , 47 , 57 , 91 , 94 , 97 , 107 , 111 , 119 ]. Bagley et al’s [ 41 ] results showed that the frequency of a student’s updates of a Facebook status appears to be associated with a risk of violating HIPAA online. Similar findings were made in Wejis et al’s [ 96 ] study. Greater disclosure on Facebook was associated with lesser awareness of the consequences of posting information on Facebook, a greater need for popularity, a higher level of self-esteem, a greater number of Facebook friends, and a higher frequency of signing in to Facebook [ 96 ]. In a study among nursing students, perceptions of confidentiality existed on the level of knowledge; all students knew that posting patient names or pictures was a breach of confidentiality. However, 34% were aware of other students who had breached patient confidentiality on Facebook [ 43 ]. “Cognitive dissonance,” a disconnect between what they thought they would do versus what they thought they should do was also reported by George et al [ 47 ].

Examples of compromising confidentiality and breaches of patient privacy were reported in several studies. In Long et al’s [ 106 ] study among Chinese urologists, nearly half of the respondents had experience posting information or pictures of patients’ SM, but only 5% of them sought their patients’ consent before posting [ 106 ]. In an exploratory qualitative study among nursing students in South Africa, students admitted that there is no responsible use of SM. They have stated that each of them perceives responsible use of SM differently. They took pictures, recorded video and audio clips of patients and of clinical interactions involving patients, and posted this information on SM compromising confidentiality [ 73 ]. In Wang et al’s [ 107 ] study, 13.4% of Chinese registered nurses (n=88) confessed that they had “sometimes” posted anonymous patient information on SM.

Blurred Professional Boundaries

Several studies in this review investigated the purpose of SM use and whether participants mixed professional and personal information and activities on SM sites (blended profiles) or adopted a separation strategy where professional information and activities were clearly separated from personal ones (dual citizenship) [ 34 , 78 , 79 , 91 , 96 ].

Numerous studies document blurred boundaries between patient and HCPs, and between students and faculty [ 40 , 43 , 47 , 59 , 64 , 65 , 68 , 70 , 73 , 75 , 78 , 82 , 85 , 98 , 100 , 105 , 107 , 114 , 117 ]. Medical students have different attitudes regarding online interaction with a patient. “Friending a patient” is generally not acceptable nor endorsed; a wide range of opinions have been observed concerning this issue, ranging from one-third for medical students in Brazil [ 59 ] that find this unacceptable to 92% for senior medical students in New Zealand [ 70 ].

Among physicians, the majority have legal concerns about communicating with patients through SM [ 78 , 105 , 117 ]. In Fuoco and Leveridge’s [ 78 ] study about attitudes toward and use of SM among urologists, online patient interaction was endorsed by only 14% of urologists. Even though 56% of urologists agreed that SM integration in medical practice will be “impossible” due to privacy and boundary issues, 73% felt that online interaction with patients would become unavoidable in the future, especially for those in practice [ 78 ].

Students were anxious about the possibility their teachers could read about their personal life on SM. Dental students are ambivalent toward “friending” a faculty member [ 65 ]. From pharmacy students’ perspectives, an active user is generally open to “friending” the outside world. However, the majority were still reluctant to “friend” faculty members at their school. Students have beliefs that student-faculty interactions should remain professional, and SM sites are not appropriate venues for such professional communication [ 40 ]. Academic faculty members were worried that connecting via SM with students or residents would blur the boundaries of the teacher-student relationship. In Jafarey et al’s [ 117 ] study, almost half of faculty members found it inappropriate to friend a current student, and friending patients was not acceptable for 70% of respondents, with major differences found in age groups; it was acceptable to friend patients to 31% of trainees and 62% of students compared to only 5% of faculty. In a similar linear progression, younger age associated with more openness to being friends with patients was also demonstrated by Klee et al [ 82 ]. Two-thirds of family medicine residents and half of practicing physician respondents believed it was not ethical to be SM friends with patients.

Brisson et al [ 114 ] found that faculty were more likely than students to have been approached by patients on SNSs (53% vs 3%). Karveleas et al’s [ 64 ] study showed a significantly higher percentage of fifth-year dental students (48.3%) compared to fourth-year students (20.6%; P <.001) who had received a Facebook friend request from one or more patients [ 64 ].

Depiction of Unprofessional Behavior

Numerous studies in this review have tried to assess the extent of unprofessional behavior posted by HCPs themselves or seen to be posted by their peers. Although there is no uniform consensus on what constitutes unprofessional behavior, studies most frequently associated it with online content pertaining to alcohol intoxication; substance or illegal drug use, nudity, and sexuality; demeaning content about patients, peers, educators, clinical sites, or the profession as a whole; discriminatory content; profanity; and aggressive/bullying content toward coworkers. Surveys that captured students’ self-report of posted unprofessional behavior reported witnessing the investigated examples with varying frequencies [ 32 , 42 , 43 , 55 , 59 , 62 , 64 , 73 , 114 , 118 ]. Among Brazilian medical students, frequencies ranged from 13.7% for “violation of patient’s privacy” to 85.4 % for “photos depicting consumption of alcoholic beverages” [ 59 ]. Posting of unprofessional content was highly prevalent among medical students in Australia despite understanding that this might be considered inappropriate and despite awareness of professionalism guidelines. A total of 34.7% of students reported unprofessional content (eg, evidence of being intoxicated 34.2%, illegal drug use 1.6%, posting patient information 1.6%, and depictions of an illegal act 1.1%) [ 36 ]. In Kenny and Johnson’s [ 51 ] study among dental students, 34% had questionable content on their profile, while 3% had definite violations of professionalism on their profile and 25% had unprofessional photographs on their profile including alcohol and different levels of nudity. Of those with unprofessional photographs, 52% had a documented affiliation with the dental school also visible on their profile [ 56 ]. In another study among dental students by Karveleas et al [ 64 ], unprofessional content had been posted by most students. A total of 71.7% of students had posted pictures from holidays, 41.5% moments in nightclubs, and 26.2% photographs wearing swimwear or underwear. Alcohol consumption and smoking were published by 19.1% and 5.5% of responders, respectively, while 0.4% of responders admitted having posted photographs of themselves using illegal drugs [ 64 ].

An international survey among health science students, from 8 universities in 7 countries, registered that a significant number of students (20.5%) across all health science disciplines self-reported sharing clinical images inappropriately [ 32 ]. Furthermore, medical students who observed unprofessional behaviors were more likely to participate in such behaviors [ 55 ], and the phenomenon of “distancing” was described among nursing students, while the existence of unwise posting on SNSs was widely acknowledged, students tended to attribute such behavior to others [ 43 ].

Age difference in the terms “older and wiser,” meaning more cautious about posting unprofessional behavior online, was proven in studies comparing students’ and faculties’ online behavior. Medical students were more likely than faculty to display content they would not want patients to see (57% vs 27%), report seeing inappropriate content on colleagues’ SNS profiles (64% vs 42%), and ignore harmful postings by colleagues (25% vs 7%) [ 114 ]. Medical students in Kitsis et al’s [ 118 ] study reported the self-posting of profanity, depiction of intoxication, and sexually suggestive material more often than faculty ( P <.001). Medical students and faculty both reported peers posting unprofessional content significantly more often than self-posting [ 118 ].

Studies that assessed the online unprofessional behavior of residents or practicing HCPs were dominantly among different physicians’ specialties (emergency medicine [EM], public health professionals, surgical residents or practicing surgeons, urology residents or practicing urologists, different residencies/specialties) [ 77 , 80 , 83 , 84 , 86 , 87 , 89 , 96 , 99 , 100 , 119 ], with 1 study investigating nurses [ 107 ] and 1 investigating pharmacists [ 34 ].

Soares et al’s [ 119 ] study compared EM trainees’ and faculties’ perceptions of unprofessional SM behaviors to those of state medical board directors from a prior published study [ 120 ]. They found that themes involving patient information, inappropriate communication, and discriminatory speech elicited similar probabilities of anticipated investigation by both EM and state medical board directors, compared to published data. However, compared with state medical board directors, EM physicians were less likely to anticipate that themes involving alcohol and disrespectful speech would be investigated. A study to assess changes in unprofessional content on urologists’ SM was done by Koo et al [ 83 ]. Comparing the cohort in practice versus the cohort at the completion of residency, there were no significant differences in how many urologists had public Facebook accounts (70% vs 71%) or whose accounts had concerning content (43% vs 40%). Examples of concerning content included images and references to intoxication, explicit profanity, and offensive comments about patients. The presence of unprofessional content at the completion of residency strongly predicted having unprofessional content later in practice. A similar comparison was made among surgical residents and practicing surgeons [ 86 , 87 ]. In a study among surgical residents, 14.1% had potentially unprofessional content, and 12.2% had clearly unprofessional content. Binge drinking, sexually suggestive photos, and HIPAA violations were the most commonly found variables in the clearly unprofessional group [ 86 ]. Among attending surgeons, 10.3% had potentially unprofessional content, and 5.1% had clearly unprofessional content. Inappropriate language and sexually suggestive material were the most commonly found variables in the clearly unprofessional group [ 87 ]. Loo et al’s [ 99 ] study among faculty and residents in Singapore suggested that doctors within the same residency do not necessarily have a uniform set of professional priorities regarding professionalism on SM. Data from Kesselheim et al’s [ 80 ] study on pediatric residents clearly demonstrates “cognitive dissonance” in residents’ approach to lapses in professionalism while using SM. More than half of the responding residents rated posting of online comments about the workplace as “completely inappropriate,” yet a similar proportion estimate that residents engage in this behavior at least monthly [ 80 ]. Among nurses in China, 7.6% reported that they had “sometimes” posted identifiable patient information on SM. When asked about colleagues’ online professionalism, half (50.3%) of the participants indicated that they had “sometimes” witnessed their colleagues’ inappropriate SM posts and 49.5% reported “never” [ 107 ].

Among pharmacists, examples of perceived unprofessional behaviors included revealing details of personal life and activities; open complaints about the pharmacy sector, coworkers, physicians, and patients; inappropriate description of pharmacists’ roles and activities; and breaches of patient confidentiality [ 34 ].

Legal Issues and Disciplinary Consequences

Unprofessional behavior on SM of HCPs can have legal consequences, potentially affecting credibility and licensure. Several studies have emphasized this issue or reflected on disciplinary legal consequences if SM are used inappropriately [ 61 , 64 , 78 , 90 , 111 , 113 , 115 , 116 ].

Fuoco and Leveridge [ 78 ] raised the controversy of whether medical regulatory bodies should monitor the SM activities of HCPs. In all, 94.6% of respondents agreed that physicians need to exercise caution in personal SM posting, although 57% felt that medical regulatory bodies should “stay out of [their] personal SM activities,” especially those in practice for less than 10 years. Most urologists agreed that care should be taken in posting on SM sites, as unprofessional posts can put one at risk of discipline, so medicolegal guidance would be beneficial in this aspect as well. Duke et al [ 115 ] emphasized that use of SM platforms, while potentially beneficial, can have professional and legal implications if not used appropriately in both personal and academic use. Faculty and students need to be aware that this could negatively impact their professional image and the nursing profession [ 115 ].

In Great Britain since 2013, all General Dental Council (GDC) registrants’ online activities have been regulated by the GDC’s SM guidelines. Failure to comply with these guidelines results in a Fitness to Practice (FtP) complaint being investigated. Documentary analysis of FtP cases from September 2013 to June 2016 revealed that 6 complaints in relation to SM were investigated. A total of 2.4% of FtP cases published on the GDC website during that period were related to breaches of the SM guidelines. All of the cases investigated were proven and upheld. Most of those named in the complaints were dental nurses, and the most common type of complaint was inappropriate Facebook comments [ 90 ]. Staud and Kearny’s [ 113 ] study identified how online SM behaviors influence the licensure and enforcement practices of dental professionals. Dental boards are aware of potential online unprofessional behaviors and have implemented various consequences. Dental boards should consider developing policies to address potential online unprofessional behavior to protect the public that they serve [ 113 ]. In a recent study among Greek dental students, 75.3% of responders admitted not being aware whether the behavior of dentists on SM could result in legal sanctions [ 64 ].

Garg et al [ 116 ] conducted a survey of individual and institutional risks associated with the use of SM among residents and faculty in EM. EM residents and faculty members cause and encounter high-risk-to-professionalism events frequently while using SM; these events present significant risks to the individuals responsible and their associated institution. Some of the observations and occurrences documented in that study fall within the scope of HIPAA and put individuals and institutions at legal risk. The authors emphasize that, in addition to federal ramifications for medical institutions in regard to unprofessional conduct on SM by employees, the individuals responsible for the high-risk-to-professionalism events face state licensing consequences.

Evaluation of Existing Approaches’ Effects on Promoting E-Professionalism

A total of 10 studies have tried to assess effectiveness of educational sessions or workshops incorporated in students’ or residents’ curriculum [ 46 , 48 , 52 , 54 , 55 , 60 , 63 , 81 , 89 , 103 ], and 1 study assessed the effects of formal SM instruction and policy on residents’ ability to navigate case-based scenarios about online behavior in the context of professional medicine [ 88 ]. In 4 studies that included medical students as participants [ 46 , 48 , 60 , 63 ], educational interventions were positively accepted by students and showed a positive impact on the way they view themselves and their use of SM.

Flickinger et al [ 46 ] stated that medical educators have an opportunity not only to provide valuable guidance to students in using SM wisely but also to promote the development of professional identities by implementing SM interventions into the medical curricula [ 46 ]. In a cohort study by Gomes et al [ 48 ], 94% of medical students reported some increase in awareness, and 64% made changes to their SM behavior due to the session, reflecting the longer-term impact. Walton et al [ 60 ] preformed an exploratory pre-post study to examine the internet presence of a Canadian medical school graduating class by scanning students’ public profiles on Facebook. They incorporated this information into an educational activity (3-hour long session) addressing professionalism and SM, and evaluated the impact of this activity on students’ SM behavior. Repeated searches for all class members 1 month following the educational intervention revealed that many students had changed their privacy settings to further restrict public access to information on their Facebook accounts. Fewer overall students could be found by any search strategy, and in particular, there was a significant decrease in the proportion that could be found using only a simple name search. Significantly, fewer students displayed personal information or friends lists. Finally, there was a significant reduction in the number of students who openly displayed large numbers of personal photographs [ 60 ].

A similar positive effect of educational intervention was described among nursing students by Marnocha et al [ 52 ]. The study assessed effects of a peer-facilitated SM education session on changes in attitudes and knowledge among recently admitted prelicensure nursing students. Participants described plans to use a more reflective, cautious, and accountable use of SM after the intervention. Uncertain or unprofessional attitudes and knowledge showed significant improvements after the intervention [ 52 ].

One study did not find a positive correlation between educational interventions and the impact on e-professionalism among students [ 55 ]. Medical students received two 45-minute educational sessions on digital professionalism. Findings of this study suggest that isolated sessions on professionalism are not sufficient to sustain perceptions and behaviors of professionalism. Their results reflect an erosion of professionalism related to information security that occurred despite medical school and hospital-based teaching sessions to promote digital professionalism. According to Mostaghimi et al’s [ 55 ] study, true alteration of trainee behavior will require a cultural shift that includes continual education; better role models; and frequent reminders for faculty, house staff, students, and staff.

A study conducted among pharmacy students showed that they are active users of peer-mediated SM learning groups. Pharmacy students have reservations regarding online professionalism and doubt the place of SM in education that includes the teacher [ 54 ].

In 3 studies that assessed the effectiveness of educational sessions on residents’ perception of e-professionalism [ 81 , 89 , 103 ], the positive impact was also determined. In Khandelwal et al’s [ 81 ] study, a postworkshop survey revealed that the postgraduate trainees perceived significant improvement in their understanding of e-professionalism. Compared with the preworkshop phase, residents were more comfortable defining professionalism, recognizing attributes of professionalism, describing the social contract, understanding the role of the code of conduct, and applying principles of professionalism to challenging scenarios [ 81 ]. Similar findings were presented in Mohiuddin et al’s [ 89 ] study where reflective practice-based sessions regarding the impact of SM on professionalism in surgery were well favored by the residents. Participants reported having an increased awareness to protect patient privacy and use SM more professionally [ 89 ]. Robertson et al [ 103 ] described a SM training program aimed to provide medical residents with academic and practical knowledge regarding the effective use of SM. Participants’ knowledge of SM policies increased as a result of the SM training. They have also increased the ability to identify potentially inappropriate media interactions and to identify appropriate responses to such interactions, and they gained an understanding of how their actions on SM affect others [ 103 ].

One study aimed to determine the effects of formal SM instruction and policy on residents’ ability to navigate case-based scenarios about online behavior in the context of professional medicine [ 88 ]. Prior SM instruction or familiarity with an SM policy were associated with improved performance on case-based questions regarding online professionalism.

Barriers to Using Social Media for Health Care Professionals

Analyzing our review sample, we have recognized that some papers highlighted important aspects of barriers that influence HCPs use of SM in the context of e-professionalism. These barriers are lack of time or time constraint, lack of knowledge or technical skills, lack of previous education or supportive institutional SM policies, ignorance to existing SM policies, and problem developing and sustaining mutual trust on SM. HCPs perceived them less as risks and more as something that keeps them away from using SM, either at all, more often, or with more quality. Lack of free time or time constraint was often recognized as a barrier [ 39 , 69 , 74 , 79 , 91 , 93 , 96 ], as well as lack of knowledge or technical skills for use of SM [ 33 , 39 , 76 , 79 , 93 , 118 ]. The majority of these studies that recognize the lack of time or lack of knowledge as barriers have respondents on the level of practicing HCPs. By age distribution, representatives of “millennials” or “generation Z” were not included as study participants. As shown in Adilaman et al’s [ 74 ] study, this demonstrates a significant gap in SM use between younger users and mid- to late-career users. This study also found that midcareer physicians (aged 45-54 years) had statistically significantly more hesitations around joining medically geared SM sites for professional purposes, compared with those aged 25-34 years [ 74 ]. In a qualitative study among physicians by Campbell et al [ 76 ], participants expressed many levels of uncertainty about their preparedness, their impact, the potential for repercussions, and the future of physicians’ presence on SM. Participants described feeling unprepared when they started using SM. Many participants described concerns such as lacking knowledge about how to use certain SM platforms versus others. Several participants felt that they were “digital immigrants” [ 76 ].

A lack of previous education about SM was emphasized in several studies [ 33 , 98 , 102 ].

A lack of SM policies was also recognized as a barrier, either as a lack of models/guidelines in how to conduct themselves online in their role as physicians, which is manifested as fear of saying the wrong thing online [ 76 ] or related mainly to being unclear about whether they are supported by their employer and professional bodies [ 93 , 97 ]. Contrary to that finding, even if institutions have SM policies or guidelines, HCPs acknowledged reluctant behavior regarding existing SM policies [ 78 , 85 , 114 ] or ignorance to their existence [ 61 , 64 , 65 , 100 ]. A lack of awareness of existing institutional SM policies was also observed for physiotherapists; 41.6% were not aware whether there was one or not [ 85 ], and half of the medical students and faculty were unaware of existing institutional SM guidelines [ 114 ].

Panahi et al [ 36 ] recognized the problem of developing and sustaining mutual trust as one of the main barriers to knowledge sharing on SM platforms [ 36 ]. Physicians trust their peers on SM in a slightly different way than in face-to-face communication. The study found that the majority of participants established trust on SM mainly through previous personal interaction, authenticity and relevancy of voice, professional standing, consistency of communication, peer recommendation, and nonanonymous and moderated sites.

Principal Findings

A scoping review method was used to capture the latest current evidence on e-professionalism of HCPs. The 88 studies included in this scoping review cover a broad spectrum of the benefits and dangers of SM on e-professionalism for HCPs, alongside barriers perceived as threats for the limitation of SM use in the context of e-professionalism and effects of existing approaches on promoting e-professionalism. This review includes multi-perspective views from various health care professions (medical, dental, nursing, pharmacy, and physiotherapy) and from various generations of HCPs (students, residents, practicing HCPs, faculty members, and PDs/deans). Overall, the quality of the studies was satisfactory. All studies were exploratory in nature, and the findings were descriptive. Medical health professionals were involved in about three-quarters of the studies. The majority of the studies were unspecific, studying use of any type of SM or SNSs. Only Facebook or “all SM/SNSs with specific reference to Facebook” was analyzed in more than one-third of the studies. Twitter [ 38 , 44 , 80 , 91 , 110 ], Instagram [ 101 ], and YouTube [ 37 ] were specifically targeted SM/SNSs in 7 studies.

Benefits of SM on e-professionalism of HCPs can be seen as improvements of established networks or possibilities for collaboration through SM sites [ 33 , 34 , 36 , 38 , 39 , 44 - 46 , 53 , 69 , 72 , 76 , 78 , 79 , 92 , 97 , 106 - 108 , 117 ]. Besides providing the opportunity for connecting with others and sharing experiences [ 38 , 39 , 46 , 53 , 69 , 72 , 78 , 106 - 108 ], SM have enabled the creation of communities for support. The benefits of SM on e-professionalism of HCPs, identified in this scoping review as professional networking and collaboration, have been documented in previous research for physicians [ 121 - 123 ], nursing profession [ 124 , 125 ], or other HCPs [ 126 - 129 ].

The benefits of peer advice, learning from peers, provision of emotional support, and identifying approaches through which physicians establish interpersonal trust on SM [ 36 , 45 , 92 ] are novel insights into the domain of e-professionalism of HCPs on SM.

Professional networking and collaborations on SM enable the development and building of professional identities for health care professions [ 34 , 38 , 39 , 45 , 67 , 73 , 104 ]. Professional identity formation among medical students now entails consideration by students about whether and how they can continue to use SM as physicians. Ruan et al’s [ 104 ] study tried to define the properties and development of the digital self and its interactions with the current professional identity development theory. SM introduces new features to professional identity in the digital world. The formation of digital identity, its development, and its reconciliation with other identities were features described, and educational institutions should give more importance to navigating professional identity development. According to Cruess et al [ 130 ], students may develop “identity dissonance” when components of their identity as physicians conflict with their identity as laypersons. Research regarding identity development in SM has been primarily confined to electronic professionalism through best practice guidelines. Evolving the possibilities of SM allows HCPs to reach a large audience and can act to increase their popularity among colleagues and patients [ 69 ]. SM also creates space for self-presentation and self-promotion that has already been embraced by some HCPs, enabling them to become microcelebrities [ 131 ].

Several studies have demonstrated students’ use of SM for acquiring knowledge, for gaining access to information from experts with whom they otherwise would not be able to connect, or for creating communities that can then be used as a means for supportive, professional, and social learning [ 44 , 45 , 58 , 66 ].

A number of studies have been conducted to investigate the ways in which health care students informally use SM for educational purposes [ 132 ]. The results identified efficient communication with educators, peer collaboration, and small group learning and sharing resources as key strengths [ 133 ]. SM has been proven to be used for educational purposes at medical schools, for example, to complement university courses [ 134 , 135 ]. SNSs can facilitate efficient communication, interactions, and connections among health professionals in education and training, with limitations identified as technical knowledge, professionalism, and risks of data protection [ 10 ]. Students’ use of SM for health education is overwhelmingly higher in the last few years, with almost the same proportion using SM often or always [ 69 , 136 ]. Our findings are consistent with previous research.

According to some studies in this review, loosening accountability can be seen as a danger on e-professionalism from two points of view, eroding public trust by providing poor quality of information on SM [ 39 , 106 , 117 ] and damage to professional image [ 43 , 45 , 51 , 56 , 57 , 59 , 64 , 66 , 68 , 70 , 73 , 102 , 106 , 112 ].

Potential damage to professional image has been depicted by students as a concern about repercussions of their posts, on career development, or on future employment since employers are checking SM profiles of candidates [ 43 , 45 , 51 , 56 , 57 , 59 , 66 , 68 , 70 ]. In addition, it has been reported that there is more awareness of online responsibilities as students progress through their program because employers can, and at times do, use SM profiles to make hiring decisions [ 56 , 137 ]. Three reviewed studies investigated PDs’ (medical and dental) attitudes about use of SM for admission criteria [ 109 , 110 , 112 ]. Students should be concerned about the level of professionalism presented on their profiles. Information available on SM has been already used regarding admissions to medical or nursing programs, selection for residence, or employment for over 8 years [ 137 , 138 ]. In 2016, the Mayo Clinic announced that it will take scholarly SM activity into account when considering academic promotion [ 139 ]. With time, it is reasonable to expect that more programs, schools, or any kind of potential employers of HCPs will use this “screening SM profiles” approach more often in the admissions process.

Compromising confidentiality concerns were described in numerous studies in this review [ 34 , 43 , 47 , 57 , 91 , 94 , 97 , 107 , 111 , 119 ], especially about breaches of patient privacy or possible risks of violating HIPAA online. As previous research shows, the public availability of information on patients and physicians represents a threat to privacy [ 140 - 142 ], with the potential for a negative impact on patient-physician relationships [ 143 , 144 ]. Students and residents have a “cognitive dissonance” approach to lapses in their professionalism while using SM. It is a disconnect between what they thought they would do versus what they thought they should [ 47 , 80 ]. This inconsistency between attitudes and actions has been observed also elsewhere [ 145 , 146 ].

Traditional boundaries are blurred on many levels by online interactions. Blurred boundaries between professional and personal spheres of SM use [ 34 , 39 , 47 , 51 , 69 , 78 , 79 , 91 , 96 , 97 , 106 ], with concerns about exposure of one’s private life, presenting details of personal life, or separating private and professional profiles, have been presented in numerous studies in this review. The recommendation that health professionals maintain a separate account with a different name, a “dual citizen approach,” that maintains online professional and private identities by creating separate online profiles was introduced in 2011 by Mostaghimi and Crotty [ 147 ]. Surprisingly this issue is still prevalent. Several studies in this review investigated the purpose of SM use, whether participants mixed professional and personal information and activities on SM sites (blended profiles) or adopted a separation strategy where professional information and activities were clearly separated from personal ones (dual citizenship) [ 34 , 78 , 79 , 91 , 96 ]. Recent research shows that, for some HCPs, the risk of using SM is still a concern for the exposure of one’s private life [ 10 , 39 , 148 ].

Boundaries are blurred between patients and HCPs, and between students and faculty [ 40 , 43 , 47 , 59 , 64 , 65 , 68 , 70 , 73 , 75 , 78 , 82 , 85 , 98 , 100 , 105 , 107 , 114 , 117 ].

Although online interaction with a patient is generally not acceptable nor endorsed, a wide range of opinions have been observed concerning this issue, ranging from one-third for medical students in Brazil [ 59 ] that find this unacceptable to 92% for senior medical students in New Zealand [ 70 ]. This disproportion in range could be explained by cultural and age differences. Some studies have demonstrated generation gap differences in friending patients, with younger age being associated with more openness to be friends with a patient [ 82 , 117 ]. Both students and faculty are worried that connecting via SM would blur the boundaries of the teacher-student relationship, also recognized in other studies [ 148 , 149 ].

Chester et al’s [ 70 ] study in this review addresses a deficit in data and knowledge regarding patient-targeted Googling. This study provides a comprehensive understanding of patient-targeted Googling in concert with SNS use among senior New Zealand medical students. Results of this study show that 16.7% of respondents had conducted patient-targeted Googling. There is some evidence of an association between SNS use and likelihood of patient-targeted Googling, with high SNS users more likely to conduct patient-targeted Googling, but as the authors acknowledge, their observations were made on a small number of observations. Previous research in the United States showed that 2.3% of medical students had visited a patient’s profile on an online social network [ 150 ].

Various concerns about potential professionalism implications [ 151 - 153 ] exist, particularly related to breaches of patient confidentiality, professional boundaries, and depiction of unprofessional behaviors. Chretien and Tuck’s [ 14 ] review of online professionalism studies found that themes involving patient identifying images, inappropriate communications, and discriminatory language were consistently regarded as most inappropriate, whereas derogatory speech, images of alcohol, and partial nudity were considered only moderate to least inappropriate. Numerous studies in this review have tried to assess the extent of unprofessional behavior, posted by HCPs themselves or seen to be posted by their peers. Surveys that captured students’ self-report of posted unprofessional behavior (eg, evidence of being intoxicated, illegal drug use, posting patient information, sharing clinical images inappropriately, and depictions of an illegal act) reported witnessing the investigated examples with varying frequencies [ 32 , 42 , 43 , 55 , 59 , 62 , 64 , 73 , 114 , 118 ].

Age difference in the term “older and wiser,” meaning more cautious about posting unprofessional behavior online, was proven in studies comparing students’ and faculties’ online behavior [ 114 , 118 ]. A similar comparison was made among surgical residents and practicing surgeons with a decreasing percentage of unprofessional content among attending surgeons [ 86 , 87 ]. An interesting paradoxical observation from Kitsis et al’s [ 118 ] study is that, although students seemed more concerned than faculty about their professional images, their online behavior did not reflect this concern. Medical students reported that they considered their online presence to be unprofessional four times more often than faculty. In view of these findings, one might expect medical students to monitor their online presence regularly. Surprisingly, they rarely reported self-monitoring and at a rate similar to the faculty. This study shows that medical students’ posting of unprofessional material does not decrease during medical school and that medical students self-post and notice peers’ unprofessional posts more often than faculty do [ 118 ].

Other studies have determined important differences exist in perceptions of inappropriate SM behavior among various stakeholders. Medical students often regard themes of speech, alcohol, and dress as components of online ‘‘social identity’’ rather than potential unprofessional behavior [ 154 , 155 ]. In contrast, patients, supervisors, and regulatory groups demonstrate more conservative views. An online survey using mock Facebook profiles found that, compared to university students, faculty and members of the public rated images significantly less appropriate [ 156 ]. Survey results showed that among students there is little consensus on what constitutes unprofessional behavior beyond the US HIPAA violations, and students have felt that posting inappropriate material on personal SM sites was “unavoidable” [ 156 ].

It seems that consensus about what constitutes unprofessional behavior, even evoked as a question since Chretien et al’s [ 155 ] study in 2010, has still not been reached. There are numerous studies with examples of definitions of unprofessional behavior on SM [ 42 , 110 , 157 , 158 ]. Although there is no uniform consensus on what constitutes unprofessional behavior, studies most frequently associated it with online content pertaining to alcohol intoxication; substance or illegal drug use, nudity, and sexuality; demeaning content about patients, peers, educators, clinical sites, or the profession as a whole; discriminatory content; profanity; and aggressive/bullying content toward coworkers. Karveleas et al’s [ 64 ] study among dental students showed that students’ perceptions of and attitudes toward e-professionalism is complicated and contradictory. In their study, posting holiday pictures or wearing swimwear was categorized as unprofessional. Are these depictions of behaviors and situations unprofessional? What constitutes “potentially unprofessional behavior” has made quite a stir recently in medical scientific circles and the medical population in general.

In December 2019, a paper by Hardouin et al [ 159 ] was published investigating open, publicly available Facebook profiles of young vascular surgeons for unprofessional posts (text, images, or video content). The paper used a coding matrix, previously developed and used in other studies, for content analysis [ 83 , 84 , 87 ]. There were two distinct categories depicting e-professionalism of found content: “clearly unprofessional” and “potentially unprofessional.” Three male researchers created new anonymous Facebook profiles and screened through the available data. In the “potentially unprofessional” category, images of trainees in swimwear (bikinis) screened in the research were included. This sparked controversy primarily on Twitter but also on other SM sites and mainstream media about the objectivity and bias of the researchers, reviewers, and editors, creating a hashtag #medbikini [ 160 ]. A substantial number of HCPs participated in the outraged reaction to branding posting such images or videos in bikinis as a possible sign of unprofessional behavior. They posted this content with #medbikini and their disapproval of such a label and referred to the gender bias of the researchers, questioning possibly outdated norms of behavior for HCPs [ 161 ]. This ultimately led to the retraction of the paper and publication of a “Retraction notice” by the editors of the Journal of Vascular Surgery [ 162 ].

In a recently published paper by Pronk et al [ 163 ] that studied all levels of medical professionals (students, residents, and specialists), the authors found that all investigated groups perceived information or pictures to be unprofessional related to alcohol abuse, partying, and sexually suggestive posts, creating a dissonance between the #medbiniki movement’s perception of professionalism and collected data [ 163 ]. However, they argue that some of the participants’ opinions could have changed due to the debate initiated by the #medbikini movement, which occurred after their data collection.

Another recent study by Meira et al [ 164 ] investigating professionalism perception of orthodontist through exposure of laypeople, dental students, and dentists to images usually found on Instagram found that images related to social and family relationships were associated with lower scores regarding the perception of professional credibility for all groups [ 164 ]. They argued that their results indicate that personal images, possibly because they are not related to the professional context, contribute little toward the professional image of orthodontists on Instagram.

Unprofessional behavior on SM of HCPs can have legal consequences, potentially affecting credibility and licensure. Several studies have emphasized this issue or reflected on possible professional consequences if SM are used inappropriately [ 61 , 64 , 78 , 90 , 111 , 113 , 115 , 116 ].

Previous research has described associations of specific SM behaviors with the risk of investigation and subsequent disciplinary action by regulatory agencies by state medical boards and reported that online violations of professionalism by physicians were quite common and often led to disciplinary actions [ 120 , 165 ]. The consequences in the breach of privacy in the nursing profession can be severe and may lead to civil or criminal penalties [ 166 ]. Recent studies have also recognized that consequences of unprofessional online SM use can result in expulsion, lawsuits, job loss, and permanently damaged professional reputations [ 167 ]. This can also result in inaction or lack of use of SM for beneficial purposes, as the fear of legal issues can hinder use. This was recognized in a recent study by Al-Khalifa et al [ 168 ] where on a population of Saudi Arabian dentist only 41% of them were inclined to give online consultations. They argued the rest were possibly fearing potential legal ramifications. In an age of social distancing due to COVID-19, this could lead to patients not receiving information or care that they need and could have possibly gotten through online contact.

Recommendations for E-Professionalism Curriculum Changes

Ten years ago, many schools lacked policies specific to SM use [ 151 ], but nowadays schools have developed specific guidelines [ 169 , 170 ]. Guidelines are also available from numerous professional societies [ 171 - 178 ], and a recent review about available guidelines from nine medical international bodies has been published [ 179 ]. Previous work on health care education interventions and experiences has noted how learners may be motivated to reduce the hazards of SM, revise SM confidentiality settings, or even terminate SM involvement upon realizing that online postings may have an enduring presence [ 180 , 181 ].

Effectiveness of educational interventions about e-professionalism or impact of existing SM policies has been recognized in this review, since numerous studies explored educational interventions for promoting e-professionalism [ 46 , 48 , 52 , 54 , 55 , 60 , 63 , 81 , 89 , 103 ].

On an educational level for students, recommendations are to include a variety of e-professionalism topics into a curriculum to provide students with a clear picture of what constitutes professional violations on SM and assist them in distinguishing between personal and professional personas online [ 42 , 43 , 47 , 49 , 50 , 53 , 54 , 64 , 103 , 111 , 114 ]. Hsieh et al’s [ 63 ] study demonstrates the possibility of how SM can be used as a learning platform for professionalism, enabling students a virtual space in which to share positive examples that reflect the authentic experience in a clinical environment. Our previous findings demonstrate that the perception of unprofessional behavior varies among HCPs, mostly associated with age of the participants [ 86 , 109 , 114 , 118 ]. Similar findings were confirmed also for health science students who struggle with the concepts associated with professionalism [ 182 ]. Teaching professionalism in general offers challenges for educators, and these challenges are amplified when the topic moves into cyberspace, where students are digital natives and faculty are generally digital immigrants [ 136 ]. Several studies in this review have recognized the need to include students in the development of guidelines [ 47 ] or to assist in education with somebody of their age group, providing personal experiences and more of a “nonauthoritative” approach [ 49 ].

O’Sullivan et al [ 32 ] have also recognized the importance of schools using an evidence-based approach to policy creation and to involve students in the process of the creation of these policies. A recent study by Wissinger and Stiegler [ 183 ] also highlights the importance of formal integration of e-professionalism into the health care curricula to prepare students for situations they will face once employed. By placing the responsibility of learning e-professionalism inside the walls of academia, students are prepared to take control of their online identity and craft a persona that represents their professional image [ 167 ]. As Chretien and Kind [ 183 ] described it, a victory for online professionalism would be providing trainees with tools and guidance needed to ascend on the SM hierarchy pyramid of needs, from public trust to discovery.

Similar recommendations were described in this review for residents, with important issues that must be addressed during curriculum development: integrate trainees as educators, encourage peer-to-peer regulation, and provide opportunity for reflection. Effective educational interventions for teaching online professionalism must include the skills necessary for residents not only to recognize inappropriate behavior on SM but also to learn how to address it themselves [ 80 , 103 ]. There is a qualitative distinction between disseminating guidelines and formally integrating SM instruction into medical curricula, which should become imperative for HCP education, undergraduate or graduate level, or continuing medical education [ 42 ]. Similar conclusions were made in a systematic review of SM in residency [ 184 ]. Economides et al’s [ 184 ] review depicts evolving perceptions and a paradigm shift, where a growing body of literature is now focusing on promoting responsible SM use, examining how SM training can enhance professional growth and academic scholarship. As the tone of the dialogue shifts from trepidation to interest or even to enthusiasm, it is clear that there is a need for formalized standards and education on SM use established within the trainee’s curriculum.

Barriers to Social Media Use for Health Care Professionals

Analyzing our review sample, we have recognized that some papers highlighted important aspects of barriers that influence HCPs use of SM in context of e-professionalism. A lack of free time or time constraint was often recognized as a barrier [ 39 , 69 , 74 , 79 , 91 , 93 , 96 ], as well as a lack of knowledge or technical skills for use of SM [ 33 , 39 , 76 , 79 , 93 , 118 ]. Studies in this review with “lack of time” or “lack of knowledge” barriers had respondents that were practicing HCPs and older HCPs; representatives of “millennials” or “generation Z” were not included as study participants. This demonstrates a significant gap in SM use between younger users and mid- to late-career users [ 74 , 82 ]. This is consistent with previous research demonstrating that in addition to the practical barriers to adoption of SM in the professional realm, a generation gap exists, with millennials using SM for contact and information far more frequently than members of generation X and baby boomers [ 150 ]. Similar results can be found in Chan et al’s [ 10 ] systematic review where identified positive predictors of use of SNSs for professional purposes were younger age (20-39 years), fewer years of professional experience (0-10 years), and lower rank, such as residents.

Our results show that even though a lack of SM policies was recognized as a barrier, even if institutions have SM policies or guidelines, HCPs acknowledged reluctant behavior regarding existing SM policies [ 78 , 85 , 114 ] or ignorance to their existence [ 61 , 64 , 65 , 100 ]. This should be considered as a warning to increase awareness on this matter, as SM will continue to be increasingly ubiquitous and integrated in health care. As Parsi and Elster [ 185 ] note, “if we fail to engage this technology constructively, we will lose an important opportunity to expand the application of medical professionalism within contemporary society.” Since the SM world is changing so fast, adopting novel approaches to existing SM policies becomes essential. As Kerr et al [ 101 ] suggest, it is imperative for nursing education, professional regulatory bodies, and employers to develop more robust and dynamic policies and guidelines related to the appropriate use of SM within the profession, especially with the growing presence of web-based HCP microcelebrities [ 131 ].

Comparison With Prior Work

Compared to other literature reviews published on related topics, this scoping review is the first to capture original research about e-professionalism in terms of methods, subjects, and themes since Chretien and Tuck [ 14 ], who conducted a synthetic review to characterize the original peer-reviewed research on online professionalism of medical students, residents, or physicians. The review included 32 studies and recognized general areas of online professionalism (use and privacy, assessment of unprofessional behavior, consensus-gathering of what constitutes unprofessional or inappropriate behaviors, and education and policies) with no clear separation between challenges or benefits and addressed only online professionalism of medical students, residents, or physicians. Other reviews presented a full spectrum of SM-related challenges and opportunities in the context of medical professionalism of diverse types of HCPs [ 15 , 16 ] or in the context of SM as an emerging tool in education [ 132 , 186 ], but these studies were conducted several years ago.

Similar conclusions were made in other research. Although there exist concerns about misuse of SM and violation of e-professionalism by HCPs, SM can also be used constructively as a tool for professional development; as a means of accessing information, marketing practices and services, job opportunities; and as a means of sharing or adding opinions on issues of interest to HCPs and to other like-minded individuals online [ 44 , 187 ].

Ventola [ 121 ] recognized benefits, risks, and best practices for HCPs. He concluded that SM can provide considerable benefits in professional networking or collaboration, professional education, patient’s care, education, and health programs. All these benefits of SM were recognized in this scoping review as well. According to Ventola [ 121 ], there are some risks related to poor quality of information, damage to professional image, breaches of patient privacy, violation of the patient-HCP boundary, and licensing and legal issues, which was also recognized in this scoping review. Likewise, risks such as privacy and accuracy of information, compromising confidentiality, eroding public trust, and loosening accountability were presented in previous research [ 156 , 188 , 189 ].

Gaps in the Literature and Potential Areas for Further Research

This review demonstrates dominance of Facebook in research done so far. With the rapid evolution of SM, future insights should be more oriented toward new and emerging SM sites. Instagram has gained an enormous following with new features like “Stories” and “Reels” within the SM itself, which are completely scientifically unexplored. Snapchat and TikTok have also gained a substantial following, especially among the student population. TikTok did not even exist in 2014; nowadays, TikTok has 689 million users worldwide [ 20 ]. They function on a completely different set of parameters, being that the content is time limited. New research should consider how to approach the youngest generation of HCPs who are using these SM sites and how to design a novel study methodology to gain insight, due to the time limitation of the content.

Gaining popularity on SM is not only reserved for adolescents and young adults. Creation of influencers who are HCPs can affect perception of the professional image, either positively or negatively. This has been rarely analyzed so far.

Geographical locations may affect the generalization of findings in research on SM use. Asian countries have regionally oriented SM and SNSs like WeChat not used in European countries or the United States. Cultural differences should also be considered.

The curriculum implementation of SM guidelines and educational efforts are also there to be evaluated. As the diversity of such actions is apparent, efficiency is key in getting the proper message to a generation of “millennials” with a short attention span.

The COVID-19 pandemic has caused much of the world’s population to isolate itself and many of us to shift our lives to digital tech platforms, especially SM and SNSs, all experiencing strong growth. Previous research has shown that more people are relying on SM to find and share health information during times of crisis. Future research should investigate how the pandemic affected our e-professional behavior. We are experiencing an unprecedented time in health care and education due to the COVID-19 pandemic, so the use of SM in patient/HCP communication and student education should also be explored in more detail.

SM can also be used in marketing and self-promotion [ 190 ]. Dental medicine is much more open to such actions, with medical professionals showing a lack of interest and being more worried about legal ramifications. Research into the reasons of such divergence and insight into the negative attitudes is essential for creating a platform for implementing SM in a positive and professional manner.

Findings of this research confirm the dominance of medical students or physicians as a study population of HCPs in the context of e-professionalism. Future research could be done to further investigate other types of HCPs with an emphasis on the specifics of each profession regarding their SM potential and use. Comparison among different types of HCPs would add novel insights to the field of e-professionalism.

Limitations of the Review

We acknowledge that scoping reviews have several limitations, but a scoping review allowed us to gain a wide-ranging understanding of the impact of SM on e-professionalism of HCPs. Research into SM is rapidly growing, and this scoping review is a snapshot of the latest current evidence on e-professionalism of HCPs.

There might be a selection bias (failure to search in additional potentially relevant databases to which the university does not have access) and a publication bias (we only searched in 3 databases, we did not extensively search for gray literature, and our search was limited to the English language). All studies were exploratory in nature, and the findings were descriptive. The questionnaires adopted in the surveys were mostly developed by the researchers, where validation mostly was not done. Research on SM is growing so fast that evidence may have been published in electronic media or platforms not indexed through the academic databases. Thus, findings in this review are limited to research published in traditional peer-reviewed journals only.

A scoping review was conducted that included 88 studies, offering current evidence on e-professionalism of HCPs. Almost all studies were found to be of adequate quality. Findings in reviewed studies indicate the existence of both benefits of SM on e-professionalism such as professional networking and collaboration, training, and education, and, on the other hand, the dangers of SM, such as loosening of accountability, compromising doctor-patient confidentiality, blurred professional boundaries, depiction of unprofessional behavior on SM, and legal consequences.

Even though there are some barriers recognized, this review has highlighted existing recommendations for including e-professionalism in educational curricula of HCPs. Based on all evidence provided, this review provided new insights and guides for future research on this area. There is a clear need for robust research to investigate new emerging SM platforms, the efficiency of guidelines and educational interventions, and the specifics of each profession regarding their SM potential and use.

Acknowledgments

The authors thank Prof Howard H Goldman and Alejandro Ortiz, PhD, School of Medicine, University of Maryland for their support. This study was funded by the Croatian Science Foundation under project UIP-05-2017 “Dangers and benefits of social networks: E-Professionalism of healthcare professionals – SMePROF.”

Abbreviations

EM	emergency medicine
FtP	Fitness to Practice
GDC	General Dental Council
HCP	health care professional
HIPAA	Health Insurance Portability and Accountability Act
IRR	interrater reliability
MeSH	Medical Subject Headings
PD	program director
PRISMA-ScR	Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews
SM	social media
SNS	social networking site

Multimedia Appendix 1

Multimedia appendix 2, multimedia appendix 3, multimedia appendix 4.

Authors' Contributions: TVR, JV, and DJ conceived and designed the review, and TVR coordinated it. TVR, JV, and LMP were involved in developing the search strategy, and TVR, JV, LMP, DJ, KS, and MM extracted the data. Data analyses were undertaken by TVR and JV, whereas data interpretation was done by TVR, JV, LMP, and MM. TVR drafted the review. All authors reviewed and approved the final version of the manuscript.

Conflicts of Interest: None declared.

Open access
Published: 11 September 2024

Digital learning in nursing education: lessons from the COVID-19 lockdown

Gro Gade Haanes ORCID: orcid.org/0000-0001-5334-6193 1 , 2 ,
Etty Nilsen ORCID: orcid.org/0000-0003-2769-675X 2 ,
Randi Mofossbakke ORCID: orcid.org/0000-0001-5900-0652 2 ,
Marianne Wighus ORCID: orcid.org/0009-0008-3252-9554 2 &
Monika Ravik ORCID: orcid.org/0000-0002-1490-9341 2

BMC Nursing volume 23 , Article number: 646 ( 2024 ) Cite this article

Metrics details

The COVID-19 pandemic necessitated a swift transition to e-learning, significantly impacting nursing education due to its reliance on practical, hands-on experiences and the critical role nurses play in healthcare. Nursing students need to achieve high levels of clinical competence through experiences traditionally obtained in clinical settings, which e-learning had to replicate or supplement. Understanding the unique challenges faced by nursing students in e-learning environments is crucial for developing educational strategies that enhance learning outcomes and contribute to improved patient care. This study aimed to explore the experiences of nursing students and newly qualified nurses (as students) with e-learning during the COVID-19 lockdown, focusing on how it influenced their learning and professional development.

This exploratory and descriptive study employed qualitative interviews with 31 participants, including full-time nursing students, part-time nursing students, and newly qualified nurses (as nursing students). Conducted online via Zoom during February and March 2022.

The findings suggest that integrating small group interactions and employing strategic pedagogical support can enhance e-learning effectiveness. However, barriers such as technological difficulties, psychological challenges, and social isolation were also identified. Understanding these unique opportunities and challenges can help educational institutions optimize e-learning strategies, ensuring nursing students are well-prepared for their crucial roles in healthcare.

The rapid shift to e-learning due to the COVID-19 pandemic presented challenges such as technological, psychological and social aspects, but also opportunities to rethink and enhance nursing education delivery. Implementing appropriate pedagogical e-learning strategies, such as scaffolding and small group learning, can better prepare nursing students for their essential roles in healthcare. This study contributes to the body of knowledge on digital education and provides a foundation for future research aimed at optimizing e-learning in nursing education.

Peer Review reports

The COVID-19 pandemic necessitated a rapid and unprecedented transition to e-learning across various educational disciplines, impacting fields that rely heavily on practical training, such as nursing. The abrupt shift to digital learning modalities highlighted the critical need for nursing students to achieve high levels of clinical competence through experiences traditionally obtained in clinical settings, which now had to be replicated or supplemented with e-learning [ 2 , 3 ].

E-learning, broadly defined as the use of electronic media and devices to facilitate learning, emerged as a crucial tool during the pandemic, enabling the continuation of education while minimizing virus transmission risks [ 4 ]. The literature reveals varied student experiences with e-learning, emphasizing benefits such as flexibility and accessibility, yet also highlighting challenges, particularly in maintaining clinical competencies and psychological well-being [ 5 , 6 , 7 ].

Literature on e-learning in nursing education has highlighted a variety of student experiences, emphasizing the benefits of flexibility, accessibility, and the potential for self-paced learning [ 8 , 9 ]. It is, however, important to recognize that e-learning encompasses more than just flexibility. Nursing education typically combines clinical and theoretical components [ 10 ], both of which were significantly affected during the pandemic. Barret [ 11 ] found that the COVID-19 pandemic had a detrimental impact on nursing education as a whole, with nursing students facing unprecedented challenges in areas such as academic requirements, additional clinical commitments, and personal safety measures. The theoretical component had to be completed entirely through e-learning on online platforms, without in-person interactions with educators and peers [ 2 ]. Furthermore, the challenges included inadequate digital infrastructure, inadequate experience of educators with teaching using technology, and difficulties in engaging nursing students on digital platforms [ 12 ]. Additionally, the clinical component faced barriers due to physical restrictions that reduced the ability of students to engage in clinical practice [ 2 ]. Some students and educators worry that e-learning formats may not effectively replicate the hands-on clinical experiences. In the study by Ravik et al. [ 2 ], there were a concern about the adequacy of e-learning in fulfilling the practical and interpersonal skill development that is central to nursing education. Also, nurse mentors at practice locations had increased responsibilities related to the pandemic, which reduced their availability for students [ 11 ]. Studies have revealed that nursing students exhibited decreased motivation during the pandemic that reduced their ability to acquire knowledge and skills [ 13 , 14 ] Some students also experienced delays in their education, resulting in extended clinical placement periods or the omission of certain training components, leading to increased stress [ 15 ]. Given the critical role that nurses play in healthcare systems, understanding the unique challenges they face in e-learning environments is important [ 16 ]. However, e-learnings efficacy in nursing education, which combines theoretical and clinical components, remains underexplored.

This study aims to explore the nuanced experiences of nursing students and newly qualified nurses (as nursing students) with e-learning during the COVID-19 lockdown, focusing on how this transition influenced their learning and professional development. While the study primarily focuses on e-learning during the pandemic, it also considers the unique challenges and opportunities presented by the sudden shift to this mode of learning.

The integration of Vygotsky’s sociocultural theory and Marton & Säljö’s learning approaches provides a theoretical framework to understand these experiences [ 17 , 18 ]. Vygotsky’s concept of the zone of proximal development (ZPD) emphasizes the role of social interaction and guided learning in achieving higher cognitive functions [ 17 ]. In the context of e-learning, this underscores the importance of structured and supportive online environments. Marton & Säljö’s distinction of how nursing students engage with digital approaches further informs our understanding of how nursing students engage with digital learning materials [ 18 ].

This study addresses significant gaps in the existing literature by providing a comprehensive exploration of the longitudinal influence of e-learning on nursing students’ clinical competencies, academic performance and psychological well-being. By examining the rapid adaptation of e-learning during the pandemic, we aim to inform future educational strategies that enhance learning outcomes and contribute to improved patient care.

This study is a part of a larger investigation exploring nursing students learning during the COVID-19 pandemic. We employed an exploratory and descriptive research design utilizing in-depth qualitative individual and pair interviews [ 19 ]. The exploratory design was chosen to investigate the nuanced experiences of nursing students and newly qualified nurses (as nursing students) transitioning to e-learning during the COVID-19 pandemic inductively and without any theoretical approaches [ 20 ]. This approach allowed for the systematic gathering of in-depth insight into an under-researched area, particularly in response to the unprecedented global health crisis. The descriptive aspect aimed to provide a comprehensive understanding of these experiences, capturing emerging themes and patterns during data collection and analysis.

Sample and recruitment

Our participants were recruited using a purposive sampling strategy, targeting nursing students and newly qualified nurses from one Norwegian university and various clinical placements [ 21 ]. Recruitment was facilitated via email invitations and postings on relevant educational and professional online forums, with a detailed explanation of the study’s purpose and the voluntary nature of participation.

The study included 31 participants divided into 3 distinct samples: nine full-time nursing students in their 3rd year, 12 part-time students in their fourth year, and ten 10 newly qualified nurses who had completed their education during the pandemic (Table 1 ). The selection of these groups was guided by the principle of information power, ensuring a rich and diversified representation of experiences to reach data saturation [ 22 ].

The inclusion of newly qualified nurses who had completed their education during the pandemic provided a unique perspective on the use of digital learning throughout their education. In addition, certain parts of their practice were replaced with digital classes, which reportedly are difficult to implement as replacements for hands-on experience [ 2 ].

Data collection

Data were collected through semi-structured interviews conducted online via Zoom during February and March 2022 due to pandemic restrictions. The interview guide, developed by the research team, focused on experiences and reflections related to e-learning and physical presence during the education process. Each interview lasted 60–90 min and was recorded and transcribed verbatim. Demographic data were collected at the beginning of each interview using a structured questionnaire, ensuring comprehensive analysis of participants’ experiences in relation to their backgrounds. The required information power was reached after conducting 29 interviews [ 22 ].

Ensuring trustworthiness

The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigor [ 23 , 24 ]. This included strategies to enhance credibility, transferability, dependability, and confirmability [ 25 ]. Researches engaged in reflexivity, examining their perspectives and potential biases to ensure they did not unduly influence the data collection and analysis.

Data analysis was conducted using inductive qualitative content analysis as described by Graneheim and Lundman [ 26 ] and Lindgren et al. [ 27 ] to condense extensive text into easy-to-understand pieces of information and to identify essential patterns. The process involved six steps: initial reading to identify core messages, data filtering to extract relevant text segments, data condensation into meaningful units, coding, formation of subcategories, and development of overarching theme. This method allowed for both manifest and latent content to be transformed into codes, subcategories, and categories, which were then synthesized into an overarching theme [ 28 ]. We also included illustrative quotes to support our research findings, making necessary adjustments for clarity. The whole research group took part in the analysis and discussed and agreed upon both categories and subcategories as well as the overarching theme.

Ethics approval and consent to participate

This study was approved by the Norwegian Social Data Service (project number 396247) and adhered to the ethical principles outlined by the National Committee for Research Ethics in the Social Sciences and the Humanities [ 1 ]. Informed consent was obtained from all participants, and data were securely stored on the university’s research server.

The study revealed three main categories and six subcategories that aligned with the overarching theme identified in the study (Table 2 ).

Learning possibilities and learning barriers

In exploring the Learning Possibilities and Learning Barriers of e-learning, this study categorizes the findings into two pivotal subcategories: Group Dynamics in E-Learning and Engagement in Virtual Settings . Each category sheds light on different aspects of the educational experience under the conditions imposed by the pandemic.

Participants reported that they prepared for the digital classes in the same way as they would for in-person classes. However, they felt that the lack of nonverbal cues and other communication differences sometimes reduced their ability to participate fully. Despite attendance being mandatory, participants did not report any significant benefits to digital classes over traditional in-person classes. Sometimes the students had been told to read or watch something in advance, such as a PowerPoint presentation or a film, as in a “flipped classroom,” which they reportedly were keen to do more often since this also could lead to greater engagement. They specifically mentioned that a film had the advantage of being able to be stopped and rewound if they did not understand parts or even all of it.

Group dynamics in E-Learning

This subcategory explores how the size and composition of learning groups (small vs. large) influence interaction, engagement, and knowledge acquisition.

The participants noted that smaller groups tend to increase the sense of responsibility that individuals had to contribute to academic discussions. One of the participants said:

“It was easier for people to speak up , and there was more discussion and reflection , so to speak.” (2–12).

The participants recognized the importance of peer interactions in gaining new perspectives and challenging their own ideas through reflection. They reported that listening to the experiences of others could increase their understanding and moments of realization. Additionally, the respondents found it useful to discuss the tasks performed by their peers, although some expressed reluctance to share their own assignments. One of the participants said:

“It was also instructive to discuss other students’ cases , but it was clear that some were hesitant to present their cases and assignments in front of everyone else. Nevertheless , I believe that most students were happy about it when they received constructive feedback , and it was instructive.” (1–8).

Engagement in virtual settings

Analysis of student participation levels during digital classes, with a focus on the impact of breakout rooms and passive learning environments.

When preparing for digital classes and group sessions, students mainly focused on their assigned tasks and prepared questions for the teacher. During group sessions, students reviewed their work and contemplated how to present or discuss their findings with their peers. Nevertheless, some students considered that the discussions during these sessions were unproductive and superficial. Some of the participants were passive, lacked motivation, and did not take the initiative to lead discussions. This resulted in some of them perceiving breakout room sessions as a waste of time:

What kept us going in these hours , in the digital hours , was that we knew we were going into these small breakout rooms. Then we got a little more sense of responsibility to follow along and participate in the teaching , compared with it becoming very passive , with only lectures without any discussion in between.” (1–6) .

While others were looking forward to participating in these sessions. Examples of these views are as follows:

“During breakout room sessions , most students appeared exhausted due to the prolonged screen time. This led to a lack of active participation , with only a few students engaging in the discussions while others found excuses to be passive.” (1–5) .

Regarding the use of black screens during digital classes, the participants felt uncomfortable about allowing others into their personal space, particularly when many students were present. They also found it inappropriate to have private activities and distractions visible in the background during academic sessions. Furthermore, they observed that distractions such as children or pets were common among students who did not use black screens. While the use of black screens was a personal choice, some participants deemed this necessary to prevent privacy invasion and distractions during digital classes:

“There was an option not to turn on the camera , and many chose that. It was the easiest option , and people felt they were still following along even without a picture. I felt very exposed when I had my camera on. So , in the end , most people chose not to have their cameras on at all. It was the easiest choice.” (1–3) .

Some participants considered it disrespectful when they attended classes with their cameras off and did not actively engage in the discussion:

“The teachers said they thought it was good to be able to see us , and I agree that it’s probably better for learning to be able to see each other. But at the same time , it’s uncomfortable to sit there and not know who is looking at you at that moment , because you don’t know…it makes you very self-conscious. It was nice to just be able to sit at home in peace , and enjoy a cup of tea , and eat at the same time.” (1–4) .

Technological challenges

In addressing the Technological Challenges faced during the transition to e-learning, our study delves into the complexities of digital Platform utilization and Interface challenges , and the various Connectivity and Technical Reliability that significantly impacted the learning process. This main category is divided into two critical subcategories that collectively explore the infrastructural and operational issues encountered by both students and educators.

The participants reported mixed experiences with the digital classes. The lack of technical proficiency among some teachers caused delays and mistakes. At the start of the pandemic, several of the clinical placements were not ready to participate in Zoom classes, which created additional stress for those who relied on their own 3G/4G data.

The participants experienced that the university overall as well as its teachers and students were not prepared for the sudden lockdown. Some of the participants experienced confusion during a hybrid lecture in which some individuals were present in the lecture room while others had to participate remotely via Zoom:

“Suddenly , the technical equipment at the university didn’t work in the lecture hall , or if there were things that needed to be demonstrated , they were too small. Or things were written on the board , while those who were present online had a PowerPoint file . So , there were some challenges , but as long as you communicated with the lecturer , it went well.” (2–3) .

Platform utilization and interface challenges

This subcategory focuses on the practical difficulties experienced by participants of digital learning platforms such as Canvas. Issues such as user interface complexity, inconsistent usage across courses, and the steep learning curves to understand their impact on the e-learning experience.

The participants complained that teachers from different subjects used the digital platform in different ways, and that it took too long working out how to use it.

When asked about their experiences of using the digital teaching and learning platform, the participants found it easy to use, but they criticized some teachers for lacking proficiency in using the platform. They found it unacceptable for teachers to make mistakes with the platform, especially when it came to submitting important assignments. The participants wanted all teachers to use Canvas in the same way and suggested having a video showing how to do this. Many participants found the Canvas layout to be messy, and some participants wondered if all teachers understood it as well as they should have. Sometimes what the participants were looking for was hidden inside other documents, and the teachers used different terms and different file names for the same things. Sometimes there was a reference to a folder that led to another folder, making it harder for the participants to find what they needed. Related information was in various places, and the participants thought that there should be fixed places where the same types of information were posted. One of the participants said:

“It was messy and I’m a little unsure if all the teachers have actually understood it 100% themselves. Because if there is one topic , a teacher has chosen to put the information in one place. So , then you expect that for the next topic , the information will be in the same place , but suddenly…no , it’s not there anymore. Apparently , it’s in a completely different place now. To be completely honest , I didn’t learn how to use Canvas properly until now , my fourth year.” (1–2) .

Some subjects had schedules that were divided into weeks, while others did not have a common structure, which caused confusion.

Connectivity and technical reliability

Connectivity and technical reliability are crucial for successful e-learning. This subcategory explores the nature of technological disruptions like internet connectivity problems, hardware failures, and software glitches that have posed significant barriers to continuous and effective learning.

Several minor technical problems occurred during teaching sessions, such as losing the Internet connection occasionally. There were also occasions when several municipalities where the students lived triggered alarms without warning, which could interrupt entire lectures. There were also times when the private networks that the students accessed where they lived were not optimal, and several of the students reported that there was no one they could ask for IT help. The university was closed, and they also did not have access to a printer when they needed one. One of the participants said:

“There have been these small technical problems. One thing is that you might lose the Internet connection during a lecture. There have been times when the municipality suddenly checks that the alarms work , which sound 10 times. And then , if I’m on placement and need to do a middle or end evaluation online , there have been issues where our private computers do not have a strong enough connection due to their ‘guest passwords’ , and when we log in to their computers , they do not have a camera. They may also have very poor speakers , so it’s hard to hear the teacher. So , it has been a challenge.” (2–7) .

Other technical problems included participants using a smartphone instead of a PC and the smartphone logging them out or being disturbed by other incoming announcements from the smartphone at the same time.

Some participants could not access the Zoom sessions due to not knowing the required passwords. This resulted in several messages going back and forth to fellow students about them not being allowed into classes that they had requested access to. This of course disrupted the teaching and took the focus away from the actual taught topic:

“Suddenly, a password was required to enter the lecture or meeting without prior notice. I also don’t think the teacher was aware of it.” (1–6)

Psychological and social challenges

In exploring the Psychological and Social Challenges associated with e-learning during the pandemic, this category addresses the emotional and social dimensions that affect student engagement and learning outcomes. It is divided into two subcategories that assess Cognitive and Emotional Engagement of shifting from traditional classroom environments to virtual learning spaces and Social Interaction and Isolation.

Participants noted that the teachers increasingly did not attend practice periods, and so the students had to rely on their practice supervisor, if they had one. Some of the participants also said that the quality of digital support and guidance they received varied markedly depending on how familiar individual teachers were with using online tools.

A lack of structure and guidance in teaching arrangements and the discussion groups contributed to some of the participants considering the group sessions to be ineffective, leaving them feeling disconnected and unengaged.

The participants argued that during the pandemic, nursing students had to complete a “corona task” as part of their education program to make up for missed practical hours, which involved writing 500 words per day for each day of absence from the clinical setting. The tasks were specific to the type of care the students were providing, such as palliative care. Each task was graded as a pass or fail, and the students had to adhere to the university’s formatting and content guidelines. Participants expressed concern that the extra workload—which was additional to their existing academic and clinical responsibilities—placed them at risk of failing the course if they became ill. The participants also noted that the degree of leniency when they became ill varied between teachers. Moreover, only some of the students had prior experience of academic writing. One of the participants said:

“Not only did you become ill and were afraid of failing , but you also had to perform a task that you didn’t know if you could complete , in addition to everything else. So , you are right that it also puts you at risk of failing. For example , XX wrote his task while he was sick , but the teachers preferred that he recovered first and then completed it. I think that’s a good arrangement , but at the same time there’s also a time pressure if you don’t get it approved before the end of the clinical practice.” (2–8) .

Cognitive and emotional engagement

This subcategory examines the cognitive load and emotional strain placed on students navigating e-learning. It delves into issues such as difficulty in maintaining concentration, motivation levels, and the general mental fatigue associated with prolonged digital interaction, reflecting on how these factors hinder the learning process.

The participants widely considered long lectures on Zoom to be boring and hence difficult for maintaining concentration, especially when the teacher was simply reading out from a document. Some of the participants who found it difficult to follow the e-learning process did not want to ask for help:

“I found it challenging to maintain structure and routines using my own initiative and responsibility during the digital classes. It was quite exhausting to have to stay at home with the uncertainty surrounding the pandemic and my own academic progress.” (3–10) .

While others consciously took a break and established a recovery regime. Two of the participants said:

“I took 10-minute exercise breaks to energize and refresh myself , as sitting in front of a computer for hours caused physical discomfort and headaches. Despite these measures , it remained challenging to maintain focus and motivation to review the material before and after class due to the taxing nature of e-learning.” (1–9) .

Maintaining concentration during the long times spent in front of a computer screen while attending full-day digital classes presented a significant challenge. Although breaks were provided, many participants tended to use this time to browse the Internet with their smartphones or watch television, leading to disengagement and a loss of focus during lectures. One of the participants said:

“The online format required more effort to concentrate compared with traditional in-person classes due to the ease of accessing other distractions such as smartphones and browsing the Internet during lectures. Consequently , I found it necessary to repeat material outside of class to compensate for the lack of focus during the lectures.” (3–8) .

Social interaction and isolation

Focusing on the loss of physical classroom dynamics, this subcategory explores the influences of reduced face-to-face interactions. It assesses how isolation and the lack of informal social exchanges impact students’ sense of community and overall mental well-being in an academic setting.

Several of the participants also said that their motivation had sometimes been lower during this period because they did not feel any social belonging or connection with the other students when they sat in their respective dormitories or homes. The students missed coming to campus and talking to other students as a large group and discussing different topics. Showing up on campus together with the other students while preparing for examinations or writing notes and other activities could have helped them. Similarly, there were some who said that they failed examinations due to their motivation sometimes being extremely low, while others also saw upsides. One of the participants said:

“The loss of motivation was quickly apparent when transitioning to e-learning , as there were several distractions at home that made it difficult to stay focused.” (1–3) .

They had not chosen to take an e-learning course themselves, but rather such an education program had been forced on them when they were supposed to attend in person. Having to deal with a course that was almost entirely online was obviously challenging, even though they could also see that there were advantages. One of the participants said:

“I mean , you have a choice of taking an online course or a physical course , and we have chosen a physical course. So , it is clear that it is something…yes. A big upheaval. But still , I will honestly admit that personally , I have found it very comfortable and actually very convenient. You get a lot of opportunities to do other things between classes , right? You are not necessarily bound to be at school. That’s good. The only thing is that it has affected the social aspect , and that , on the other hand , is something that I find challenging. Not meeting fellow students and being able to discuss and , you know , be together.” (1–4) .

In traditional courses students have the opportunity to socialize and interact with their peers and teachers before, during, and after lectures, in person. They can also ask the teacher questions. However, the shift to e-learning resulted in the atmosphere becoming serious and somewhat intimidating. It was not as easy to ask the teacher questions before and after the lecture. Although students could see and recognize their peers on Zoom, not everyone actively participated in the discussions. While some were engaged and shared their thoughts, others became invisible and passive. This was similar to being in a physical lecture hall, but in-person interactions allowed for more opportunities to connect with and form impressions of others. This was perceived as a loss:

“I think it’s very sad that I have lost…study buddies , and I haven’t gotten any student environment or anything like that. So , studying has become very lonely , and with that , I feel that I have lost a lot of learning opportunities.” (3 − 2) .

Some of the participants acknowledged that digital learning can be quite individualistic, and those who only worked on their own might have missed out on opportunities to learn from others.

The aim of this study was to explore the nuanced experiences of nursing students and newly qualified nurses (as/while nursing students) with e-learning during the COVID-19 lockdown, focusing on how this transition influenced their learning and professional development.

The COVID-19 pandemic prompted a rapid and significant shift to e-learning across educational disciplines, with particularly profound impacts in fields that rely heavily on practical training such as nursing [ 29 , 30 , 31 ].

In our study, students reported a reduction in opportunities for practical training, affecting their confidence and competence. This aligns with literature that highlights the need for also simulated practice in e-learning nursing programs generally [ 32 ]. We consider this is worth mentioning even though simulation is not the focus of this paper. Furthermore, the abrupt nature of the shift to e-learning underscored the importance of technical support and accommodations, which have been a greater challenge in nursing education compared to other disciplines where theoretical content predominates. Our participants expressed frustration over insufficient support to handle technical issues, a concern also echoed in another study examining the transition to e-learning under pandemic conditions [ 13 ]. These specific challenges in nursing education necessitate targeted pedagogical adjustments to support both academic and practical learning in an unpredictable and digital learning environment.

This study’s findings contribute to the broader discourse on e-learning by exploring its specific implications within nursing education during an unexpected global health crisis [ 31 , 33 , 34 , 35 , 36 ]. This study is on e-learning during the COVID-19 pandemic and not on the shift per se, however the unique context of a sudden shift due to a pandemic presents particular challenges and opportunities that our study has explored in depth.

Pandemic-specific findings and General E-Learning challenges

While many of the challenges identified in our study are consistent with general e-learning issues, the sudden and forced nature of the transition during the COVID-19 pandemic brought unique pressures. For instance, the rapid shift left little time for institutions to prepare optimal e-learning environments or for students to adjust to new learning modalities, exacerbating stress and anxiety. These conditions are distinct from planned e-learning strategies where students choose to enroll in e-learning courses, suggesting that future strategies should consider the abruptness of transitions and provide additional support during such times [ 37 , 38 , 39 ].

Sociocultural perspective in E-learning

This study has illuminated various aspects of the transition to e-learning for nursing students and newly graduated nurses during the COVID-19 pandemic, with a particular focus on how this transition has affected their learning processes and professional development. In light of the challenges and opportunities presented by e-learning, it is fruitful to apply a sociocultural perspective, as described by Vygotsky [ 17 ], to deepen our understanding of these phenomena.

Vygotsky’s [ 17 ] theory of the Zone of Proximal Development (ZPD) provides a useful lens for understanding how learners can be optimally supported in an e-learning environment. The ZPD defines the difference between what a learner can do alone and what he or she can achieve with guidance and support from a more knowledgeable other [ 20 ]. During the pandemic, physical classrooms were replaced by digital platforms, and the traditional interaction between student and teacher was transformed. This necessitates that learning platforms and pedagogical methods be adapted to maximize educational support in the virtual learning environment, in line with Vygotsky’s principles [ 17 ].

A key takeaway from our study is the importance of scaffolding in e-learning environments. The concept of scaffolding, as discussed by Bruner [ 40 ], involves providing temporary support to students that is gradually removed as they become more independent. In the context of e-learning, this means creating structured, accessible, and predictable e-learning environments that can guide students through their educational journey. Our findings suggest that clear, consistent, and engaging instructional design is crucial for facilitating deep learning, where students engage critically and reflectively with the course material.

The benefits of small group learning

Sociocultural theories also emphasize the importance of collaboration and dialogue in learning processes [ 17 ]. Although e-learning can be experienced as isolating, findings from our study indicate smaller group dynamics as a critical factor in enhancing e-learning effectiveness. This aligns with research by Wong (2018), who found that small groups facilitate more personalized interactions and deeper engagement, which is vital in a practice-oriented field like nursing. These groups allow for a transition from superficial to deep learning approaches, as defined by Marton and Säljö [ 18 ], by fostering critical engagement with material and collaborative learning experiences.

Addressing technological and psychological challenges

Our study also brings to light the technological challenges that can impede e-learning [ 41 ]. As Kumar Basak et al. noted, effective e-learning platforms must be robust, user-friendly and aligned with educational goals [ 42 ]. The frequent technical disruptions experienced during the pandemic highlighted the necessity for reliable digital infrastructure and adequate support for both students and educators [ 43 , 44 , 45 ]. This is especially crucial in nursing education, where the stakes of training are inherently high due to the direct implications for patient care.

Additionally, the psychological and social challenges identified in our research reflect findings by Bdair, who highlighted the potential drawbacks of e-learning, such as inadequate interactions and increased feelings of isolation [ 8 ]. These challenges are particularly significant in nursing, where learning is not only about acquiring knowledge but also about developing empathetic patient care skills, which are best nurtured through direct human interactions.

Integration of theory and practice

The challenges of integrating theoretical knowledge and practical skills in e-learning contexts, especially in nursing education, which is traditionally very practice-oriented, require innovative approaches to simulate practical experiences. This underscores the importance of ‘scaffolding’, where educators provide temporary support to students that they gradually withdraw as the students become more independent (Bruner [ 40 ]. E-learning platforms must be designed to support this pedagogical approach, clearly aligning with Vygotsky’s theories of learning through social interaction and supported exploration.

Integration with broader literature.

In comparing the challenges faced by nursing education during the rapid shift to e-learning with those in other disciplines, it becomes evident that the nature of nursing importantly amplifies these challenges [ 46 ]. Unlike disciplines primarily focused on theoretical knowledge, nursing education relies heavily on hands-on skills that are crucial for professional competence and patient care. The practical skills required in nursing, such as administering medications, performing physical assessments, and managing emergency situations, demand a level of tactile and sensory feedback that is inherently difficult, if not impossible, to replicate through e-learning platforms [ 2 ].

One of the significant strengths of this study lies in its timeliness and relevance. Conducted during an unprecedented global health crisis, it captures the immediate experiences and reactions of participants as they navigated the sudden transition to e-learning. This firsthand perspective is invaluable, offering real-time insights into the resilience, innovation, and adaptability of students and educators under crisis conditions.

Furthermore, this study systematically explores a wide range of themes related to e-learning in nursing education, addressing both the challenges and opportunities presented by this modality. By focusing on specific themes such as technological reliability, psychological impact, and pedagogical effectiveness, the research provides a detailed and balanced view of how e-learning can be optimized in nursing education. The use of qualitative methods enriches the data, allowing for a depth of understanding that can inform future educational strategies and interventions.

Limitations and future research directions

Despite these strengths, the study has limitations that must be acknowledged. First, the sample is not representative of all nursing students globally or even across Europe. The participants were selected from specific geographic and educational settings within Norway, which may limit the transferability of the findings to other regions or educational contexts. External validity should be handled cautiously. In applying a holistic view, we have taken into account connections and influencing environments [ 47 ].

Another potential limitation is related to the rapidly evolving digital landscape. The digital landscape in general and e-learning platforms in particularly evolve rapidly. Therefore, the challenges faced during the initial phase of the pandemic might have differed from those faced later as institutions, students, and educators became more accustomed to digital teaching methods.

These limitations suggest that while this study has provided valuable initial insights into the challenges and possibilities of e-learning in nursing education during a crisis, further research is needed to understand the implications and to develop more-robust e-learning strategies for nursing education.

To build upon this study and address the identified limitations, the following research directions are proposed:

Long-term Perspective: There is a need for longitudinal studies that follow the development of e-learning in nursing education over time. This will help understand the long-term implications of digital teaching methods and how they can be improved for future crisis situations.

Technological Development: Research should focus on how the rapidly changing digital landscape affects the e-learning experience. This includes examining new technologies and platforms that can enhance the efficiency and user-friendliness of e-learning in nursing education.

Pedagogical Strategies: It is important to develop and test robust pedagogical strategies that effectively integrate e-learning. Future studies should explore various teaching methods and their impact on learning outcomes for nursing students.

Interactive and Immersive Technologies: Investigate the use of interactive and immersive technologies such as virtual reality (VR) and simulations in nursing education. Studies should assess how these technologies can complement traditional teaching and improve practical skills.

By exploring these research directions, future studies can contribute to enhancing the effectiveness and relevance of e-learning in nursing education and ensure better preparedness for future crisis situations.

Implications for nursing education

Based on our research, educational institutions should consider the following strategies to enhance e-learning in nursing education:

Implement Robust Scaffolding : Develop and maintain structured, engaging, and accessible e-learning environments that provide the necessary support for students to achieve deep learning. This includes clear guidelines, consistent course materials, and active learning opportunities that guide students towards independence.

Utilize Small Groups : Promote the use of small groups in e-learning courses to enhance interaction and engagement. This approach not only supports deeper learning but also helps in developing the critical communication and teamwork skills essential for nursing.

Invest in Technology and Support : Ensure that the technological infrastructure supports seamless e-learning experiences. This includes reliable internet access, intuitive learning management systems, and prompt technical support to address issues as they arise.

Continuous Professional Development for Educators : Equip educators with the skills and tools necessary to effectively facilitate e-learning. This includes training in digital tools, pedagogical strategies for digital teaching, and methods to engage and assess students remotely.

Monitor and Adapt Strategies : Regularly review and adapt e-learning strategies based on feedback from students and educators, ensuring that the educational offerings meet the evolving needs of the nursing profession.

The rapid shift to e-learning presented by the COVID-19 pandemic has posed challenges, such as technological, psychological and social aspects, it also offers an opportunity to rethink and enhance how nursing education is delivered. By understanding and implementing effective pedagogical e-learning strategies such as scaffolding and small group learning, educational institutions can better prepare nursing students for their crucial roles in healthcare. This study contributes to the body of knowledge on digital education and serves as a foundation for future research aimed at optimizing e-learning in nursing education.

Data availability

Availability of data and materialsTo access the dataset used and analysed during the current study, please contact the corresponding author.

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Acknowledgements

We wish to thank all the participants who made this study possible.

No specific funding was provided for this study.

Open access funding provided by University Of South-Eastern Norway

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Gro Gade Haanes

USN Research Group of Clinical Competence, Department of Nursing and Health Sciences, Faculty of Health and Social Sciences, University of Southeastern, University of Southeastern Norway, Porsgrunn, Norway

Gro Gade Haanes, Etty Nilsen, Randi Mofossbakke, Marianne Wighus & Monika Ravik

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Contributions

All authors (GGH, MW, EN, RM and MR) agreed on the study design and worked together to design the interview guide. The GGH, MW and MR collected the data. The first (GGH) and last (MR) authors was responsible for drafting the manuscript. All the authors (GGH, MW, EN, RM and MR) worked together on the analysis in the early and final phases of the analysis; the first (GGH) and last (MR) authors significantly contributed to the data analysis. All authors (GGH, MW, EN, RM and MR) critically reviewed the manuscript.

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Table of Contents
Volume 17 - 2012
Number 3: September 2012
Advancing Nursing Through Social Media

Advancing Nursing Practice Through Social Media: A Global Perspective

Jean Barry is a Consultant, Nursing and Health Policy, at the International Council of Nurses. Jean’s portfolio at ICN includes addressing ICN’s work in nursing regulation, nursing education, and issues related to maternal/child health. She has worked in the area of nursing regulation for over 20 years, first at the provincial level in Canada; then at the national level at the Canadian Nurses Association as the Director of Regulatory Policy; and for the last two years at the international level at ICN. Jean works regularly with the World Health Organisation; non-governmental organisations; and national and international organisations addressing health care professional education and regulation. Her global work in nursing regulation includes regular environmental scanning, where the issue of the appropriate use of social media has recently surfaced as a significant issue.

Nicholas R. Hardiker is Professor and Associate Head (Research & Innovation) of the University of Salford School of Nursing, Midwifery & Social Work. Nick has a background in nursing and has Bachelors, Masters, and Doctoral degrees in computer science from the University of Manchester, UK. He has nearly 20 years experience of theoretical and applied research in health informatics, with a particular focus on health records and terminologies. Nick holds an adjunct position of Professor at the University of Colorado, Denver, USA, and is currently Director of the International Council of Nurses eHealth Programme. He has published widely and is asked regularly to speak at conferences and seminars. He is Editor-in-Chief of Informatics for Health and Social Care; is a member of national and international standards bodies and think tanks; and regularly provides advice to organisations such as the UK Department of Health on informatics issues

Social media has been used globally as a key vehicle for communication. As members of an innovative profession, many nurses have embraced social media and are actively utilizing its potential to enhance practice and improve health. The ubiquity of the Internet provides social media with the potential to improve both access to health information and services and equity in health care. Thus there are a number of successful nurse-led initiatives. However, the open and democratising nature of social media creates a number of potential risks, both individual and organisational. This article considers the use of social media within nursing from a global perspective, including discussion of policy and guidance documents. The impact of social media on both healthcare consumers and nurses is reviewed, followed by discussion of selected risks associated with social media . To help nurses make the most of social media tools and avoid potential pitfalls, the article conclusion suggests implications appropriate for global level practice based on available published guidance.

Key words: information and communication technology, social media, social networking, content communities, blogs, microblogs

Social media is now well-embedded in our information gathering and sharing strategies, and it is revolutionising the way we communicate. The use of information and communication technology (ICT) and the Internet continues to grow in all regions of the world. Over 2 billion Internet users globally represent 37% of the world’s population ( Internet World Stats, 2011 ). Hand-in-hand with this increase is the exponential growth of the use of social media, both within the general population and by the health care community. Kaplan & Haenlein ( 2010 ) define social media as “a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of User Generated Content” (p. 61). They characterise the many forms of social media into six main types: collaborative projects (e.g., Wikipedia ® ); blogs and microblogs (e.g., Twitter ® ); content communities (e.g., YouTube ® ); social networking sites (e.g., Facebook ® ); virtual game worlds (e.g., World of Warcraft ® ); and virtual social worlds (e.g., Second Life ® ). Social media is now well-embedded in our information gathering and sharing strategies, and it is revolutionising the way we communicate.

Globally, over 20% of Internet time is spent on social network and blog sites ( NielsenWire, 2010 ). At the end of June 2012, Facebook ® had over 950 million monthly active users ( Facebook, n.d. ). Also in March 2012, Twitter ® had 140 million active users, generating over 340 million tweets daily ( Twitter Team, 2012 ). The power of social media’s outreach and impact was evidenced by recent events in North Africa and the Middle East. A study out of the University of Washington which analysed more than three million tweets, several gigabytes of YouTube ® content, and thousands of blog posts, found that social media played a central role in shaping political debates in what is now commonly referred to as the “Arab Spring” ( O’Donnell, 2011 ).

...social media is also finding a place in public health communication strategies. Not surprisingly, social media is also finding a place in public health communication strategies. The World Health Organization (WHO) has a Facebook page, a Twitter ® feed, and a significant presence on YouTube ® . WHO is using social media to disseminate public health information, to counter rumours, and to keep the global public informed during disease outbreaks or disasters ( Jones, 2011 ). As an example, WHO used Twitter ® during an influenza A (H1N1) pandemic and had more than 11,700 “followers.” As the experience of WHO indicates, one fact sheet or an emergency message about an outbreak can be spread through Twitter ® faster than any influenza virus ( McNab, 2009 ).

The Use of Social Media Within Nursing

Social media is gaining popularity among healthcare professions, including nursing. The United Kingdom’s (UK) nursing and midwifery regulator, the Nursing & Midwifery Council, estimates that there are now around 355,000 registered nurses and midwives on Facebook ® in the UK alone. ( NMC, 2012 ). With UK adults representing less than 5% of the global Facebook ® user base, the number of nurses and midwives using Facebook ® worldwide must now run into several millions.

...individuals, healthcare institutions, and educational programs are both embracing social media and recognizing that caution is needed. The wide usage of social media both outside and within the healthcare community has far reaching implications for healthcare and the nursing profession, in terms of increased opportunities to communicate at personal and professional levels and enhanced access to information by both healthcare providers and members of the public. In addition, individuals, healthcare institutions, and educational programs are both embracing social media and recognizing that caution is needed. Professional, ethical, regulatory, and legal issues must be addressed. For nursing, this is evidenced by the growing volume of policy and guidance documents that focus on the use of social media. Examples from several professional organisations (see Table 1 ) illustrate the worldwide focus on the use of social media in healthcare.

Table 1. Examples of Policy and Guidance Documents with a Focus on Social Media and Nursing

The American Nurses Association (ANA)	( ) includes a statement of principles, a webinar, a fact sheet, a tip card, and a tips section about the use of social media:
The National Council of State Boards of Nursing (NCSBN)	( ) and other documents related to social media are available on the following website:
The Nursing and Midwifery Council (NMC)	( ). Available:
The Nursing and Midwifery Board of Australia (NMBA)	( ). Available:
The Royal College of Nurses of Australia (RCNA)	( ). Available:
The Canadian Nurse Protective Society (CNPS)	( ). Available:
The College of Registered Nurse of British Columbia (CRNBC)	Professionalism, Nurses and Social Media (2011). Available:

In addition, there have been many published articles providing direction and commentary with respect to the use of social media by health care professionals in such journals as the International Journal of Nursing Regulation ( Anderson & Plunkit, 2011 , Cronquist and Spector, 2011 ), New Zealand Journal for Nursing Praxis ( Wilson, 2011 ), Nursing Review ( Sweet, 2012 ), Imprint ( Stryker McGinnis, 2011 ), and Military Medicine ( Balog, Warwick, Randall, & Keiling, 2012 ). Our search of articles in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medline published from 2009 to the present day located over 1200 records with either ‘social networking’ or ‘social media’ in the title.

Participants from countries in the Middle East, Asia, Africa, Europe, and the South Pacific ...engaged in dynamic dialogue on social media... Although the published literature is primarily from the United States (US), Canada, UK, Australia, and New Zealand, the use of social media (and the issues surrounding its use) is not confined to these countries. Users of LinkedIn ® , a professionally-oriented social networking site, are located in more than 200 countries ( LinkedIn, n.d. ), and Facebook ® is available in 70 languages with over 80% of its users located outside the US and Canada ( Facebook Newsroom, n.d. ). Participants from countries in the Middle East, Asia, Africa, Europe, and the South Pacific attending the 2011 International Council of Nurses Credentialing and Regulators’ Forum in Taipei, Taiwan engaged in dynamic dialogue on social media, citing many examples related to both the advantages and challenges with respect to its use in nursing and healthcare in their countries. As cited by one participant in this forum, “At a recent forum hosted by the International Council of Nurses and attended by representatives from 17 countries, it was clear to me that most organizations are wrestling with the expanding influence of this communication tool” ( Robinson, 2011 , p. 42). Recognition of the impact, in terms of its great potential and its inherent risks, of social media on the global nursing community is growing. The importance of the dialogue on social media at this forum was also highlighted in professional journals and communications from a number of other organisations who participated ( Bard, 2012 , NMBA, 2011 , RCNA, 2011a ).

The Impact of Social Media

Recognition of the impact, in terms of its great potential and its inherent risks, of social media on the global nursing community is growing. It is widely-recognised that social media can be a powerful tool for communicating, influencing, and educating. Much, therefore, is to be gained with respect to its use in healthcare and nursing. This section will consider, from an international perspective, the impact of social media on both the public as consumers of healthcare information and nurses.

Impact on Healthcare Consumers

Social media provides consumers of healthcare with tools by which they can share with others their health concerns even as they arise, and receive a very In remote areas of the world, social media delivered via mobile phone may obviate the need for more expensive ICT and may increase access and equity to health care information and services. immediate response, either from healthcare providers or from others members of the public. Individuals who have similar health concerns can form virtual communities through which they can connect, interact, and share experiences. A national survey in the United States carried out by the Pew Research Center indicates that one in three adults in the US (30%) say they or someone they know has been helped by following medical advice or health information found online ( Fox, 2011 ).

The wide outreach of social media can also provide opportunities for the promotion of programmes and services, increasing awareness in the communities served by nurses ( Rutledge, et al, 2011 ). In remote areas of the world, social media delivered via mobile phone may obviate the need for more expensive ICT and may increase access and equity to health care information and services. To this end, “Closing the Gap” (in access and equity), including through the use of technology, is a theme of International Nurses’ Day for the period 2011-2013.

Impact on Nurses

ICN... provides opportunities for online dialogue by nurses from around the world through discussion forums. For nurses themselves, social media provides opportunities to dialogue with colleagues and to stay abreast of recent health care developments. This may be particularly beneficial for those working in more rural or remote areas and who may feel removed from traditional resources and support. ICN, for example, provides opportunities for online dialogue by nurses from around the world through discussion forums for educators, students, nursing regulators, advanced practice nurse, and nurses engaged in rural and remote practice settings. Examples of dialogue on these international forums include: students discussing opportunities for international placements; educators posing questions about social media guidelines for students; rural and remote nurses dialoguing on transition programs for those entering rural and remote practice; regulators discussing requirements for language fluency; and advanced practice nurses considering career options and research issues. It would be impossible to provide a comprehensive list of all of the many nursing-oriented social media initiatives and innovations. The following examples are provided to illustrate how nurses are taking advantage of, in different ways, opportunities afforded by social media:

The rich information that results from the use of social media, and the accessibility of that information, makes it a very useful resource for healthcare and/or health and nursing research ( Sweet, 2012 ). Examples of this include the use of Twitter® content in predicting and tracking disease outbreaks such as influenza ( Schmidt, 2012 ) and the use of data mining techniques to determine the nature of communities from physical activity-related Twitter® content ( Yoon, 2011 ).
Nursing education programs are using social media to communicate with current, past, and potential students to connect and to share information. An example of this is the use of Facebook® to connect with former nursing students in order to support educational research ( Amerson, 2011 ). Nursing students also use social media to dialogue amongst themselves and with the larger nursing community ( McNeil, n.d. ).
Many healthcare, professional, and regulatory organisations are using social media to enhance a two-way dialogue with the public and healthcare professionals. For example, the Canadian Nurses Association, the American Nurses Association, the Royal College of Nurses of Australia, DENOSA in South Africa, the UK’s Royal College of Nursing, and the Cyprus Nurses and Midwives Association all use social media to reach their members and members of the public. In February 2012, a live social media event was held by the Nursing & Midwifery Council, “Talking with patients online: What are the boundaries?” This event reached over 24,000 Twitter® followers, an example of the popularity and the scope of this type of outreach.
In partnership with three other nursing organisations, and with the support of Sanofi, ICN has been participating in the development of the Connecting Nurses initiative. Connecting Nurses seeks to provide a forum for nurses from around the world to share their ideas, advice, and innovations. Connecting Nurses is now an integral part of ICN’s eHealth Programme which seeks to transform nursing through the visionary application of ICT. There are two programmes within Connecting Nurses: Care Challenge and Information Shareapy. Care Challenge is an annual contest that highlights nursing innovations and helps to put them into practice. This challenge encourages nurses from across the world to upload their ideas, thereby forming a content community. In 2012, 20 entries received awards in one of two categories: “Helping Hand,” which included a financial prize to support the innovation; and “Nurses in the Limelight,” which offered the opportunity of a professionally-produced video to showcase the innovation. For more information, visit the Care Challenge web site at: www.care-challenge.com/ . Information Shareapy, which will launch in 2013, is a prototype patient education service for nurses and midwives to share links to high quality, reputable health resources with their patients, families, friends, or colleagues. The goals of Information Shareapy include to help nurses: connect with each other and with other health professionals; in their interactions with patients; and stay updated. This initiative therefore shares some of the features of collaborative projects, content communities, and social networks.

Selected Risks Associated With Social Media

The examples above, and many more in the literature, leave little doubt that social media has much to offer. However, there are risks associated with its use. This section will address such worldwide concerns as unmoderated content, privacy violation, unprofessional behaviour, and organisational risk.

Unmoderated Content

There is evidence to suggest that members of the public are discerning in terms of their willingness to trust health information on the Internet... There is evidence to suggest that members of the public are discerning in terms of their willingness to trust health information on the Internet and use a range of criteria, such as sponsorship by a health organisation, and/or taking recommendations from and discussing findings with health professionals, to assess the reliability of online information ( Diaz et al, 2002 ). However, one potential risk associated with social media results from the un-moderated distribution of information; this may lead to bad decisions by both healthcare providers and members of the public. Jones ( 2011 ) provides an example of this from Japan. In the aftermath of the 2011 Great East Japan Earthquake, there was growing concern about radiation leaks and rumours spread though social media and other means that drinking iodised wound cleaner and consuming large quantities of salt would reduce potential adverse effects. However, WHO was able to successfully counter these rumours through similar means (i.e. using Twitter ® ) to dismiss the rumours and provide more accurate information. This resulted in a decrease in the number of messages being circulated advising people to buy salt.

Privacy Concerns

According to the U.S.-based National Council of State Boards of Nursing (NCSBN) ( 2011 ), breaches of privacy and confidentiality can be intentional or inadvertent and can have serious implications for nurses, their patients, and their employer. These breaches can occur in a variety of ways, including via comments on social media sites in which a patient is described in sufficient detail to be identified; referring to a patient in a degrading or demeaning manner; or posting videos or photos of patients.

In a survey conducted by NCSBN around the misuse of social networking, 33 state boards of nursing (of the 46 that responded) indicated having received complaints about nurses who had violated patient privacy by posting information on social networking sites. Twenty six of those boards took disciplinary action ( Cronquist & Spector, 2011 ). A 2010 survey of Canadian nursing regulators revealed similar concerns around activities such as posting pictures of clients, posting descriptions of identifying events, and using social networks to air grievances and complaints about colleagues, clients, and employers ( Anderson & Puckrin, 2011 ).

...as online activity increases, [professional] boundaries can become blurred. Nurses are professionally accountable for developing an understanding of the boundaries between private, public, and professional life and acting accordingly. However, as online activity increases, such boundaries can become blurred ( Anderson & Puckrin, 2011 ).

Nevertheless, employers, regulators, and the public expect privacy to be maintained and healthcare professionals to be respectful when using ICT, including social media, and have taken action when violations have occurred ( Anderson & Puckrin, 2011 ). Nurses need to understand that breaching confidentiality is not only risking the trust that exists between patient and nurse, it may also result in discipline or termination at the employer level, in professional sanctions against the nurse’s license to practice, or even in legal action. For example, a bulletin that provides legal protective advice to Canadian nurses describes how one nurse was found guilty of unprofessional conduct by her professional licensing body because she posted a patient's first name and the patient's personal health information on a co-worker's Facebook ® page ( CNPS, 2010 ). The same bulletin indicated that the breach of professional standards, in these contexts, could also be a breach of privacy legislation and could result in charges being brought against the nurse.

Unprofessional Behaviour

Areas where social media has been inappropriately used by health care professionals, in addition to breaches of privacy, include bullying of colleagues (or for students, bullying of other students); online criticism of colleagues or employers; and unprofessional behaviour that may be in breach of codes of conduct ( CNPS, 2010 ). Thompson et al. ( 2008 ) reported that in an evaluation of the social networking accounts of medical students and residents, 70% were found to have included images containing alcohol, racially toned language, misogynistic statements, and foul language in their postings.

Presenting an unprofessional image not only is bad for the image of healthcare professions as a whole, but may affect employment opportunities. Presenting an unprofessional image not only is bad for the image of healthcare professions as a whole, but may affect employment opportunities. Potential employers sometimes monitor an applicant's use of social media when making hiring decisions ( RCNA, 2011b ). While controversy exists regarding the legal and moral basis of this practice, at the moment there are few, if any, formal regulations in place to prevent this monitoring. Users of social media are left to navigate this evolving venue and should consider the overall image they present.

Nurses also need to use caution regarding what they post using social media about others. If defamatory comments are made by a nurse about another person or institution on a social media site, a civil lawsuit alleging defamation could be commenced against the nurse ( Cronquist and Spector, 2011 ). As well, nurses may face loss of employment if the nurse’s actions violate the policies of the employer ( Cronquist and Spector, 2011 ).

Organisational Risk

For employers, there may be a number of concerns regarding the use of social media impacting, among other things, corporate reputation. The NSCBN White Paper ( 2011 ) provides an example where the inadvertent post of a student with information and a photo about a paediatric patient she cared for resulted in not only the student being expelled, but also the clinical placement hospital being reviewed under privacy legislation (i.e., HIPAA). Another outcome was the nursing education institution was banned from use of the unit as a clinical site for future students.

Employers need to have in place a formal policy on the use of social media... From a human resource perspective, there are obvious issues concerning productivity, efficiency, and attention ( Lyncheski, 2010 ). Employers must decide how to strike the balance between a workplace that permits access to social media sites and one that protects confidentiality, security, and the employer’s legal interests ( Lyncheski, 2010 ). Employers need to have in place a formal policy on the use of social media and to communicate widely and enforce the policy, providing clear consequences for any violations ( Burke & Goldstein, 2010 ) bearing in mind that published guidelines and documents are effective only when nurses have support applying them to practice issues ( Anderson & Puckrin, 2011 ).

Conclusion: Practice Implications for Individuals, Healthcare and Educational Institutions, Professional Associations, and Regulators

In light of growing use of social media, with potential for both benefit and harm, nurses throughout the world need to draw on available guidance as necessary. The following list, although not comprehensive, is applicable to global settings and draws on current published guidance by professional organisations, regulators and others, to provide pointers for the responsible use of social media so that nurses are well-placed to avoid any potential pitfalls.

For Individuals

Legal authority is of particular importance when providing health information, advice, or services through social media, as the recipient of these services could reside outside the area in which the nurse is licensed to practice. Be aware of and adhere to legal, regulatory, educational institution, and/or employer requirements, guidelines, and polices. As with any other area of nursing practice, if nurses are providing health services through ICT, they should ensure they have the required competencies, are practicing within their scope of practice, and are legally authorized to do so ( Canadian Nurses Association, 2007 ). Legal authority is of particular importance when providing health information, advice, or services through social media, as the recipient of these services could reside outside the area in which the nurse is licensed to practice.
Maintain patient privacy and confidentiality at all times. Do not take photographs or videos of patients on personal devices, including cell phones. Do not distribute by any electronic media, any patient-related image, or information that may be reasonably anticipated to violate a patient’s rights to privacy or confidentiality, or otherwise degrade or embarrass the patient ( NCSBN, 2011 ).
Do not use social networking sites to distribute sexually explicit material, nor in any way which is unlawful ( NMC, 2011 ).
Maintain clear and appropriate boundaries. Do not accept patients as social network “friends.” Socializing with patients online may damage the nurse-patient relationship ( NMC, 2011 ). A “friend request” does not authorise the nurse to engage in a personal relationship with a patient ( NCSBN, 2011 ).
Do not discuss work-related issues online, including conversations about patients or complaints about colleagues ( NMC, 2011 ). Do not criticize or otherwise project an unflattering image of your educational institution, workplace, teacher, co-workers, or supervisor.
Be judicious in the use of social media. Reputations can be affected by information found online and can affect the outcome of future endeavors. Go back to your social media sites and ask the questions, “Is this how I want to be seen?” and “Can any of the information be taken out of context?” ( RCNA, 2011b ).
If the answer is anything other than “yes” to the question: “Would I pin this on a public notice board?” do not post it via social media ( CRNBC, 2011 ). Strongly consider if you really want information in the public domain and whether the information is respectful, appropriate, and inoffensive ( NMBA, 2010 ).
Be aware that everything you post online is public, even with the strictest privacy settings. Once something is online, it can be easily copied and redistributed. Presume that everything you post online will be permanent and will be shared ( NMC, 2011 ).
Report objectionable material ( ANA, 2011 ; NCSBN, 2011 ) and take action if you are the subject of complaints or abuse via social media ( NCSBN, 2011 ).
Keep your personal and professional lives separate. If you are using social media in a professional venue, create different accounts for professional and personal activities ( CRNBC, 2011 ; Stryker McGinnis, 2011 ).
If you are going to engage in the use of social media become “tech savvy” (i.e. knowledgeable about technology) ( Stryker McGinnis, 2011 ). For example, ensure that you understand the social media service’s privacy policy, and use appropriate privacy settings ( ANA, 2011 , NMBA, 2010 , NMC, 2011 ).
Recognize with every post and every tweet, you are helping to create and reinforce a global image of nursing ( McGinnis, 2011 ).

For Healthcare and Educational Institutions

Set clear policies and guidelines, widely distribute them, and enforce them consistently ( Burke & Goldstein, 2011 ; Lyncheski, 2010 ).
Provide guidance for nurses to apply policies and guidelines and put them into practice ( Anderson & Puckrin, 2011 ).

For Professional Associations and Regulators

Engage registrants and members in dialogue and reflection regarding responsible use of social media ( Anderson & Puckrin, 2011 )
Raise awareness of the power of social media and the possibility that information shared on the Internet may be universally and indefinitely accessible ( Anderson & Puckrin, 2011 )
Utilise case studies and practice standards to delineate between private, public, and professional actions ( Anderson & Puckrin, 2011 )
Support nurses and their employers in the development of social media resources ( Anderson & Puckrin, 2011 ).

Educators, employers, and regulators across the world need to communicate clearly and effectively to students, nurses, and healthcare consumers about the appropriate use of social media. Social media continues to evolve, and its use continues to increase exponentially. Educators, employers, and regulators across the world need to communicate clearly and effectively to students, nurses, and healthcare consumers about the appropriate use of social media. It is essential that policies and guidelines continue to evolve to keep pace with socio-technical advances and in accord with educational, employment, regulatory, and legal decisions that are made regarding its use. Individual students and nurses need to be aware of and adhere to these polices to intentionally avoid the pitfalls around use of social media – pitfalls that can negatively and profoundly impact patients, colleagues, educational institutions, employers, and the healthcare professions. We are in exciting times with unprecedented opportunities for rapid and wide-reaching communication and sharing and it is essential that nursing and healthcare communities safely harness the power of social media for global outreach.

Jean Barry, MSN, RN E-mail: [email protected]

Nicholas R. Hardiker, PhD, RN E-mail: [email protected]

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September 30, 2012

DOI : 10.3912/OJIN.Vol17No03Man05

https://doi.org/10.3912/OJIN.Vol17No03Man05

Citation: Barry, J., Hardiker, N., (September 30, 2012) "Advancing Nursing Practice Through Social Media: A Global Perspective" OJIN: The Online Journal of Issues in Nursing Vol. 17, No. 3, Manuscript 5.

Article September 30, 2012 Communication Technology and Social Media: Opportunities and Implications for Healthcare Systems Betsy Weaver, EdD; Bill Lindsay; Betsy Gitelman
Article May 13, 2013 Initiating Collaboration among Organ Transplant Professionals through Web Portals and Mobile Applications Susan Alexander, DNP, RN, AHNP, AHCNS ; Haley Hoy, PhD, RN ; Manil Maskey, MS; Helen Conover, MS; John Gamble, BS; Anne Fraley, BSN, RN
Article September 30, 2012 Guidelines for Using Electronic and Social Media: The Regulatory Perspective Nancy Spector, PhD, RN; Dawn M. Kappel, MA
Article September 30, 2012 Social Media Use in Nursing Education Terri L. Schmitt, PhD, RN, FNP-BC; Susan S. Sims-Giddens, EdD, RN; Richard G. Booth, MScN, RN
Article September 30, 2012 Health Tweets: An Exploration of Health Promotion on Twitter Lorie Donelle, PhD, RN; Richard G. Booth, MScN, RN

IMAGES

How To Use Social Media Effectively in Nursing
Advancing Nursing Practice Through Social Media
4 ways nurses can use social media for career success
Social Media's Role in Expanding the Reach of Nursing Research
4 Positive Uses of Social Media in Nursing
(PDF) Possible influence of social media on shaping the image of nurses

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COMMENTS

Using social media in contemporary nursing: risks and benefits
Abstract. Social media has become incorporated into the practice of contemporary nursing. It must be acknowledged by the nurse and the nursing profession that social media has the power to enable the nurse to network with colleagues and share research findings through both private and open forums. However, it also has the potential to ...
Ethical Decision-Making Among Nurses Participating in Social Media: A
A review of the literature returned few research articles that address the attitudes and ethical decision-making (EDM) of actively practicing nurses in the United States. ... Social media posts and pictures available to the public possibly impact public opinions of the nursing profession. Social media use has become prevalent across the world ...
Nurses' use of social media during the COVID-19 pandemic—A scoping
A scoping review inspired by Arksey and O'Mally was conducted by searches in Medline, CINAHL, Academic Search Complete and Web of Sciences. Empirical research studies investigating nurses' use of social media in relation to COVID-19 were included. Exclusion criteria were: Literature reviews, articles in languages other than English ...
Social Media in Nursing Education: A Systematic Review
Social media emerged as a nursing education intervention in the mid- to late 2000s (Schmitt et al., 2012). Although the use of social media in nursing education is still relatively new, incorporating social media in the classroom is helpful for learning with the current generation of students (Ross & Myers, 2017).
Exploring nurses' experiences of social media and in-person educational
Study design. As part of a trial [], a qualitative study was conducted to explore nurses' experiences of social media and in-person education approaches.The study used the directed content analysis approach. The goal of a directed content analysis approach is to validate or extend conceptually a theoretical framework or theory [].Existing theory or research can help focus the research question ...
Nursing students' use of social media in their learning: a case study
Social media has diverse applications for nursing education. Current literature focuses on how nursing faculty use social media in their courses and teaching; less is known about how and why nursing students use social media in support of their learning. The purpose of this study was to explore how nursing students use social media in their learning formally and informally.
Exploring nurses' online perspectives and social networks during a
Research aims. The online perspectives of nurses from around the world, and with varying professional backgrounds, could provide valuable insights into nurses' social media behavior, the challenges faced during the early stages of COVID‐19, and how the nursing profession responded to this global pandemic.
#nursing. What Nurses Do on Instagram— A Mixed Methods Study
Kung and Oh (2014) indicated that the use of social media is an effective and substantial tool to reach and educate a large number of nurses worldwide with quick information in nursing education, nursing practice, and nursing research. Social networking platforms can significantly influence the development of professional identity ...
Social Media in Nursing Education: A Systematic Review
Method: This systematic re-view examined and ranked the level of evidence that sup-ports social media use in nursing education. Results: A total of 19 studies published between 2017 and 2022 were evaluated and described in an evidence table. Results re-vealed social media is used in a variety of settings and in diferent ways, including ...
Nursing students' use of social media in their learning: a case study
Theoretical considerations. Social learning theories like social constructivism are appropriate for framing studies involving social media because they view learning as an active and collaborative process [36-38].Social constructivism is based on three assumptions: (1) meanings are constructed by humans as they engage with the world they are interpreting; (2) humans engage with their world ...
Social Media Usage Among Nurses: Perceptions and Practices
ng landscape within the nursing profession is necessary to inform policy and develop effective guidelines. METHODS This was a single-center prospective observational study involving nurses at a large academic medical center. Nurses completed an anonymous questionnaire regarding their personal use and perceptions of social media in the context of clinical medicine. RESULTS A total of 397 nurses ...
Using social media to engage nurses in health policy development
More research on the ethical and professional issues associated with using social media in nursing education, research and practice would be helpful to protect students, nurses, patients, educators and researchers and ensure they are competent in using these digital tools. ... (@was3210) for his helpful blog on social media research and Emma ...
Nurses' use of social media during the COVID-19 pandemic-A ...
The article aims to explore how nurses use social media in relation to the COVID-19 pandemic. Method: A scoping review inspired by Arksey and O'Mally was conducted by searches in Medline, CINAHL, Academic Search Complete and Web of Sciences. Empirical research studies investigating nurses' use of social media in relation to COVID-19 were included.
Social Media Usage Among Nurses: Perceptions and Practices
Objective: This study aims to examine the existing perceptions and social media practices of nurses in a large academic medical center. Background: Limited data are available about the perceptions and social media practices among healthcare providers. An understanding of the social networking landscape within the nursing profession is necessary to inform policy and develop effective guidelines.
The influence of social media on student nurses: A systematic mixed
Moreover, social media has demonstrated manifold benefits for student nurses, spanning the augmentation of their interest, curiosity, self-motivation, and academic performance in their nursing studies (Gulzar et al., 2021), to the cultivation of personal, professional, and societal connections and networks (Kapoor et al., 2017).
How nurses can use social media to their advantage : Nursing2024
Department: TECH NOTES. How nurses can use social media to their advantage. Reinbeck, Donna PhD, RN, NEA-BC; Antonacci, Jaclyn MA. Author Information. Donna Reinbeck is an assistant professor at the Medical University of South Carolina in Charleston, S.C., and Jaclyn Antonacci is a social media coordinator at William Paterson University in ...
Review The value of social media use in improving nursing students
Tuominen et al. (2014) Social Media in Nursing Education: The View of the Students. Finland (Academic setting) To survey second-year nursing students' social media usage in studies and in their free time: Quantitative method Descriptive survey research design Data were collected by questionnaire Data were analysed using SPSS
Nurses' use of social media during the COVID-19 pandemic—A ...
Background During the COVID-19 pandemic, nurses stand in an unknown situation while facing continuous news feeds. Social media is a ubiquitous tool to gain and share reliable knowledge and experiences regarding COVID-19. The article aims to explore how nurses use social media in relation to the COVID-19 pandemic. Method A scoping review inspired by Arksey and O'Mally was conducted by ...
Social Media and Nursing Activism: A Literature Review
As nurses begin to embrace social media, there is a need to further explore social media activism in nursing education, leadership and research. Implications for Nursing Education. Social media in health policy education increases understanding and engagement in complex and relevant health policy issues (Gazza, 2019; Mercadante & Rambur, 2020).
Diffusion of social media in nursing education: A scoping review
Social media is beginning to be integrated into undergraduate nursing education increasing frequency as an innovative teaching strategy. It is imperative nurse educators formally explore the efficacy of various forms of social media on undergraduate nursing student outcomes. 20. Lopez and Cleary: 2018: Australia: Commentary article: Social ...
Dangers and Benefits of Social Media on E-Professionalism of Health
The purpose of this scoping review is to characterize the recent original peer-reviewed research studies published between November 1, 2014, to December 31, 2020, on e-professionalism of HCPs; to assess the quality of the methodologies and approaches used; to explore the impact of SM on e-professionalism of HCPs; to recognize the benefits and ...
Social Media in Occupational Health Nursing: Helpful or Harmful?
We explored the ways occupational health nurses can use social media as a helpful resource as well as identified potential concerns associated with its use. Methods: A review of the literature was conducted between December 1, 2019, and April 10, 2020, using PubMed and Google Scholar. Key search terms included social media, social network ...
Social Media and Nurses: Insights for Promoting Health for Individual
This article provides a brief overview of social media and then explores nursing health and social media and risks for nurses . Social media use also extends to healthcare organizations ; with implications for consumers of healthcare delivery . ... Some research supports social media as an effective tool for nursing students to develop their ...
Digital learning in nursing education: lessons from the COVID-19
Design. This study is a part of a larger investigation exploring nursing students learning during the COVID-19 pandemic. We employed an exploratory and descriptive research design utilizing in-depth qualitative individual and pair interviews [].The exploratory design was chosen to investigate the nuanced experiences of nursing students and newly qualified nurses (as nursing students ...
Advancing Nursing Practice Through Social Media: A Global Perspective
This article considers the use of social media within nursing from a global perspective, including discussion of policy and guidance documents. ... Facebook: A tool for nursing education research. Journal of Nursing Education, 50(7), 414-6. Anderson, J., & Puckrin, K. (2011). Social network use: A test of self-regulation. Journal of Nursing ...

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Nurses’ use of social media during the COVID-19 pandemic—A scoping review

Introduction

Identifying the research question

Identifying relevant studies

Study selection

Charting the data

Analytical strategy

Characteristics of the studies

Social media as knowledge nodes

Social media as profession-promotion

Social media as a disciplinary tool

Supporting information

Dangers and Benefits of Social Media on E-Professionalism of Health Care Professionals: Scoping Review

Joško Viskić

Lovela Machala Poplašen

Kristijan Sedak

Associated Data

Conclusions

Introduction

A Scoping Review

Search Strategy

Study Inclusion and Exclusion Criteria

Eligibility and Data Extraction

Quality Evidence Assessment

Ethics Approval and Consent to Participate

Characteristics of the Reviewed Studies

Assessing the Quality of Studies

SM Use Patterns Among Health Care Professionals

Benefits of Social Media on E-Professionalism of Health Care Professionals

Professional Networking and Collaboration

Professional Education and Training

Patient Education and Health Promotion

Dangers of Social Media on E-Professionalism of Health Care Professionals

Loosening Accountability

Compromising Confidentiality

Blurred Professional Boundaries

Depiction of Unprofessional Behavior

Legal Issues and Disciplinary Consequences

Evaluation of Existing Approaches’ Effects on Promoting E-Professionalism

Barriers to Using Social Media for Health Care Professionals

Principal Findings

Recommendations for E-Professionalism Curriculum Changes

Barriers to Social Media Use for Health Care Professionals

Comparison With Prior Work

Gaps in the Literature and Potential Areas for Further Research

Limitations of the Review

Acknowledgments

Abbreviations

Multimedia Appendix 1

Digital learning in nursing education: lessons from the COVID-19 lockdown

Sample and recruitment

Data collection

Ensuring trustworthiness

Ethics approval and consent to participate

Learning possibilities and learning barriers

Group dynamics in E-Learning

Engagement in virtual settings

Technological challenges

Platform utilization and interface challenges

Connectivity and technical reliability

Psychological and social challenges

Cognitive and emotional engagement

Social interaction and isolation

Pandemic-specific findings and General E-Learning challenges