Douglas P. Olsen, PhD, RN, associate professor, College of Nursing, Michigan State University, writes about ethical issues for AJN.

Recently, a disciplinary committee in Canada found a nurse in breach of the Canadian Nurses Association’s Code of Ethics for Registered Nurses for posting negative comments on Facebook and Twitter about the care given to her grandfather in a long-term care facility before his death. The nurse was accused of violating her grandfather’s confidentiality, not using proper processes for noting complaints about his care, and potentially harming the institution’s reputation. She was found guilty of professional misconduct but not guilty of violating his privacy. The ethical breach was based on her public declarations about the nursing care.

Key to the Saskatchewan Registered Nurses’ Association decision to find the nurse guilty appears to have been the fact that the nurse prefaced remarks with the phrase, “As a nurse . . . ” Adding this phrase to one’s communications confers the authority of scientific and experiential expertise. It further implies that one is versed in the proper procedure and standards for evaluating accuracy and relevance of clinical information and that one’s conclusions are communicated honestly for constructive purposes. The credibility added by identifying the nursing credential is deserved—and therefore carries responsibilities.

What are the conditions for an ethical response when speaking publicly ‘as a nurse’?

The voice of nursing—because of our knowledge, earned in the classroom and through intimate contact with the sick, the dying, and currently healthy patients—is essential to keeping public discourse on health care rational and moving toward better quality of life for all. The ANA Code of Ethics is clear throughout, but especially in provisions 8 and 9, that nurses have an ethical obligation to speak out on anything that affects the health of the population. However, public communication from nurses needs to be of the highest professional standards to maintain deserved credibility.

Professional communication has higher standards than lay communication.

Speaking “as a nurse” invokes those standards and creates the reasonable expectation that the statements are informed by special knowledge. The public legitimizes and empowers nursing through licensure, and in return expects value in the form of quality nursing care—which includes thoughtful, knowledgeable contribution to public health care discourse and policy formation.

Similar to shared decision making with patients, public health discourse involves back-and-forth exchanges, in which the public makes its desires for health care known and nursing contributes by informing the public regarding what good nursing care can accomplish and detailing the required resources to accomplish agreed-upon goals. Public communication that fails to meet professional standards is much like giving poor nursing care: it violates nurses’ obligation to the public, damages our standing with public trust, and harms the ‘patient’ (in this case, society).

The blurring of the distinction between public and private communication on the Internet and on social media threatens the maintenance of professional standards in public communication. Many social media messages have the character of personal communication. One’s Facebook page might include baby pictures and holiday cookie recipes as well as health lifestyle tips, provided by someone “as a nurse.”

Not only does much social media seem more personal, it is easy to post quickly, without the same consideration that one would give a more clearly public presentation, for example, the preparation a nurse might do before offering lifestyle advice at a health fair. Communication  via internet and social media is public even beyond a pre-internet understanding of what it meant to be publicly exposed, making statements instantly and permanently available to millions.

The following suggestions are made to keep communication on and off social media ethical when speaking “as a nurse.”

  • Statements about the clinical effect or efficacy of an intervention or recommendation should be based in evidence sufficient to inform clinical action. Where the evidence is more uncertain or equivocal, that should be stated. Technical details in discussions of evidence should be appropriate to the audience; not too complex when targeting a lay audience, but sufficiently detailed when speaking to professional peers to meet their expectations for applying the information. For example, general health tips on your Facebook page should be clear to most audience members, while a posting about clinical topics on this blog should demonstrate consideration of the evidence that a professional nurse could evaluate.
  • Statements about service delivery should be based on evidence. Where evidence is lacking, the rationale for the statement should be provided: for example, “In my experience as a patient, wait times are . . . .” or, “In my practice, patients report . . . .”
  • When posting about or otherwise discussing care witnessed as a patient, friend, or family member, mentioning one’s status as a nurse makes such statements a professional communication. This includes listing your credential or degree with your name. Such communication would also be considered professional if posted or discussed in a venue that implied your status as a nurse, such as participating in a discussion at the Web site allnurses.com.
  • Before discussing problematic care of an individual, report the problem through the proper channels. For example, speak with the nurse providing the care you are concerned about. Listen carefully, consider all issues, and if still not satisfied, speak to the charge nurse or nurse manager, and so on up the chain of command.
    • If the problem involves abuse, look to your mandated reporter obligations before considering public revelation.
    • If the problem involves criminal or dangerous behavior, look to proper authorities before considering public revelation.
  • Before discussing problematic care, ensure that all relevant information is in hand and reviewed before reaching conclusions about the care being discussed.
  • Never identify a patient or use identifying information—including name, address, any of the HIPAA identifiers, or enough information that the person could be identified—without clear informed authorization from that person. (Here’s a quick quide to patient deidentification approaches and a list of 18 patient identifiers of potential concern.)
    • If you are seeking the person’s authorization to disclose information publicly, the patient should be informed of likely consequences. For example, if the person’s information was being used in politically controversial testimony, he or she should be informed of possible negative publicity or of reporters seeking him or her out for further information.
  • Events occurring in the context of nursing care should not be revealed for the sake of mean-spirited humor, even when the patient identity is protected. An example might be the periodic posting of odd items removed from patients’ rectums.
  • Narrative accounts of the nursing experience should reflect well on the profession and bring problems to light in the spirit of working to improve matters.
  • Before discussing systemic or institutional problems or abuses, follow proper reporting procedures. If those responsible do not respond in a satisfactory way, consider whistle-blowing. When considering whistle-blowing, plan a method which confers the most credibility on your accusations and avail yourself of whatever protections are available to you (for example, see this information on whistle-blowing from the American Nurses Association). Facebook and similar social media channels are not the appropriate venues for serious whistle-blowing communications.
  • Know the legal consequences of your actions. Speaking out as a nurse, especially on social media, carries the potential for severe legal consequences. The inspiration for this post was a disciplinary hearing about a nurses’s Facebook and Twitter posts. When I mentioned the case to several colleagues, they expressed surprise at the finding that the nurse violated the Canadian Nurses Association’s Code of Ethics. These suggestions are about being ethical in public communication and are not legal advice.

Common wisdom provides a starting place for assessing the appropriateness of postings and public discussion. Consider the effects of any potential public communication or posting from the non-nurse perspective. Does the message reflect well on nursing and, if it doesn’t, is the criticism fair? Does the message lead to a constructive dialogue on how to improve the situation? Are you posting out of spite or anger? Finally, have you done all that you can to remedy the situation, short of whistle-blowing?