Since the introduction of social media, there has been much discussion about its use in professional practice. Within many of the health professions this discussion has been directed towards the personal use of social media and its possible effect on the individual's professional registration. The usefulness of social media within one's professional life has been largely ignored. Much of the advice given by managers and academics, especially to midwives and student midwives, has been alarmist regarding the risk to an individual's professional registration if they fail to abide by the regulatory framework of the profession. Social media, however, is the latest evolution in a series of communication pathways and as such should be judged in the same way as any other form of communication. This article aims to debate the opportunities and risks associated with the use of social media and offer a balanced argument for professional engagement with social media.
What is social media?
Social media is the platform by which information and ideas can be created and shared using online networks and virtual communities (Fisher and Clayton, 2012; Thackeray et al, 2012). Information can be sent almost instantly to thousands of people worldwide without, in most cases, any interference by governments or organisations. The four most popular social media tools are Facebook, YouTube, Twitter and LinkedIn (Alexa, 2014) but the technology is constantly evolving and there are many more available. It is difficult to predict which platforms will maintain their popularity. Within the midwifery community, Google+ is currently being embraced as a professional tool for networking across the profession. Whichever platform is used, however, it can be easily accessed by computer, laptop, tablet and smartphone so that communication can be instant and always on hand.
The rapid rise in the use of social media is changing the way we communicate with each other at a great pace. At the click of a button thoughts can be shared with thousands of others. Herein lies the potential risk to professional registration and it is for this reason that the Nursing and Midwifery Council (NMC) and many other professional bodies have written guidance aimed specifically at social media (NMC, 2012a). Although many NHS employers and universities have developed permissive social media policies, the NMC guidance is often misrepresented by members of the midwifery profession who have little meaningful understanding of the issues as they do not engage with social media and who give advice based on little knowledge of the facts. This advice often includes warnings not to engage with platforms such as Facebook, or if wishing to do so, not to be identifiable, not to mention the midwifery profession, or place of residence, because this may identify the individual or the clinical area in which he/she works and may result in loss of midwifery registration. Yet provided the midwife, or student, abides by the regulations of the profession, there is no greater likelihood of losing registration than through any other form of communication. What must be realised is that anything posted anywhere on social media can be quickly shared, or copied and shared, to a large number of people. The information can also be considered to be permanently available to the world; even if deleted it may already have been copied, or be retrievable.
Another issue is that the ability to communicate instantly via social media takes away the time to reflect before making posts or statements that, on reflection, might be moderated before publication. It is wise to consider carefully whether the information is respectful, appropriate and professional and whether it should be permanently visible in the public domain. The question of professionalism is a particular concern to health professionals and one that needs much discussion (Jones and Hayter, 2013). It is unfortunate that some members of the profession who have a good knowledge of the concept of professionalism may have the least experience of social media, and are therefore less likely to effectively educate those entering the profession often with considerable knowledge of social media but little knowledge of professionalism.
Anecdotally, it has been found that many universities and Trusts offer little appropriate education on the issues relating to the use of social media in the health professional arena, and thus midwives and students either become scared of using it, do so in private, or use closed groups with or without using a pseudonym. Thus while other industries have been quick to embrace the benefits of social media, health professionals have been very slow to engage (Anderson, 2012). Yet social media is a powerful tool that can used to the benefit of midwives, students and their clients to network, provide education and give health education messages.
The NMC and social media
Midwives and students are regulated professionally by the NMC which gives clear guidance on professional behaviour through The Code: Standards of conduct, performance and ethics for nurses and midwives (NMC, 2008). The Code is used as a key tool in determining fitness to practise if personal or professional misconduct is alleged. The Code sets out the expected behaviour of midwives on the register, with student midwives being advised in the guidance on professional conduct for nursing and midwifery students (NMC, 2012b). Specific guidance on applying The Code to the use of social media is offered (NMC, 2012a).
The NMC states that nurses and midwives must ‘uphold the reputation of your profession at all times’ while students must ‘uphold the reputation of your chosen profession at all times’. In this specific guidance the NMC (2012a) goes on to say that ‘conduct online and conduct in the real world should be judged in the same way, and should be of a similar high standard. Nurses and midwives will put their registration at risk, and students may jeopardise their ability to join our register, if they:
The NMC points out that this list is not exhaustive and that if there is any doubt about whether a particular activity online is acceptable, it can be useful to compare with a real-world analogy (NMC, 2012a).
The NMC has found it necessary, however, to provide practical advice to further define unprofessional behaviour when using social media. This advice states, rightly, that if the midwife identifies herself as a part of the profession on a social networking site such as Facebook, she should act responsibly at all times and uphold the reputation of the profession (NMC, 2012a). This is the guidance given by The Code on professional behaviour in any environment, as well as using a social media platform. If this guidance is followed, the midwife's professional registration is not at risk and professionals should be mindful of this. There has long been debate about what the exact meaning of ‘upholding the reputation of your profession at all times’, but if being photographed drunk at a party means that the health professional is not upholding the reputation of the profession at all times, this applies equally to photos available in hard copy as those online. Equally, if a midwife writes a ‘post’ online about a birth she has attended, in such a way that it is identifiable or demonstrates poor practice, this is as unprofessional as discussing it verbally or via text message. The main difference with both these examples is the number of people likely to see such material. They are both equally right or wrong. Education is the key.
There are two situations discussed in this practical guidance, however, which have generated ongoing debate. The health professional is advised not to befriend patients and service users online even after the patient is no longer in their care (NMC, 2012a). This is not specified in The Code (NMC, 2008). Midwifery as a profession encourages close relationships to develop with clients due to length of contact and due to the partnership that develops between two women with similar experiences in many cases and it is not unusual for friendships to develop that will last a lifetime, long past the termination of the professional relationship. It is surely an issue for the individual midwife to define when professional boundaries are likely to be crossed.
The second area of discussion surrounds the statement: ‘Do not discuss work-related issues online, including conversations about patients or complaints about colleagues. Even when anonymised, these are likely to be inappropriate’ (NMC, 2012a). This guidance has never been applied previously to other forms of communication such as journal articles, the classroom or conference presentations. Story telling/discussion around case histories have long been invaluable forms of reflective practice. Midwives work as autonomous individuals and have few opportunities to learn from each other except through reflecting on practice, adhering to The Code by anonymising the service user. This guidance about online discussion of cases is therefore inconsistent with the advice to compare real-life and online communication.
Using social media professionally
The rapid development of the technology underpinning social media allows us to communicate with individuals and families across the world as never before. As of 1 January 2014, 1.3 billion people have Facebook accounts, 48% of whom log in daily (Wagner, 2014). One billion users access Facebook monthly via their mobile devices. Over 500 million tweets are sent every day on Twitter (Holt, 2013) and more than 100 hours of video uploaded to YouTube every minute (Schroeder, 2013).
Referring to the impact of social media in medicine, Ferguson et al (2007: V) suggest that ‘This massive, complex, unplanned, unprecedented and spontaneous medical empowerment of our lay citizens may turn out to be the most important medical transformation of our lifetimes’. It has been reported that 35% of US adults consult Google about their medical symptoms (Painter, 2013) and 95% of women use the internet to access information about pregnancy (O'Higgins et al, 2013). However, health professionals need to educate patients to exercise caution with information available online as some medical information may be inaccurate. Midwives and other health professionals need to understand the possible impact of social media on the understanding of health-related issues in their clients/patients and develop evidence-based online content and support mechanisms. How can midwives achieve this?
Empower and educate women
Facebook groups are available to support women with a range of issues in pregnancy, for example ‘obstetric cholestasis support’ and ‘VBAC support group UK’. These popular groups have been set up by the women themselves to enable the members to discuss the current evidence and hospital policies they may meet when looking at options. Few midwives are members of these groups but when they are, their advice is valued. Information is thus placed in the hands of the women and they come to the maternity services armed with knowledge and pertinent questions and the support of others to question policy and practice. Some midwives and other health professionals are, however, readily accessible on Facebook and other social media platforms with groups or pages set up to support women and their families. These are excellent examples of using social media to provide support and health education messages. Teen Mums 2B Lourdes Hospital is a Facebook page run by the teenage pregnancy midwife in Drogheda, Republic of Ireland. She advertises parentcraft classes for teenagers and offers ‘a place for you to comment and chat and get all the support you need’. @GussieGrips is a physiotherapist who humorously tweets three times a day to remind followers to do their pelvic floor exercises. These two initiatives could very easily be mirrored in a range of projects to support women and their families.
Links to YouTube videos containing parenting skills such as how to give a baby a bath, how to change a nappy, and breastfeeding advice can be included on leaflets provided by the health professional to offer women accessible video support. Information about the issues that concern parents around the process of birth can be provided through social media platforms to ensure informed decision making. A virtual tour of the birthing centre and other maternity facilities would familiarise the family with the facilities available. One excellent international example of the use of social media to educate health care workers and the families they serve is the Global Health Media Project (Global Health Media, 2014). This website contains videos on a wide variety of topics aimed at helping ‘health workers save lives by using advances in information and communication technologies to make what was impossible yesterday, possible today’. These videos focus on newborn care and although the website is primarily aimed at developing countries, their use can be transferred to UK practice. The videos cover a wide range of topics such as the home visit, breast engorgement and umbilical infections.
Network with professionals
Midwifery professional organisations have a presence on social media. Both the NMC and the Royal College of Midwives (RCM) have a Facebook page and Twitter account to encourage communication between the professional organisation and the people they represent. Some members of the NMC and RCM are enthusiastic individual users of these platforms, and play a key role in disseminating information about issues being discussed in the midwifery arena.
Using social media to reflect on practice and discuss current and emerging treatments can be a cost effective way of providing continuing professional development (CPD) for midwives. Regular ‘tweetchats’ such as those provided by @wemidwives give midwives the opportunity to discuss current issues and the transcript is readily available thereafter using platforms such as Storify for those researching the topic or those unable to join the chat ‘live’. Regular webinars such as those delivered monthly, and free of charge, by the Association of Radical Midwives provide midwives and students the opportunity to debate and discuss issues with leading midwives and others involved in childbirth, an opportunity unlikely to be offered in any other environment. Online conferences are similarly of benefit. The annual Virtual International Day of the Midwife conference on 5th May, also freely accessible, allows midwives from all over the world the opportunity to network and share clinical experiences, and models the concept of free online resources for midwives in any context, including resource-poor countries.
Both online and face to face conferences can benefit from the use of social media in their advertising campaigns. Facebook pages, ‘teachmeets’, scheduled tweets, ‘tweetchats’ with speakers are all examples of using social media to entice participants to the conferences. The RCM recently used many of these platforms and developed an app for its annual conference. The sessions give a taster of the information to be presented and enhance the more usual methods of advertising.
Twitter is a useful platform for individuals who are unable to attend a conference as members can follow the discussions using a hashtag search term e.g. #…conf or by following other midwives who are tweeting from the event. These can be collated utilising a platform such as Hootsuite, a tool that allows the management of all of an individual's social media accounts in one place.
Blogs can be used for discussing professional issues, and stimulating debate. Experts in the field of midwifery regularly debate hot topics and share their knowledge with other members of the profession, giving access to experts who would not be accessible in other forums.
Social media also allows viral communication to cross the world ranging from the latest findings of a significant piece of research or government report, to a rallying cry to join a revolution such as the Independent Midwife UK (IMUK) campaign to secure affordable insurance to enable independent midwives to continue working in the light of the implementation of the EU Directive on Cross-Border healthcare (European Union, 2011). This social media campaign led to women and midwives marching to Westminister together to highlight their concerns about this issue. An e-petition supported the Free Agnes Gereb social media campaign. Agnes Gereb is an Hungarian obstetrician and midwife who was placed under house arrest for supporting women giving birth at home. The campaign identified and highlighted the international difficulties midwifery is having in some countries at present.
Supporting student midwives
Student midwives have been quick to use social media since its inception initially with email groups such as studentmidwifeuk, later evolving into forums such as StudentMidwife.net and The Midwifery Sanctuary. These groups and forums have had an extremely useful function providing support from the beginning of the process of considering midwifery as a career, writing personal statements, managing finances etc. while undertaking the midwifery degree and finally searching for a job as a midwife. One of The Midwifery Sanctuary's most useful features is the ‘unfoldings’ forum in which clinical practice situations are anonymised and presented as a ‘what would you do next’ discussion: storytelling at its most useful and an invaluable learning tool for both midwives and students. Such is the fear of disciplinary action, due to the NMC guidance regarding discussing practice, that most members of these forums use pseudonyms.
The opportunities to use social media in educating students have generally, however, been ignored. Universities use Virtual Learning Environments (VLE), social media platforms that provide students access to lecture notes, clinical placement details, provide feedback on assessment and, rarely, to use wikis, Twitter and the VLE forum for classroom-related discussions. There is a wealth of discursive material available on this topic and this paper will not enter this debate. Students have responded by setting up their own social media accounts for peer support, often as closed groups on Facebook. Despite encouragement to use university equivalents to Facebook, take up is extremely poor and thus it may be more useful to join the students where they are, on Facebook. Students can be placed in maternity units many miles from the university and often many miles from each other. This is a time when support is vital and setting up a Facebook group could provide this. ‘UWS Midwifery’ is an example of this; it is a closed group, so members and posts are restricted to University of the West of Scotland (UWS) students and graduates. It has proven to be useful to students, providing answers to questions from each other and local midwives regarding the practicalities of placements—shift times, uniform details, access to specialist midwives and study days, for example. But what is not discussed here or, as far as is visible in other groups, is reflection on clinical experiences. As discussed above, this may be due to the fear of disciplinary action in the light of the NMC guidance on the practical use of social media and the advice given by senior midwives to steer clear of social media professionally.
Other social media platforms such as YouTube and other video sites can be extremely useful for demonstrating processes and procedures. No complex technology is required to upload videos to these platforms. A simple smartphone, tablet or digital camera will record short clips successfully and these are simple to upload to YouTube. For the student midwife, many clinical skills can be demonstrated and be freely available for reference whenever the student requires to update her knowledge. A quick search of YouTube will discover many births uploaded by parents which may enable the student to have a broader sense of the birthing process than she will gain from her own placements, often in only one maternity unit. In addition, universities can use social media to advertise Open Days, to provide interviews with current students via YouTube or a similar video channel and to provide online information about facilities such as the library and practical rooms.
Nurses and midwives can play a key role in developing online resources for patients and health consumers and some forward-looking universities are producing assignments for students around developing information resources online such as websites that provide information for pregnant women.
Conclusion
Social media is having a transformative impact on society and on the way in which we communicate on a daily basis. The emergence of social media is ‘a story about community and collaboration on a scale never seen before…it's about the many wresting power from the few and helping one another for nothing and how that will not only change the world but also change the way the world changes’ (Grossman, 2006).
Social media is here to stay. Therefore midwives must use it in positive and constructive ways to enhance their practice and to provide the best care for women. There is no doubt that there is a risk surrounding confidentiality and consent, and unprofessional behaviour. However, by neglecting the education of student midwives, and midwives, in the safe use of social media, we are missing opportunities to network and share information which far outweigh any risks involved. Midwives need to work towards improving health through utilising social media which has the power to revolutionise the information freely available to all at the click of a button.