Week 7: Electronic health-care technologies within clinical practice settings

This week my nursing informatics class explored the use of electronic health-care technologies in clinical practice settings. The class discussed the use of many different technologies, including electronic health care records, personal health records, telehealth, and HUGO.

TELEHEALTH 

The group facilitating the discussion this week provided the following definition of telehealth: information and computer technology used to support healthcare, services, and expertise over any geographical distance. The group  discussed how one of the most important factors in using telehealth technology is that it allows nurses and other health care providers to give care over large geographical distances; therefore, it allows people in remote or rural areas to receive care at home without having to travel large distances. 

What is telenursing? What is the role nurses in telenursing? 

According to Lorentz (2008) telenursing incorporates all forms of nursing care delivered at a distance through the use of electronic technology. Telecare nursing, a subset of telenursing, is when nurses receive and interpret information obtained from patients through the phone (Lorentz, 2008). Telecare nurses direct and coordinate care to patients, rather than providing hands on nursing care (Lorentz, 2008). Telehomecare nurses are another subset of telenurses; their role is to deliver healthcare services electronically to patients in their own homes. In this mode of care patients are given the necessary home monitoring equipment, and nurses teach the patients and their family how to use the equipment (Lorentz, 2008). Telenurses are responsible to uphold the same standards or practice as other nurses (Schlachta-Fairchild, Elfrink, & Deickman, 2008). However, of College of Nurses of Nova Scotia is the only province in Canada to create nursing guidelines specific to Telehealth. 

HUGO

The class discussion explored the HUGO program , and the benefits and challenges that it presents to the health care system. HUGO stands for healthcare undergoing optimization (Walker, 2013) It incorporates the following four components:

(1)  a computerized provider order entry (CPOE)

(2) an electronic medication administration record (eMAR)

(3)closed looped medication administration (CLMA)

(4) and electronic medication reconciliation (e Med Rec)

According to Walker (2013) HUGO will benefit the health care system by improving access to health care services, decreasing medication errors, improving patient outcomes, improving medication compliance, improving communication between health care proving, and improving antibiotic therapy. Overall, implementing the HUGO system will streamline services making them more efficient. 

The following images show how HUGO will streamline medication services: 

The medication process before HUGO

The medication process with HUGO

ONTARIO TELEMEDICINE NETWORK

Through researching about telehealth in Ontario, I discovered another ehealth technolgoy used in Ontario to provide care to patients: Ontario Telemedicine Network (OTN). OTN is an independent, not for profit organization funded by the government of Ontario.  OTN definies telemedicine as "the provision of health care by means of telecommunications and information technology" (Williams, 2013).  OTN provides a variety of services including teledermatology, telestroke, teletrauma, teleburn, telehomecare, teleophthalmology, and mental health services. From 2012 to 2013 in Ontario more than three hundred thousand patient received care through OTN. In addition, the use of telemedicine saved the health care system sixty million dollars in what would have been allocated to patients having to travel to receive health-care as part of the Nothern Health Travel Grant. 

In their 2012-2013 report OTN discusses their new telemedicine nurse initiative. The organization is working with the Local Health Integration Networks (LHINs) in Ontario to hire and train 191 telemedicine nurses whose role is to provide virtual patient consultations, conduct assessments, train patients and provide knowledge. OTN has also created a Clinical TMC Certification Program as the best practice standard for nurses working in Telemedicine.

This Video explores how one LHIN in the Ottawa region is using Telemedicine by arranging videoconferencing between physicians and patients to provide care. Research indicates that videoconferencing allows physicians to prescribe treatments immediately which results in less anxiety for patients and prevents further health complications (Lorentz, 2008). After watching the video, the aspect that left the biggest impression with me is how videoconferencing supports a client centered approach to care and how it addresses the social determinants of health.

This video is also from the Ontario Telemedicine Network explores how telehomecare works and how it is benefiting patients. It also explores the role of the telemedicine nurse specialist in providing telehomecare services.  

This image shows the teledermatology service 

How does the use of telemedicine impact the outcomes of patients? How does it impact nursing care?

Scholarly research concerning telenursing explores both the benefits and the challenges it poses to providing health care services. According to Lorentz (2008) the main argument to support telenursing is that is it makes health care services easier to access for patients. Telenursing also supports a client centered approach to health care services, because it eliminates patient's travelling costs in order to access health care services (Lorentz, 2005). Research indicates  that telenursing may be especially useful for providing care to people with mobility problems and the elderly. Furthermore research supports that elderly people value telehomecare services; in one study over half of the elderly participants reported that they preferred telehomecare visits using videoconfrencing over face to face care (Lorentz, 2008). In addition, nurses have reported that telenursing is in opportunity to provide more efficient care compared to face to face nursing; in one study nurses reported that 40% of their in home visits did not require hands on care and could be replaced with telenursing (Lorentz, 2008). Another benefit of telenursing is that it allows for more frequent visits to patients and therefore better patient outomes (Lorentz, 2008). For example, in one study the patients of nurses who provided care through telenursing had improved healing rates compared to patients who received face to face nursing care (Lorentz, 2008). In addition to supporting a client centered care approach, allowing patients to save money, and enabling nurses to provide more frequent visits, telenursing has also been proven as an effective means of diagnosing disease(Schlachta-Fairchild, Elfrink, & Deickman, 2008). 

Research indicates that diagnosis through telemedicine is just as effective as face to face diagnosis. For example, a study found that remote diagnosis using elecrocardiogram results as just as reliable as interpretation done in person (Schlachta-Fairchild, Elfrink, & Deickman, 2008). 

However, research indicates that nurses are concerned about how telenursing impacts the therapeutic nurse-client relationship, including the inability of nurses to use therapeutic touch to communicate with patients (Lorentz, 2008). Other concerns with the use of telemedicine are issues with maintaining privacy and confidentiality, the possibility of equipment malfunctioning, and inaccurate diagnoses due to patient or caregiver errors(Schlachta-Fairchild, Elfrink, & Deickman, 2008). There are also concerns that some nurses may view technology as a tool to replace nursing care, rather than simply a means in which to provide care (Schlachta-Fairchild, Elfrink, & Deickman, 2008). 

References

Brown, E., & Marshall, R. (2013). Embarking on the journey for virtual care. Ontario Telemedicine 

     Network. Retrieved from http://otn.ca/sites/default/files/otn-annual-report-2012-13.pdf

Lorentz, M. (2008). Telenursing and home healthcare: The many facets of technology.  Home Healthcare 

     Nurse, 26(4), 237-43. doi: 10.1097/01.NHH.0000316702.22633.30
Ontario Telemedicine Network (Producer). (2011). Telehomecare 1 min video [video]. Available 

     from https://www.youtube.com/watch?v=U_W-AE-91Mw

Ontario Telemedicine Network (Producer). (2013). Telemedicine in the Champlain Region [video].

     Available from https://www.youtube.com/watch?v=ta8nj4fV6BY

Schlachta-Fairchild, L., Elfrink, V., & Deickman A. (2008). Patient Safety and Quality: An Evidence-

     Based Handbook for Nurses. Retrieved  from http://www.ncbi.nlm.nih.gov/books/NBK2687/

Walker, R. (2013, May1-3). Healthcare Undergoing Optimization. [E-Health Summit]. Retrieved from h

     ttp://files.canadianhealthcarenetwork.ca/pdf/CHM/ehealthsummit/2013/eHS_2013_4_Walker.pdf

Telenursing in hospice palliative care: an innovative program in B.C. (Week 7)

Artifact: "Telenursing in hospice palliative care": an innovative program in B.C.

While researching the different ways that electronic health care is used in clinical practice settings, I found an interesting article that discusses an innovative telenursing program for patients in palliative care. In the last months and weeks of life many terminally ill Canadians choose to be at home and are cared for my their family and friends, with possible additional supports from nurses (Roberts, Tayler, MacCormack, & Barwich, 2007). However, for these patients and  their families there are few health care services that are accessible in the evening and through the night. In order to provide better access to services with palliative patients and their families B.C. NurseLine (a teletriage and health information call center), the British Columbia Ministry of Health, and the Fraser Health Hospice Palliative Care Program collaborated to create an innovative after hours telenursing service specific to palliative care (Roberts, Tayler, MacCormack, & Barwich, 2007).
When patients are admitted in the telenursing program they are given a special number to call if they are in need of health care services between 9 p.m. and 8 a.m. When patients or their family call, they are connected to an RN who can provide them with information and support (Roberts, Tayler, MacCormack, & Barwich, 2007). If the callers require more specialized knowledge related to palliative care the RN can contact an on call PRN, who will then contact the caller and provide the necessary support. Furthermore, the PRN can contact an on call physician to seek further advice or new orders.
Feedback from patients who have used the telenursing service suggest that the service is effective in providing support to palliative patients and their families. Data from the programs indicate that the service helps to keep patients at home through the night rather than going to an emergency department;  91% of callers reported that they were able to stay home through the night with the support of the telenurses(Roberts, Tayler, MacCormack, & Barwich, 2007). Other benefits of the program have been identified as improved symptom management and enhanced support of caregivers(Roberts, Tayler, MacCormack, & Barwich, 2007).
The effectiveness of this telenursing program suggest that it would be beneficial to create similar programs in other Canadian provinces.

Reference

Roberts,D., Tayler, C., MacCormack, D., & Barwich, D. (2007). Telenursing in hospice palliative care.

     The Canadian Nurse, 103(5), 24-7. Retrieved from http://www.canadian-nurse.com/

Canadian's attitudes concerning genetic privacy

When reflecting on the issue of genetic discrimination, I decided to further explore how Canadian's feel about genetic privacy. Despite the fact that the data I found is not specific the genetic privacy in the context of health care setting, it reflects the general attitude regarding genetic privacy. 

The 2011 Canadians and privacy survey (presented by the Office of the Privacy Commissioner of Canada) gathered data regarding Canadian's attitudes towards genetic privacy.

The survey indicates that the majority of Canada are concerned about the issue of genetic privacy and how it might impact their insurance and employment (PRIV, 2011). 

When asked their opinion regarding companies who offer genetic testing Canadian's reported the following: 

• 79% - are concerned about the genetic information being used in a disclosed or unauthorized way by the company 
• only 6% - indicated they had no concerns about the information being used in an unauthorized manner
• 78% - are concerned about giving the information to organizations that are not subject to health privacy regulations 
• 50% are concerned they may be required to provide the results to insurance companies 

Images retrieved from: https://www.priv.gc.ca/information/por-rop/2011/por_2011_01_e.asp#toc3d

Reference
Office of the Privacy Commissioner of Canada. (2011). 2011 Canadians and Privacy Survey. Retrieved    
      from https://www.priv.gc.ca/information/por-rop/2011/por_2011_01_e.asp#toc3d

Genetic discrimination and the Huntington's Society of Canada

The video below comes from the Huntington Society of Canada. It explores the consequences of genetic discrimination in regards to having a genetic test performed to see if a person will develop Huntington's disease. Furthermore, the video advocates for measures to protect Canadians from genetic discrimination.  

Reference
Huntington Society of Canada (Producer). (2013). Huntington Society of Canada: Do you really want 

     to know? [ video]. Available from https://www.youtube.com/watch?v=xAO3CLWWJfQ

Week 9: Personalized Health Care and Pharmacogenomics. An exciting innovation in health-care or a dangerous tool?

The focus of this week's discussion in my health informatics class is electronic health technologies in clinical practice settings. The concepts of personalized medicine and pharmogeconomics were discussed. 

I researched the definitions of each concept (personalized medicine, pharmacogentics, and pharmacogenomics), to further enhance my understanding of the concepts after the class discussion. 

Definitions : 

"Personalized medicine refers to the delivery of health care based on the individual uniqueness of the person. It utilizes individual's genetic and genomic information to make medical decisions about their care..." (Chadwell, 2013, pg. 1) 

 Pharmacogenetics is defined as ‘‘the study of inherited differences in drug metabolism and response’’. (Chadwell, 2013, pg. 1) 

 Pharmacogenomics as known as ‘‘the general study of all the many different genes that determine drug behavior" (Chadwell, 2013, pg. 1) 

Throughout the class discussion both the possible benefits and consequences of personalized medicine were discussed. I created a list of benefits and consequences to organize the information . 

  Benefits of Personalized Medicine: 

• improves the ability to diagnose and predict disease (Chadwell, 2013)
• contributes to providing interventions earlier in the course of diseases (Chadwell, 2013)
• may lead to the development of  customized and personalized prescriptions (Issa, 2007)
• improves patient compliance (Issa, 2007)
• reduces or completely eliminates the  costs related to disease management (Issa, 2007) 
• supports a client-centered care (Chadwell, 2013) 

Consequences/ challenges of personalized medicine: 

• genetic discrimination 
• issues in ensuring equitable access to genomic technologies (Issa, 2007) 
• issues in ensuring privacy and confidentiality of genetic information (Issa, 2007) 
• issues related to the use of genetic information by insurance companies and employers (Issa, 2007) 
• psychological impact of knowing genetic information (Issa, 2007) 
• the possibility of social stigmatization for patients based on their genetic information (Issa, 2007) 

Genetic discrimination in Canada 

Through the class discussion,I become interested in the issue of genetic discrimination in Canada and I decided to further explore the topic. 

In Canada, there are some regulations that indirectly inform the issue of genetic discrimination. For example, it is a right under the Canadian Charter of Human Rights and Freedoms that addresses the right to equality and to not be subjected to discrimination (CCGF,2009). However, there are NO legal documents that specifically address and prohibit genetic discrimination (CCGF, 2009). Furthermore, Canadian laws permit insurance companies to have requirements related to providing health information and this information can be used to determine eligibility for insurance and to set premiums ( CCGF, 2009). In addition, insurers can ask clients about their genetic information, family history, and must consent to have their information verified (CCGF, 2009). 

After exploring the laws and regulations around genetic discrimination in Canada, I was left with the following questions: 

 How might genetic discrimination impact people's social determinants of health? How does genetic discrimination ultimately impact people's health?  

In nursing it is important to consider the social determinants of health when assessing clients, and to provide holistic care. Genetic discrimination has the ability to impact a person's social determinants; therefore, it is an important issue for nurses to consider. Genetic discrimination by employers and insurance companies can lead to unemployment and low socio-economic status. In addition, the fear of genetic discrimination from employers and insurance companies may prevent people from participating in genetic testing (CCGF, 2009). Genetic testing benefits individuals by empowering them to be proactive about their health, plan of their future, and make important life decisions (CCGF, 2009); therefore, if people are too afraid to get tested they will not get the benefits. 

In reflection

In the overview for this weeks class we we're asked to reflect on the following questions: 

What are your beliefs about personalized medicine, or, genomic investigations related to your DNA sequencing? Would you want to know if you had a massive predisposition to illness or a specific medical condition? 

Through the information that I have gathered from the class discussion and researching personalized medicine, I feel that the benefits of personalized medicine outweigh the possible consequences. Although, I feel strongly that  a personalized medicine approach should not be integrated into the Canadian health-care system until Canada creates laws that protects its citizens from genetic discrimination. 

References

Chadwell, K. (2013). Clinical practice on the horizon: Personalized medicine. Clinical Nurse Specialist, 

      27(1), 36-43. doi: 10.1097/NUR.0b013e31827770301000-00010

Issa, A. M. (2007). Personalized medicine and the practice of medicine in the 21st century. McGill Journal 

     of   Medicine, 10(1), 53–7. Retrieved from http://www.med.mcgill.ca/mjm/  

N.A. (2009). About genetic discrimination. Retrieved from the Canadian Coalition for Genetic Fairness          website: http://www.ccgf-cceg.ca/en/about-genetic-discrimination

Apomediation tools for health care consumers, and health care professionals

      After the class discussion I wanted to further explore apomediation tools and how they are being used in the health care sector. I have created a prezi to demonstrate and organize my learning: http://prezi.com/hqryxghx7_wf/?utm_campaign=share&utm_medium=copy

References

Cassa, C., Chunara, R., Mandl, K., & Brownstein, J. (2013). Twitter as a sentinel in emergency situation:

     Lessons from the Boston marathon explosions.PLoS Curr. 2013 July 2; 5:      

     ecurrents.dis.ad70cd1c8bc585e9470046cde334ee4b. doi: 10.1371/currents.dis.ad70cd1c8bc585e9470046cde334ee4b

Gawande, A. (2013, April 17). Why Boston's hospital's were ready. The New Yorker. Retrieved

     from http://www.newyorker.com/online/blogs/newsdesk/2013/04/why-bostons-hospitals-were-                    ready.html

Week 6: Consumer Health Informatics and e-health

This week my nursing informatics class discussed consumer health informatics and e-health.
One of the major themes that was discussed throughout the class was the concept of apomediation in the context of health care services. In class the term apomediation was defined as skipping the middleman and allowing patients to go directly to the source of information. I further explored the concept of apomediation in the assigned course article "Medicine 2.0: Social Networking, Collaboration, Participation, Apomediation, and Openness”. 

The article discusses the topic of apomediation as it relates to health care. According to Eysenbach, there are three ways in which health care consumers access information and services: 

1)      Health care providers directly giving information or providing health care services to a patient, or web portals that contain information only from health care experts. In this model the health care provider is viewed as the intermediary (or a middleman) between the patient and the information or service.

2)      In the second model the patient bypasses the middleman, in a process known as disintermediation, in order to access health care information or services. An example of this model is a patient searching for health information on the internet.

3)      The third way in which a patient can access health information is a subset of disintermediation known as apomediation. In the article Eysenback describes apomediation as people or tools which stand by to guide a consumer to high

quality information and services without being a prerequisite to obtain that information or service (Eysenback, 2008).

The article gives the following examples of apomediaries or apomediation tools:

·         Ratings in amazon.com or epinions.com

·         PICS or MedPICS labels (enable machine interpretation of user ratings)

·         Collaborative filtering and recommender systems (such as StumbleUpon.com)

·         second generation internet-based services and tools that let people collaborate on a massive scale and share information online

·         Social networking sites

·         Blogs

·         Wikis

References 
Eysenbach, G. (2008). Medicine 2.0: Social networking, collaboration, participation, 
apomediation, and openness. Journal of Medical Internet Research, 10(3), e22. 

doi:10.2196/jmir.1030 

Week 5: Consumer Health Informatics and eHealth

The topic discussion for this weeks health informatics class was consumer health informatics and ehealth. The class focused on the shift in healthcare known as consumer health informatics and the possible benefits and consequences on patients becoming more involved in their own health care.

When I think of patients becoming more involved in their own health care I think of health literacy. If clients seeking out health information do not have a high degree of health literacy than it could have major consequences on their health.

Visual representation of health literacy

Week 4: Evidence Informed Practice in a Technology Enhanced Workplace

Evidence informed vs. evidence based practice

This week my nursing informatics class discussed the concepts of evidence based and evidence informed nursing practice. Prior to the class, I had no knowledge of these concepts. Through class discussion I began to grasp a basic understanding of the concepts. My concept of evidence based practice developed to include that it is rigid and "black and white". By this I mean that research leads to evidence that clearly and directly informs the nurse of the appropriate intervention.  In addition, I learned that it consists of applying relevant and reliable nursing research to a clinical situation. In comparison, I understand evidence informed practice to be more holistic in that the nurse needs to think critically and consider multiple factors other than relevant research that may relate to a clients' care. Furthermore, I understand that clinical decisions are based not only on nursing research, but factors unique to a given situation including the following: culture, religion and ethics. Through the exploration of nursing literature my understanding of evidence based and evidence informed nursing practice has continued to grow and develop.

In nursing literature, evidence informed practice is defined as a continuous process that considers evidence from nursing research and other sources including clinical expertise, client preferences, available resources, and cultural and religious norms to inform decision making (CNA, 2010). Potter and Perry (2010) state that evidence informed practice "deemphasizes ritual, isolated and unsystematic clinical experience; ungrounded opinion; and tradition as bases for nursing practice" (pg. 86). However, the definition of evidence informed practice is not always the same in nursing literature, and frequently overlaps with the definition of evidence based practice.

In nursing literature evidence informed practice and evidence based practice can have very similar definitions. Melnyk and Fineout-Overholt (2011) define evidence based nursing as continuous approach to clinical decision making that involves the selection of the best available evidence to inform practice, nurses' personal clinical expertise and patients values and preferences. Furthermore, evidence based practice has been described as the integration of research evidence, information about patient preferences, clinical skill level, and the available resources to inform practice (Ciliska et al, 2001).The overlapping theme in the definitions of evidence based practice seem to be that it involves more factors than just research based evidence.  This concept of evidence based practice contradicts the Canadian Nurses Association (CNA) which states that main distinction between evidence based and evidence informed practice is that evidence informed practice considers factors beyond evidence to make clinical decisions and evidence based nursing does not (CNA, 2010). The differences in how evidence informed and evidence based practice are defined in nursing literature make it difficult to understand how the concepts differ. However, I believe this may be due to the developed of the concept of evidence based practice in the nursing profession.

The idea of what constitutes evidence based practice has evolved over time in the nursing literature. Malone et al. (2004) states that evidence used in evidence based practice comes from a variety of sources including research, clinical experience, clients, and the context or environment (Rycroft-Malone, Seers, Titchen, Harvey, Kitson, & McCormack, 2004). It considers the different sources of knowledge that inform practice other than "technical or propositional" knowledge, such as clinical experience and Carper's ways of knowing (Rycroft-Malone, Seers, Titchen, Harvey, Kitson, & McCormack, 2004, pg.84). However, Rycroft-Malone et al. (2004) state that there is an underlying assumption in nursing  that knowledge from clinical experience lacks credibility, and challenges this assumption by suggesting that evidence based practice requires knowledge from clinical experience. An earlier definition of evidence based nursing stated that it nursing practice based on research results or evidence (Beyers, 1999). 

Putting it all together...

In conclusion, the definitions of evidence based and evidence informed nursing are not always clear in the nursing literature. My concept of these terms has developed to include that they are not mutually exclusive, and that is it important to consider the client holistically including both research based evidence and other factors to inform practice.

Evidence Based Practice

This image of  a evidence based model shows that evidence based practice is considered to include factors other than research. 

This image is the John Hopkins Nursing Evidence Based Model

References

Canadian Nurses Association. (2010). Evidence informed decision making and nursing practice. Retrieved from http://www2.cna-aiic.ca/CNA/documents/pdf/publications/PS113_Evidence_informed_2010_e.pdf

Beyers, M. (1999). About evidence-based nursing practice. Nursing Management , 30(6), 56, Retrieved from http://search.proquest.com.proxy1.lib.uwo.ca/docview/231439882/fulltextPDF?accountid=15115

Rycroft-Malone, J., Seers, K., Titchen, A., Harvery, G., Kitson, A., McCormack, B.(2004). What counts evidence in evidence based practice? Journal of Advanced Nursing, 47, 81-90. doi:  10.1111/j.1365-2648.2004.03068.x

Potter, P.A., & Perry, A.G. (2010). Canadian Fundamentals of Nursing. Toronto: Elsevier Canada

Week 3:Ethical Practice and Privacy

This week in my informatics nursing class discussed the concepts of  ethical practice and privacy as they relate to the use of social media. After class I was left with the following question:

1.What are the professional regulations and  obligations of nurses concerning the use of social media?


In this posting I will explore the information nursing literature has gathered related to my question and attempt of develop a greater understanding about the contexts where it is appropriate for nurses to use social media with a client and the obligations I will have to uphold in my future practice.

Questions 1: What are the professional regulations for nurses concerning the use of social media?

     Nurses commonly use social media in the workplace. Results from a 2011 survey determined that 88% of nurses between 18 and 24 and 67% of nurses over 55 use social media (The Standard, 2012). Furthermore, over half of nurses reported that social media is critical or important to their practice (The Standard, 2012). The CNO's standards of practice documents are applied in the context of social media to guide its appropriate use, including the following standards: practice, the therapeutic nurse-client relationship, and ethics (CNO, 2013). Many workplaces also have polices for the use of social media (The Standard, 2012). It is important to ensure the appropriate use of social media, because of the increasing number of nurses being investigated and disciplined by their college for its misuse (ONA, 2011). Nurses need to use their clinical judgment and reflection skills before posting online.

     Prior to posting online nurses should reflect on the standards of practice that apply to the situation (CNO, 2013). Nurses may need to consider the following before deciding to post on social media: who will see the post; if  the post is ethical; how the post reflects on the profession or as an individual professional; if it breaches confidentiality or privacy of clients, colleagues, or the workplace; if it interferes with a therapeutic relationship with a client; and if it portrays client, colleagues or the workplace in a negative manner(CNO, 2013). Situations may arise where the nurse is in danger of damaging the public's trust for the profession of nursing, crossing boundaries with clients, breaching privacy and confidentiality or negatively impacting the therapeutic nurse-client relationship, if he or she is not well informed on the appropriate use of social media (CNO,2013).
   
Nurses are responsible for maintaining public interest and avoiding social media interactions that damage the public's trust and respect for the profession; therefore, posting negative or inappropriate comments about a client, colleagues, or workplace is not appropriate (The Standard, 2012). Nurses have access to sensitive private health information and an obligation to maintain privacy and confidentiality; therefore, posting information that contains clients' personal information is not appropriate (CNO, 2002). The use of social media could also lead to crossing boundaries and damaging the therapeutic nurse client relationship. For example, if a client sends you a friend request on facebook. In this situation the nurse needs to reflect on if he or she still has a therapeutic relationship with the client and consider the reasons why the client is contacting him or her (CNO, 2013). The standards of practice decision tree can also be used to determine if a post is appropriate (CNO, 2006).

In this example I will show how a nurse is not meeting the standards of practice by making inappropriate postings on social media. 

Scenario: A nurse is frustrated with her colleagues and workplace. She decides to tweet about her frustrations on her break and makes negative comments about her colleagues and workplace.
Accountability 
The nurse has a professional obligation to act in a way that promotes respect for the profession (CNO, 2006). By publicly portraying her colleagues and workplace in a negative way the nurse is not promoting respect for the nursing profession. The nurse is also accountable for demonstrating fidelity to her employer and  by publicly criticizing her employer she is not upholding her duty (ONA, 2011).
Leadership
The nurse is not practicing the standard of leadership, because she is not taking action to resolve the conflict with her colleagues and workplace (CNO, 2002)
Relationships 
The nurse is not showing effective conflict-management skills , or promoting a work environment based on trust and respect (CNO, 2002).

Ethical Dilemma Artifact: 

While researching I found an interesting ethical dilemma that relates to client privacy and the use of social media. The nurse wrote to the Nursing Times magazine asking for advice on an ethical dilemma. 

The dilemma: 

The nurse is caring for a client who was cognitively intact, but physically disabled (Chinn, 2012) The client lives in a long term care facility and had no family, but he enjoys connecting with new people on Facebook(Chinn, 2012) He asks nurses to take photos of him and post them on the website, because he is not physically able to do this task himself. The nurses use their personal cell phones to take the photos, because the client does not have one. The nurse is aware that taking photos of clients in not permitted (Chinn, 2012). 

 This situation is a good example of an ethical dilemma a nurse might face due to social media. By agreeing to take the picture of the man and posting them online the nurses are contributing to building the therapeutic nurse-client relationship. Taking the photos are serving the needs of the client; therefore, it is part of client centered care (CNO, 2006). However, by taking photos of the client and posting them online the nurses are technically using social media in an inappropriate manner. To solve this problem the nurse communicate with her manager about the concern, and work together to find a solution so that the patient can continue using Facebook without nurses having to violate confidentiality and privacy (Chinn, 2012). They could then work together and explore if the patient could get a cellphone, or if the organization could create a policy that would allow nurses to take photos of patients with the patient's consent (Chinn, 2012). This dilemma sheds light on the issue of some organizations not having appropriate policies in place to deal with social media concerns. 

The CNO's Social Media: Reflect Before you Post video 

https://www.youtube.com/watch?feature=player_embedded&v=VvTpnckfFyk#t=825

References

Chinn, T. (2012, June). Ethical problems. Nursing Times, 43 (6), 12-13. doi: 10.1097/01.NURSE.0000429807.41730.65

College of Nurses of Ontario. (2002). Professional Standards. Retrieved from http://www.cno.org/Global/docs/prac/41006_ProfStds.pdf

College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Retrieved from http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf

College of Nurses of Ontario (Producer). (2013). Social Media: Reflect before you post [ webcast]. Available from http://www.cno.org/en/learn-about-standards-guidelines

Ontario Nurses' Association. (2011). Inappropriate use of social media and internet use at work and home. Retrieved from http://www.ona.org/documents/File/professionalpractice/ONA_TipSheetInappropriateUseSocialMedia_20120206.pdf

The Standard. (2012). Survey says: nurses weigh in on social media and professionalism. The Standard, 37(2), 14-15. Retrieved from http://www.cno.org/Global/4-LearnAboutStandardsAndGuidelines/pubs/mag/TSMVol37No2.pdf

Ethical Practice: "Naughty nurses" on Instagram

  "Naughty nurses told to behave after posting saucy selfies on social media"

I discovered an interesting article while researching nursing students’ presence on social media that explores the controversial actions of young nurses in Australia on the website Instagram. The nurses work at the NSW hospital in Australia and posted photographs of themselves in the workplace and “selfies” while at work. They now face the possibility of termination by hospital (Silmalis, 2013).One photograph in particular shows an extreme lack of professional judgment and concern for the standards of the nursing profession on the part of the nurse. The picture consists of the nurse with a male client who seems to be under anaesthesia, and is tagged by the nurse on Instagram as “sex change”, “highasakite” and “nomorewilly” (Silmalis, 2013). The nurse clearly violated the client’s privacy and confidentiality by taking a photo of him and sharing it on social media without his consent (CNO, 2006). The nurse’s inappropriate actions reflect extremely poorly on the profession of nursing; therefore, the nurse also did not live up to the standard of accountability. In addition, the nurse’s actions did not comply with the standard of the therapeutic nurse-client relationship in regards to the aspects of maintaining trust, showing respect, and providing client-centered care (CNO, 2006).  

Some of the photographs posted on Instagram by the nurses from NSW hospital

Nurse posting "I pull all the bitches from work" with this photo in Instagram

References

Harris, S. (2013, October). Nurses aren't too naughty. The Telegraph. Retrieved from http://www.dailytelegraph.com.au/

Week 2: Ethical Practice.

Social Media and Ethics: the Doyle Byrne Scandal 

Doyle Byrnes posing with a human placenta

In week two of my nursing informatics course the class focused on ethical practice. The class discussed a controversial news-story about an American nursing student named Doyle Byrnes who took a picture of a placenta during a clinical placement and posted the picture on Facebook. The nursing student was expelled for her behavior, but went on to successfully sue her school for the right to reapply for the nursing program. An important factor in her case was that Doyle had informed her clinical instructor she was taking the photo and the instructor did not explain that it was inappropriate.  My class discussed how the use of social media by nurses and nursing students raises complicated ethical questions, and uncertainty concerning its appropriate use.  In this posting I will discuss how Doyle's actions were inappropriate and how they did not live up to the standards of the nursing profession.  

It was inappropriate for Doyle to both take the picture and post it on a social media website, because she did not live up to the professional standards of practice set by the College of Nurses of Ontario (CNO). The client was not identifiable by the photo of the placenta, so privacy and confidentiality were upheld. However, Doyle's actions still crossed ethical and professional boundaries. The CNO’s standard of accountability states that nurses are responsible for acting in a ways that “promote respect for the profession” (CNO, pg.4, 2006). Yet, Doyle’s actions reflect poorly on the profession in terms of nurses’ professionalism and trustworthiness. Furthermore, her actions did not live up to the standards set by the CNO for the therapeutic nurse-client relationship. An important aspect of the therapeutic nurse-client relationship is trust (CNO, 2006). Doyle's unprofessional actions negatively impacted the general public’s perception of nursing as a trustworthy profession. Through her actions Doyle did not live up to the standard of respect in the therapeutic nurse-client relationship (CNO, 2006). She did not have permission from the client to take a picture with her placenta; therefore, she showed the client a lack of respect by not allowing her to choose if she was okay with her placenta being photographed. Furthermore, Doyle did not show the client empathy. Her actions show that she did not consider how it might make a person feel if a health professional took pictures with his or her body part, and shared them social media. Overall Doyle showed a lack of judgment and consideration to the standards of nursing practice. 

Ethical Reasoning and Online Social Media

In continuation with the concept of ethical practice, my class was assigned to read an article called "Ethical Reasoning and Online Social Media". The article discusses a study where undergraduate nursing students were  assessed on their awareness to posting sensitive clinical information on social media, and the implications that the student's lack of awareness might have on the profession of nursing (Englund, Chappy, Jambunathan, Gohdes, 2012). The results of the study indicate that undergraduate nursing students are not aware of their legal and ethical role of maintaining privacy and confidentiality when using social media ( (Englund, Chappy, Jambunathan, Gohdes, 2012). After reflecting on the article, I found that I do not fully understand what is appropriate to post about a clinical placement or work experience online and what is not. Prior to reading the article I felt that it is inappropriate to write a social media post that contains any identifying information about a client or workplace; however, my understanding of what is identifying information developed with gaining new knowledge for the article. For example,I did not realize that it is inappropriate to identify the social group to which you are providing care. Furthermore, prior to exploring the ethical and legal polices related to social media and nursing I felt that it was inappropriate to post a negative comment about the workplace or a patient, but I felt that it was more appropriate if the comment was positive. My feelings were consistent with the findings of the study which found that less experienced nursing students were confused by the appropriateness of posting a comment if it was positive or complimentary"(Englund, Chappy, Jambunathan, Gohdes,pg 246, 2012). In addition, after reading the article I have a greater understanding of the importance of teaching nursing students about the appropriate uses of social media. Though reflecting on my own understanding of ethics related to social media and nursing, I have developed a greater awareness to what I post on social media related to my nursing experiences. 

References 

Englund, H., Chappy, S., Jambunathan, J., & Gohdes, E. (2012). Ethical reasoning and online 

social media. Nurse Educator, 37(6), 242-247. doi:10.1097/NNE.0b013e31826f2c04 

Week 1: What are Health and Nursing Informatics?