Author: Chilvers, Jacqueline
Date published: April 1, 2011
The Healthy Child programme (DH, 2009a) emphasises the importance of an open invitation to request a face-to-face consultation with the school nurse and of young people assuming greater independence for their own health. It also draws attention to the importance of local authorities and health providers working together to ensure easy access to sexual health services, in addition to the provision of support for mental health, weight difficulties, drug and alcohol misuse and smoking cessation.
The use of social networking has been identified as a significant opportunity to reach individuals with health communication and social marketing messages, even in disadvantaged areas (Uhrig et al, 2010; Khan et al, 2009). Around 70% of teenagers use social networking sites (Lenhart et al, 2010), which perhaps reflects the long understood basic human desire to belong to a group and feel connected to others (Maslow, 1943). Thus, there appears to be a significant opportunity to reach young people via this method. The school nurse's response was to implement a 'Facebook' page aimed at local secondary school students, with the aim of increasing access to appointments, give health information and signpost to other services where needed, all via a platform young people are already engaged with. This improved access to services (Facebook can be easily accessed via mobile phones in addition to computers and iPods) and contributed to the required 'You're Welcome1 criteria, used to demonstrate that services are young people friendly (DH, 2007a).
The implementation team included school nurses, public health and service managers, information technology (IT) department, communications department and IT governance (some of whom but not all had experience of social networking or Facebook). School staff were consulted and kept up to date with proceedings, which was important due to the time consuming nature of thorough planning. Procedures that reflect the identification and prevention of risk were approved via IT and clinical governance groups. A pilot Facebook page is due to go live shortly, with audit and evaluation planned to take place after two terms, to include views of both site users and non users in addition to statistics regarding the use of the site. If successful, the Facebook page will eventually be expanded to include a larger population of students, supported by school nurses in other parts of the county.
It is worth noting that the leadership style and change management approach were key factors in the early stages of the project, along with young people's involvement and a planned evaluation. However, there is not scope to explore these factors within this paper, which focuses on the identification of risk, ethical and sustainability issues, and gives practical examples of how these issues can be overcome while meeting governance requirements.
The National Patient Safety Agency (NPSA, 2007) uses a 'qualitative' risk assessment process, which implies that there is a good deal of subjectivity involved in risk assessment. Issues perceived to be 'unlikely' (and therefore indicating a lower risk rating) by one professional may be perceived to be less unlikely by others, such as the likelihood of receiving abusive messages.
Green (2009) advises that is important to avoid relying on subjective measures. For example a value judgement, or focusing on single events such as negative Facebook media attention, does not equate to a risk (Wardrop, 2009). Communicating with the school management team, youth service, young people, primary care trust managers and colleagues about potential risks and how these could be reduced ensured that a balance of views from stakeholders could be considered (DH, 2007b).
Students sharing too much or the wrong information on social networking sites is a concern. However, social networking is about information sharing, so what are the implications for implementation?
The NMC (2008a) reminds nurses that any information posted on the internet is in the public domain, that nurses must uphold the respect for the profession at all times and respect people's confidentiality. The RCN (2009) emphasises the fact that message boards (ie a Facebook wall) are subject to the same laws as print. Posting only health information linked to reputable sources agreed with governance teams and senior colleagues ensures rigour for the school nurse, so any potential problem is more likely to lie with information posted by users of the site.
There is an argument for open participation of users rather than expert control when social networking is used as a health promotion platform (Uhrig et al, 2010; Khan et al, 2009). It has been asked whether the spontaneity of social networking should be utilised, or a watchful and precautionary perspective maintained (Barnes and Barnes, 2009). Not allowing posting by users reduces the risk of corporate damage or misinformation being posted on the wall - an important aspect of risk management is to minimise risk for the organisation as well as the clients (Ryan and Morgan, 2004).
Although there is no specific guidance for using social networking as a health promotion tool, the aforementioned professional and policy guidelines, research and opinion from the information management field led to a decision that the Facebook page would be configured so that young people cannot post comments or pictures on the wall. Instead they will be able to read updates posted by the school nurse, see links to other organisations using Facebook such as the local youth service, and email the school nurse with any problems or worries. In this way both confidentiality and corporate image can be maintained. Young people are also reminded about email security on the information section of the Facebook page.
Another area of risk is that of abuse or issues concerning a young person's welfare being disclosed via the messaging system. Everyone who works with children and young people should be able to recognise and act upon evidence that a child's health or development is being impaired, especially when they are suffering or likely to suffer significant harm (HM Government, 2010). Consequently, the NMC requires all school nurses to be competent in this area (NMC, 2004).
ChildLine offers email messaging as a method of contact for children and young people, and their procedures were helpful in minimising risk for the Facebook page (NSPCC, 2008). These are clear that if any information is received where there is risk of significant harm, then referral to an external agency is required. These procedures also recognise that communication may be anonymous, and that such cases may need referral to an external agency. Although Facebook has a real name culture and it is a violation of terms and conditions (Facebook, 2010a) to create a 'fake' or second profile, there is no guarantee individuals abide by this.
As with any safeguarding procedure, in cases of concern the school nurse would need to consult with the named nurse for safeguarding children and line manager, who would then support referral to social services or police, even if the identity of the young person needs further investigation. In addition, the Facebook page will always carry information about alternative sources of help and support for vulnerable young people who may need urgent support.
Abusive or inappropriate content
Some staff perceived a risk of receiving abusive or inappropriate content via the messaging system. After comparing NSPCC (2008) procedures, the decision was made that a standard email response would be used in the event of such an occurrence for the school nurse. This can be reinforced by information provided on the Facebook information page.
The implementation process revealed a potential threat to privacy. Facebook terms and conditions state that users may only create one profile - that is, a person cannot have a work and a personal profile. Any Facebook page would have to be created by a professional who may also use Facebook outside of work. Facebook recommends the use of a cornmunity page for teachers and others who wish to engage with students while maintaining the privacy and anonymity of their personal life (Facebook, 2010b). There is currently no messaging system attached to a community page, so an email address to a school nursing email account would have to be published on the site. This would have the benefit of not only protecting privacy and home-work boundaries, but would reinforce that the student is engaging with the school nursing service, rather than one particular school nurse, creating a confidential, safe service that reduces the risk of dependency on an individual worker (NSPCC, 2008). The email address, once known to the student, would also enable access from a platform other than Facebook, for example a school or personal email address, creating even wider access.
Risk reduction always requires a robust system of record-keeping. There may be more than one nurse accessing the email address, and clarity is required regarding which emails have been responded to and what the response was. Dale and Woods (2000) emphasise that inadequate communication that leads to misunderstanding is one of the highest risk factors in any organisation. Robust record-keeping is therefore essential, highlighting the need for the nurses to adhere to agreed procedures.
Currently only 13% of enterprises use a records management plan for social networking sites (Barnes and Barnes, 2009). However for the specialist community public health nurse (SCPHN), the principles of good record-keeping apply to all types of communication, including email (NMC, 2009). A simple query can be recorded on an audit form and the email and reply saved to a specific location on a secure server. This will help with documentary evidence and audit.
Where the contact is more complex, the need to keep records must he explained to the young person, while explaining what confidentiality means for them and when information might have to be shared. This, along with data protection information is posted on the Facebook information page.
Non-focai young people
Use of the Facebook page by young people who are not living in the area or attending local schools may create a conflict between workload, duty and rights. The school nurse has the duty to promote the health and wellbeing not only of their clients but of the wider community (NMC, 2008b).
Considering this alongside the ethical principles outlined by Beauchamp and Childress (2001) resulted in procedures that include clarity on the Facebook page as to what, where and who the service is aimed. Users from other areas are redirected to their local services, following safeguarding guidelines if needed. It will be necessary to audit known instances, in order to ascertain whether this is a tangible issue and if measures are effective.
The SCPHN has a duty to ensure that a young person is competent to consent to care (NMC, 2008c) and this applies to contact by email. If intervention is required beyond initial signposting or information giving, the young person must be competent to give consent and understand the implications of any necessary information sharing.
To enable the user to understand consent and confidentiality, relevant information can be posted on the website then discussed and reinforced by the SCPHN when an episode of care is opened.
Advertising on Facebook cannot be controlled by the page administrator, and adverts cannot be seen to be endorsed by the primary care trust. This was easily managed by the use of a disclaimer on the Facebook information page.
The sustainability of the project is two-fold. Financial and staffing implications are largely unknown before audit and evaluation. Time is allocated for checking and responding to emails. If there is a large increase in interventions, sustainability will depend on the ability to manage the caseload, ensuring maximum efficiency of existing resources, and if necessary to work with senior colleagues to present a business case for resources.
Secondly, there is the question of what would happen if the school nurse managing the Facebook page leaves the service. A second Facebook user is already required to administer the Facebook page in case Of emergency. The NHS email address does not require Facebook access, which limits the number of Facebook users needed. It is considered likely that within the service someone would be willing to administer the page and upload information (which could be prepared by another school nurse within the trust).
In the unlikely event of this not being the case, space could be used on a school or primary care trust website to give health information and promote the email messaging service. Therefore, the establishment and maintenance of partnerships within the school nursing teams, primary care trust and school will be necessary in order to effectively respond to staffing changes that could otherwise compromise the sustainability of the project (Altman 2009).
This paper has aimed to inform other professionals who wish to use social networking to engage with clients. It has highlighted areas that must be considered to enable robust processes when using social networking to engage with young people.
The idea of using social networking as a means of engaging young people is still a new one for school nurses, and a high level of risk is perceived. However, it is possible to recognise and manage these risks, ethical and sustainability issues in order to safely and successfully implement this intervention, which aims to make access to services easier for young people.
The author thanks health visitor Julia Cole for the original concept and Wiltshire Primary Care Trust.
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Jacqueline Chělvers PGDipPH, RGN, SCPHN
School health nurse, Wiltshire Primary Care Trust