Caught in the web

The internet is having a profound impact on how healthcare is delivered, managed and discussed – and there’s no turning back. We explore some implications for the public and the professions

Digital technologies have changed our lives. We feel the impact of the 'digital decade' in the way we use the media, entertain ourselves and connect with our friends and families. Being online has become an unremarkable, mainstream element of many people's daily experience. Whether you check Facebook on your smartphone as you wake up, or you are a Twitter refusenik confused by David Dimbleby mentioning hashtags during the BBC television programme Question Time, we all find ourselves caught up in the world wide web.

Being online is transforming our social lives - and changing the world. The Arab Spring of 2011 highlighted the power of blogs and social networks to mobilise real-world communities and transform societies, with digitally connected citizens playing a central role from Libya to Bahrain. Closer to home, Twitter and BlackBerry Messenger might have played some part in fanning the flames of last summer's riots in England, but the Big Society response that followed could only have been facilitated through a social network. Organising themselves around the Twitter hashtag #riotcleanup, hundreds of people armed with brooms took to the streets of London.

The online world can seem bewilderingly complex, especially for nurses, midwives and patients who are reluctant to be swept along by the digital revolution. Though websites and services may be daunting for a first-time visitor, scratch the surface and you will find the same information, news and gossip that people share with each other in everyday conversation. Beyond the jargon (see our glossary), so much is familiar.

New technology creates opportunities for patients and service users to access healthcare information online, and to connect with others with similar conditions, but this is close to the familiar world of glossy leaflets and support groups. In the arena of health promotion, social marketing and public health practitioners have harnessed online tools to help transform health outcomes, but the principles, messages and methods remain much the same. Furthermore, as we explore later, although social networking sites like Facebook present new challenges for nurses, midwives and students, as well as the institutions where they work and learn, those challenges centre on a perennial concern - appropriate professional and personal behaviour.

Empowerment and reliability

Beyond the challenges for people trying to understand and use these technologies, the world wide web also presents new opportunities to empower people to improve and maintain their health - by placing the tools to discover and share information directly in their hands. Empowerment may be a relatively straightforward idea in the context of online behaviours, but it is considerably more complex in the world of healthcare. It can underpin both the role of professionals in guiding patients' choices, and the concept of patients as consumers who make decisions independently of professional advice. It does, however, provide a useful prism through which to view the development of a wide range of technologies and their impact on patients (Lemire 2010).

Patients and service users are becoming more empowered as they use the tools of the world wide web to learn and apply expert knowledge, and play a more active role in the prevention, treatment and monitoring of their own illnesses and conditions. Empowerment has a role to play collectively too, as groups of patients and carers participate in solidarity networks and advocacy groups centred on specific conditions and experiences.

Ready access to health information online can give empowered patients access to a range of materials that may help them manage their own conditions. If access to a real-world healthcare professional is needed, patients may find it useful to 'triage their conditions with the easiest or most appropriate information source first ... the convenience of accessing online self-care information rather than visiting a health professional is oft en cited as a motivation for using the internet' (Eysenbach 2008). This can speed up diagnosis, and lead to more informed discussions between patients and professionals.

It can also lead patients to develop a firm self-diagnosis that may make it harder to explore the problem when they do eventually meet a health professional. Yet dealing with patients who are attached to inaccurate but seemingly credible information that supports their view of the world is not a new phenomenon. More positively, the world wide web opens up many possibilities for patients who want deeper knowledge of their health problems, and find information that leads to more sophisticated questions.

Credible information

Conversations about the credibility of online information are particularly important with patients whose approach to searching the web can be characterised, perhaps unfairly, as diagnosing with Google and treating with Wikipedia. Avoiding low quality and potentially harmful healthcare information online in itself represents a challenge. Initiatives like the Information Standard, designed as an accreditation scheme for online health information and supported by the Department of Health (England), may help address this but their reach will always be limited to mainstream websites willing to enter a certification process.

Information is easily distorted as it is replicated across the web, and both patients and professionals need help to find, evaluate and use high quality peer-reviewed information controlled by experts. What is most important is the credibility of the sources cited by a particular piece of health information, not how frequently it appears in online searches.

Communities and crowds

The internet, as well as being a source of health-related information, also provides mutual support opportunities for patients and service users online. Sometimes these online communities are managed by organisations that provide support in other ways, such as Breast Cancer Care's online community of 17,000 members. Others emerge spontaneously and organically in online spaces that were not designed for the purpose. There is room for healthcare professionals to engage here too. The Terrence Higgins Trust, for example, has an online outreach programme, with sexual health advisers available in chat rooms.

How can we engage with discussions about health in online spaces that deliberately exclude healthcare professionals? Take the continuing controversy around 'pro-ana' websites, which have been criticised for promoting anorexia nervosa among young people. Such sites do express a form of empowerment, but they are extremely worrying because of the potential harm to people who follow their advice. This has led to calls to have them classified as harmful (Royal College of Psychiatrists 2009), and blocked automatically by internet service providers.

Pro-ana websites are of course an extreme example. Many self-organising online communities provide valuable and health-enhancing spaces for those affected by eating disorders. Professionals need to tread carefully, to understand when to step in and when to step back while patients support each other.

Sharing experiences online

Patients and service users are not going online just for information and support. As more people use Facebook, Twitter and other social networks, more are sharing their thoughts and experiences in real time with their friends and the wider world. Talking online about experiences in healthcare environments is becoming more common, though there are competing views about whether the open, public nature of social networking sites increases or diminishes the likelihood of someone disclosing personal information (Bateman et al 2010).

This sharing can include good news, from celebrity mums using Twitter to announce their pregnancies and praise their midwives, to the hundreds of patients who shared their personal experiences of high quality NHS care in 2009, using the hashtag #welovethenhs. Patients also talk about poor experiences, like journalist Mark Sparrow. His experience of hospital food during a long in-patient stay was so poor that he photographed and blogged about every meal. This eventually led to a television documentary (Channel 4 2011).

Sharing personal information online may be a particular problem if people talk not only about their own experiences but also those of others. Just 23 breaches of patient confidentiality by NHS staff [PDF] were found on social networking sites between 2008 and 2011, (Big Brother Watch 2011), but the more widespread breaches of confidentiality by patients usually go unchallenged and unreported. While acknowledging the importance of empowering all service users, open discussions about responsibility and respect may be needed to deal with these situations.

Useful channels for those who wish to share their experiences can be provided by initiatives like Patient Opinion. This online service encourages open sharing of positive and negative stories, with opportunities for healthcare providers to respond. Such channels can be a force for good by bringing problems and solutions into the open, and providing an impetus for change.

Whether you yourself go online or not, you cannot ignore the impact of the world wide web. People in the care of nurses and midwives are increasingly going online to find healthcare information, create communities and share their experiences. It would be foolish to make predictions about the future of healthcare online, but the desire of many patients and service users to empower themselves and take control of their own health and wellbeing is not going away.

In a world transformed by digital technology, nurses and midwives can play a vital role in using the rich resources of the internet to support the health and wellbeing of people and communities, in the real world and online.

References

• Bateman, P J, Pike, J C and Butler, B S (2010). To disclose or not: publicness in social networking sites. Information Technology & People, 24(1), pp 78-100.
• Big Brother Watch (2011) NHS Breaches of Data Protection Law: How patient confidentiality was compromised five times every week. [pdf]
• The Truth about Hospital Food (2011). [Television programme] Channel 4, 21 February 2011, 20:00.
• Custers, K, and Van den Bulck, J (2009). Viewership of pro-anorexia websites in seventh, ninth and eleventh graders. European Eating Disorders Review, 17(3), pp 214-219.
• Eysenbach, G (2008). Credibility of Health Information and Digital Media: New Perspectives and Implications for Youth. In: Metzger, M J and Flanigan, A J, ed (2008), Digital Media, Youth, and Credibility. Cambridge, MA: The MIT Press, 2008. 123-154.
• Lemire, M (2010). What can be expected of information and communication technologies in terms of patient empowerment in health? Journal of Health Organization and Management, 24(2), pp 167-181.
• Nursing and Midwifery Council (2008). The code: Standards of conduct, performance and ethics for nurses and midwives.
• Nursing and Midwifery Council (2011). Social networking sites.
• Ofcom (2011). Communications Market Report: UK.
• Office for National Statistics (2011). Internet Access - Households and Individuals, 2011.
• Royal College of Psychiatrists (2009). Psychiatrists urge action to tackle 'pro-ana' websites danger.
• Wolters Kluwer Health (2011). Point-of-Care Survey.

1. Google recognises misspellings of my name, and asked me "Did you mean: Andy Jaeger"
2. Most of the misspelled links are actually to me or my stuff
3. I've been quoted in a Wikipedia article about a character on Holby City! Who knew?

It's a good quote too, from back in 2007:

"Nurses who become prostitutes to pay the bills, nurses who kill their husbands, nurses who abuse the system to get their own way - Holby City has always been a hotbed of slanderous storylines. Good people doing bad things makes excellent entertainment... The bald fact is that real life nurses doing their jobs well just aren't that entertaining."

The whole Wikipedia article is here.

NHS Facebook misuse should be resolved at local level

The author of recent guidance on using social media for nurses and midwives says NHS managers should be able to actively respond to issues around how their staff use social media.

Andy Jaegar, assistant director of public and professional communications at the Nursing and Midwifery Council (NMC) and author of recent guidance on social media, says that NHS managers must be better equipped to handle issues around social media.

The regulator has seen an increase in the number of enquiries from nurses and midwives about social media and referrals that directly relate to social networking, but despite this there are still managers who are "social media refuseniks".

"One of things that we say in our advice is that if a manager has responsibility for investing in a complaint about the use of a social networking site, that they should join the social networking site so that they understand the mechanics of how it works. People need to familiarise themselves with this kind of thing," he says.

"I think actually what it needs is a robust response at a local level. In our advice much of what we've done is interpret the standards that already exist around conduct, performance and ethics. We're just helping people to understand what it is that is going on and then act appropriately."

But he says: "that really is better done not with a set of national guidelines from the Department of Health, but with local managers taking responsibility and understanding the issue and dealing with it for themselves."

Last month a snapshot survey of some of England's biggest trusts by the Guardian's healthcare network showed that 72 separate actions were carried out by 16 trusts against staff who inappropriately used social media between 2008-09 and October 2011, suggesting social networking sites are presenting some challenges to the health service.

Jaegar say one of the things that prompted the guidance over the summer were questions from employers about issues of confidentiality and when it was appropriate or not to be friends with a patient on Facebook. This led to guidance being created largely based on the NMC's code of conduct for nurses and midwives.

"We heard from students, nurses and midwives about the inconsistencies in the way that their managers were dealing with problems that they were raising about colleagues or other students' use of social networking sites," Jaeger says. "So some of what we've included in our advice is around the managers who are having to deal with these issues. It's actually for them to have some understanding of social networking sites and how they work, but also to take the issues that are raised with them as seriously as if they had happened in a real world scenario."

The British Medical Association (BMA) also issued guidance around the same time as the NMC as it said it felt that with more people using social media, advice and guidelines were lacking.

The NMC's guidance has proved a success among healthcare professionals, and the guidance has received 50,000 page views since it was published in July.

From his own experience, Jaegar explains that while there are some managers who use Facebook and Twitter, there are some that are "social media refuseniks". This becomes an issue when these managers fail to understand the ethics around social media, which makes it hard for them to tackle problems that arise as they might not see why something may be inappropriate.

Jaegar says: "When I've given talks on this I've used the example of somebody taking photographs of their colleagues, changing them and putting rude captions on them and sharing them online.

"If you view that as seriously as if somebody had done that and pinned it on a staff noticeboard, it gives you as a manager a better steer about how important it is that you deal with those kinds of things robustly and not just think because it happened on a social networking site like Facebook that it's not important, because it is."

Jaeger says he believes that staff misuse of social media is largely unintentional, but there are cases that the NMC deals with which are "absolutely deliberate" – which is perhaps not surprising given that the regulator deals with referrals relating to nurses and midwives that may not be fit to practice. Such instances include pursuit of relationships with patients and bullying and harassment of colleagues.

Looking to the future, Jaegar says that the NMC is currently helping the British Psychological Society to produce its own set of social media guidelines for psychologists. He says the NMC is also interested in encouraging healthcare professionals to use social networking sites to positively engage with patients and share good health stories. He adds that it would be disappointing if some health professionals stayed away from sites like Facebook just because they were scared of misusing it.

"We're starting to think about, organisationally, the kind support we can give to nurses and midwives who are positively using social media as a way of talking about health," he says. "There are potentially so many positive benefits. It's an area we're looking at, and we'll be publishing something in the new year on the subject."

This interview, by Paul Prentice, originally appeared on the Guardian Voluntary Sector network.

Does 'big society' spell the end of charity as we know it?

When is a charity not a charity? We are seeing the end of the clear dividing line between what government does and what the voluntary sector does. The government at all levels has made it clear that it is uninterested in directly providing public services, leaving it to charities, social enterprises and ethical companies to battle it out. The Victorian notion of a charity – giving money, goods or time to others – is becoming unfamiliar to the British public in the age of the big society. Are we, therefore, seeing the end of charities as we've known them?

"The public connect charities with poverty and the needy" says Rosie Chapman, who has spent many years formulating what charities should be. "The reality is much wider." Until recently, Chapman was director of policy and effectiveness at the Charity Commission, and despite clearly being an advocate of charities, she holds "quite an old-fashioned view" of the state's role in society. Charities are increasingly threatened as independence decreases, and government-funded dependency increases.

"There's a huge scope for what a charity can do, provided you show there's a public benefit which outweighs private gain. Clearing the rubbish? You could argue that there's an environmental and health aspect to it," says Chapman. "And it doesn't matter if there's a monopoly. Look at Royal National Lifeboat Institute, for example".

A good example of a charity taking advantage of opportunities in this new world of charitable activity is Mosaic Clubhouse, which focuses on recovery for people from mental illness. The Clubhouse "movement" started in New York in the 1950s, and was designed to prevent stigmatisation. Run by and for the benefit of its members, who come and go as they please, Mosaic is principally funded by Lambeth council and other public sector bodies including the NHS.

"Clubhouse is the perfect big society model in lots of ways," says Andy Jaeger, a trustee for the charity. "It's about people taking a stake in their own lives."

According to Jaeger, there is much that the third sector can do in this instance that could never be matched by centrally managed programmes of care. Central government is focused on short-term intervention but Clubhouse membership is always open to those who need it, meaning that a community has developed over the years which can provide longer, more sustained support.

"Lambeth recognises there is a need for a recovery-focused model," says Jaeger. "It has one of the highest rates of mental ill-health for anywhere in the UK." The Clubhouse is crucial in providing a stable, yet innovative service. The charity is welcoming an increase in its funding, somewhat against the trend. "But there's an increased expectation of what we do as a result," says Jaeger.

The charity will move to new premises, from its pleasant Georgian building in Balham to a site in nearby Brixton. An "infohub" service will be provided, catering not just for people with mental ill-health, but potentially anyone in the wider community. There will be a continuation of the activities its community engages in, such as cooking or gardening, but the new centre will also provide psychological therapies in the same building, which explicitly do not fit the ethos of the Clubhouse movement that exists all over the world.

"It's challenging to the Clubhouse model, which makes decisions as a community," says Jaeger. "And there are tensions as a result. We're being asked to do more, doing it better and adding value. But we are not free." Staff still need paying, and rent and bills have to be paid. Jaeger accepts that the Clubhouse is not the kind of charity that necessarily attracts big public donations.

For small charities like Mosaic Clubhouse, negotiating with local authorities and other funders can provide a challenge to their independence as service providers. "We are having to beg and borrow financial and legal services," says Jaeger. It's the sort of resource that multi-national private sector players have much readier access to.

There is no doubt that charities such as Mosaic Clubhouse are doing much-valued work. But is the goodwill of charities maybe valued a little too much by government, to the extent that it ends up being taken for granted? Chapman thinks it might be.

"Charities should have the independence to say no," says Chapman. "Freedom over the board and freedom by the board must count for a lot. But the way levers of power are exercised in charities means that influential people get to become trustees. On the face of it, you could see a charity seeing almost anything. But charities don't have to pay the cost of democracy – and it's cheaper if a local authority hasn't got to pay into a local government pension scheme."

Fundamentally, people in the third sector appear to be optimistic that the big society agenda will work, partly because they know it already exists. But they remain cautious because they know the funding doesn't. There are new models of delivering services, new types of organisations and a charitable sector that is ever more flexible in what it delivers. The dilemmas faced by organisations such as Mosaic – whether an organisation should rescind its independence, coupled with strict conditions of funding – could ultimately undermine the enthusiasm of today's social entrepreneurs; the old charity model doesn't necessarily fit with the new environment.

Facing the music

Healthcare regulation faces a cacophony of criticism. How should it change and what part should the public and professionals play?

‘When people’s lives and wellbeing are at stake, the public doesn’t want to hear about light touch regulation,’ according to Cynthia Bower, Chief Executive of the Care Quality Commission (CQC), the health and social care systems regulator for England (Santry 2011). She was setting out her plans in response to damning criticism, but also adding her voice to a broader debate about regulation and its purpose. Amid a crescendo of concerns about poor care, from Mid Staffordshire to the Vale of Levento Winterbourne View, healthcare regulation is in the spotlight.

There are different types of healthcare regulation and a plethora of regulators. Yet professionals have dominated regulation for much of its 500-year history. Professional self-regulation developed to recognise specialist skills and ensure that only those meeting the standards set by their peers gained professional status. As late as the 1970s the Merrison Committee, examining the role of the General Medical Council (GMC), concluded that a regulatory body must also be a professional body.

As it turned out, the 1975 Merrison report played the final chords of professional self-regulation. Its proposals represented ‘the last moment when so confident astatement of the superiority of the professions, their right to control their own affairs and their ability to act in the public interest could be made’ (Davies and Beach 2000). Significant changes began in the world of nursing and midwifery regulation. The General Nursing Council and Central Midwives Boardwere replaced by the UK Central Council for Nursing, Midwifery Council and Health Visiting (UKCC), which was in turn superseded by the Nursing and Midwifery Council (NMC).

‘Amid a crescendo of concerns about poor care, healthcare regulation is in the spotlight’

There were changing registration requirements, rising fees and growing numbers of fitness to practise cases. Amid this noise the mood music of regulation itself was changing, though almost unheard at the time. Better regulation required a balancing of the interests of the professions with those of employers, service users, educators and others, are view of the UKCC concluded (JM Consulting 1998). In tune with the emergence of patient-centred care in the 1990s, professional self-regulation gave way to a subtle but significant variation and professional regulation in the public interest came to the fore. Systems regulation also began to develop, with the Commissionfor Health Improvement founded in England in 2001.

The review that led to the establishment of the NMC chimed with a new regulatory paradigm that found its expression later in the Hampton principles (2005) and the Legislative and Regulatory Reform Act (2006). Regulators should not set aspirational standards, and should only intervene if there is a threat to public protection. Regulation should be transparent, accountable, proportionate, consistent and targeted. Above all, it should be ‘light touch’.

Politicians like cutting red tape and light touch regulation is an engaging idea, but hard to sustain when faced with care scandals. This is creating tensions in people’s expectations of regulation, as shown in the current debate on whether statutory regulation of healthcare support workers would improve care. Two recent documents highlight some of the complexities.

Enabling excellence (2011) sets out the government’s proposed direction for healthcare regulation. It adheres to the Hampton principles, and is a continuation of the regulatory paradigm of the late 1990s, being a strategy not just for reform but also for simplification. It says statutory regulation should not be extended to healthcare support workers, and instead supports a voluntary arrangement (‘Transforming regulation’, NMC Review, issue 1, p33).

Contrast this with a recent report of the House of Commons Health Committee (2011), whose chair Stephen Dorrell MP introduced it by saying, ‘At a time when there are signi?cant concerns about standards of care… it is important that the professional regulators step up to the plate.’ In a view reminiscent of Merrison, the report encouraged the NMC to ‘embrace more ambitious objectives for professional leadership’. Moreover, directly challenging government policy, it endorsed mandatory statutory regulation of healthcare support workers, as ‘the only approach which maximises public protection’.

Some opponents of extended regulation think professional regulation has failed to change the quality of everyday healthcare. Their concern that its focus on individual responsibility may lead to scapegoating has some justi?cation. And the regulatory system may in itself be inadequate to deal with increasingly complex issues, with the current separation of the potentially punitive power of a professional regulator and the enforcement regimes of a systems regulator. The regulatory paradigm that neatly separates individuals and systems is ?awed.

Take systems regulation. Despite the CQC’s recent promise that its inspections will focus more broadly on quality of care and the views of service users, systems regulation must necessarily focus on processes and policies. When failure is investigated, responsibility heads to the highest possible point in an organisation, and corporate decapitation is called for. Enforcement actions, whether closure of services or financial penalties, are not in themselves transformative. They may reduce the likelihood of terrible incidents, but they cannot alone create better outcomes.

‘We need a new language of regulation that deals with the collective and focuses on the everyday’

Professional regulation, on the other hand, focuses on individual responsibility at the expense of a corporate view. Investigated through the prism of professional misconduct, responsibility for failure tends to gravitate to the front line, and the person furthest down the chain of command is made the scapegoat. The professional regulator can remove a single dangerous person from a healthcare environment, but the removal alone does not necessarily improve the situation.

These are descriptions of extremes, and the reality is significantly more nuanced. Nevertheless, there is a gap between professional and systems regulation in dealing with the everyday reality of complex healthcare delivery. Even in the simplest of healthcare interactions, the planning, delivery and assessment of care is neither an individual act, nor the working out of a system, but a collective effort. Neither end of the regulatory spectrum adequately deals with collective action or collective responsibility.

Individual healthcare professionals create collective norms as they work together, and those norms in turn shape them. Those collective norms are codified into systems, which in turn influence collective activity. Without an acknowledgement of the power of the collective as a bridge between the individual and system, our understanding of healthcare delivery is incomplete, and our regulatory paradigm cannot be effective. In its current form, systems regulation cannot support collective responsibility, while professional regulation is too focused on punishing individuals to deal with collective failure.

Regulation is under great pressure, and perhaps even failing. We need a new language of regulation that deals with the collective: an effective regulatory regime that focuses on the everyday, not the extremes. New thinking is needed to help regulators safeguard public health and wellbeing, and drive up standards. This thinking needs to focus not just on patient safety, but also on public trust in the professions. It must avoid over-regulation, especially when it damps down positive innovation. Balancing these issues and concerns, three simple principles are central to the new regulatory paradigm: being proactive, rethinking standards and reaching out.

Being proactive

In the new paradigm, regulators have a responsibility to be proactive. For the NMC, this means responding decisively when concerns are raised. For example, the request that universities remove their nursing and midwifery students from Pilgrim Hospital in Boston, Lincolnshire, in response to serious concerns raised by the CQC, shows the power of collective action to improve healthcare education. Being proactive also means that the NMC has started initiating its own investigations, using powers under section 22(6) of the Nursing and Midwifery Order 2001. Over 200investigations have already been launched this year in response to media reports. Standing on the sidelines waiting to be invited in is no longer adequate. As Cynthia Bower says, regulators have to ‘cross the threshold’ and work collaboratively with organisations under pressure to support andenable change.

Rethinking standards

Reimagining regulation also means a fundamental rethink of the purpose and nature of standards. Standards for education and practice are NMC core business, but have too often described the bare minimum of expected quality. Used as a blunt regulatory tool, they allowed the removal from the professions of people who signi?cantly underperformed, but they have never been aspirational. Too many professionals upholding NMC standards found they simply supported existing good practice, and no more.

The NMC is now committed to setting what it describes as ‘standards with stretch’ in the current reviews of the code (NMC 2008) and record keeping guidance (NMC 2009). It recognises the need for collective effort to implement, change and improve practice at every level and in every setting. It will also set standards that focus on improving health outcomes. Looking for measurability and impact in the setting of standards is challenging, especially when the relationship between the regulator, the standards and the multifactorial delivery context is so complex. Setting standards with stretch requires regulators to become professional leaders.

Reaching out

Finally, the new regulatory paradigm requires regulators to reach out to the public by setting out clearly the standards of care they can expect, and providing an open door for expressions of concern when those standards are not met. Professional regulation, even if it is exercising professional leadership, cannot be the sole domain of professionals. Healthcare regulators are required by law to regulate in the interests of public health and wellbeing, but in reality can be far removed from the everyday concerns of patients and service users. The NMC is now listening closely to those concerns, and ensuring their voice is heard at every level of regulatory decision-making. Regulators must also reach out to each other and act collaboratively with employers for the collective good. The NMC memorandums of understanding with systems regulators across the UK help ensure information is shared, and concerns that otherwise would fall into the regulatory gap are acted on. It is also engaging more positively with employers.

Whatever happens in these uncertain times, the healthcare environment will continue to change. Can regulation also change fast enough to safeguard public health and wellbeing, and drive up professional standards? There may be trouble ahead, but it’s time for regulation to face the music.

References

• Davies, C and Beach, A (2000). Interpreting Professional Self-Regulation. London: Routledge.
• Department of Health (2011). Enabling Excellence: Autonomy and Accountability for Health and Social Care Staff. Command paper Cm 8008. London: TSOL
• Hampton, P (2005). Reducing administrative burdens: effective inspection and enforcement. London: HMSO
• House of Commons Health Committee (2011). Annual accountability hearing with the Nursing and Midwifery Council (2011). HC 1428, London: TSOL. Available at [http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/1428/1428.pdf]
• JM Consulting (1998). The Regulation of Nurses, Midwives and Health Visitors: Report of a review of the Nurses, Midwives and Health Visitors Act 1997. Bristol: JM Consulting
• Nursing and Midwifery Council (2008). The code: Standards of conduct, performance and ethics for nurses and midwives.
• Nursing and Midwifery Council (2009). Record keeping: Guidance for nurses and midwives.
• Nursing and Midwifery Council (2010). Raising and escalating concerns: Guidance for nurses and midwives.
• Nursing and Midwifery Council (2011). Transforming regulation. NMC Review, issue 1, p33.
• Santry, C (2011) In charge of the not-so-light any more brigade. Health Service Journal, 28 July 2011, pp16-17.
• Legislative and Regulatory Reform Act (2006). London: HMSO
• Report of the Committee of Inquiry into the Regulation of the Medical Profession (1975). Command paper Cm 6108, London: HMSO [Merrison Committee Report]

A selection of links below. By the way, you know you've arrived in life when the Grauniad spells your name wrong. See the end of the first link.

• Guardian: Facebook friends a no-no for doctors
• Guardian: Doctors told not to make friends with patients on Facebook
• BBC: Medics warned over Facebook risks
• Daily Mail: Doctor no (Facebook): Medics warned not to make friends on social networking site
• TechRadar: Social networks and responsible jobs don't mix

Patient confidentiality matters in cyberspace too

Ever taken a picture of a really interesting leg wound and shown it to a friend at a party?

Ever uploaded a picture of yourself and a patient on Facebook? Ever tracked a service user down using social media? All of that may leave you spiralling into orbit at the suggestion that you’d behave with such disregard for patient confidentiality, dignity and your own professional status. But there are nurses who have done all of those things. The NMC is investigating an increasing number of referrals about nurses’ fitness to practise in relation to their social media usage. So much so that last week it issued guidance about how nurses and student nurses should behave on Facebook, Twitter and LinkedIn .

According to the NMC’s Andy Jaeger, assistant director, professional and public relations, who wrote the guidance, the rise in inappropriate usage is down to a lack of understanding about just how public the information you share in cyberspace really is and how to manipulate your privacy settings. He confirms the NMC is investigating “several” cases around social media usage.

Despite policies about mobile phone usage, often nurses have their mobiles on them at all times, giving them the ability to photograph, share information and relay opinions without taking a moment to stop and think whether they really should. In the US, nurse Doyle Byrnes posed with a patient’s placenta and posted it on Facebook, while in the UK, nurse Timothy Hyde was struck off the register last year as a result of misconduct involving Facebook.

The NMC suggests that with around 78,000 UK Facebook users listing their profession as nurse, midwife or health visitor (and it believes 355,000 Facebook users are from the professions), such cases are only likely to increase. So think carefully about what you upload. Sounding off about a bad day may be tempting, but it could be construed as breaching patient confidentiality and land you in hot water. You may be a model nurse in the workplace, but make sure you are in cyberspace too.

Midwives and nurses given social network advice

Nurses and midwives have been given a set of guidelines to help them steer clear of misconduct cases related to the inappropriate use of social network sites.

Many firms and organisations have noticed the popularity and ease of use of the likes of Facebook and Twitter and have opted to create a professional network for the benefit of the increasing number of Gen Y staff.

However, the Nursing and Midwifery Council (NMC) has seen a notable rise in the number of people being found to be discussing privileged information over the internet - most of the time unwittingly.

Assistant director of professional and public communications at the NMC Andy Jaeger, told People Management magazine the new advice was being made available to the UK's 660,000 registered nurses and midwives to stem the flow of misconduct cases.

"This guidance is about responsible use and encouraging employers to investigate issues proportionately and seriously, rather than issue blanket bans," he told the publication.

Facebook is an increasingly powerful website, as it has more than 750 million active users.