Q: One of my coworkers was suspended for mentioning our agency on social media. Isn't that a violation of freedom of speech?

Answer: Social media is a great example of the complexity that technology has introduced to society. Conversations that would have been conducted in person, over the telephone, or in small work groups are now often conducted online in some form. One of the differences between face-to-face and online communication is that in an online environment communications are recorded. Those involved in online communication may have intended the conversation to be private, but privacy should never be assumed. Healthcare professionals should be concerned with the legal and ethical considerations associated with any form of online communication and use of social media.

Our First Amendment right to free speech has been debated in society and in the courts since its inception. There have always been limitations to this right, (such as yelling "fire" in a crowded theater). But as with many issues today they are amplified by the integration of technology into society. This issue is further complicated when healthcare professionals are involved. There are certain expectations by which all professionals conduct themselves while in their place of work. Should these expectations extend beyond our work life into our personal life? Social media challenges our concepts of privacy, social norms, and the reach of our First Amendment rights.

The courts continue to deal with the social network challenges. In Tatro v. University of Minnesota, Amada Tatro was a junior in a mortuary science program at the university. She posted statements involving violent thoughts toward a cadaver she nicknamed "Bernie" (Creeley, 2012). When she was punished for these statements that she considered private to her social network, she claimed it within her First Amendment rights to post these statements. The school felt differently because she had agreed to both the university code of conduct and the academic program rules that included the use of cadavers. Her statements included, "Amanda Beth Tatro Gets to play, I mean dissect, Bernie today. Let's see if I can have a lab void of reprimanding and having my scalpel taken away," and "Who knew embalming lab was so cathartic! I still want to stab a certain someone in the throat with a trocar though" (Tatro v. University of Minnesota, 2012). She was issued a failing grade in her anatomy course as part of the sanctions imposed resulting from an Office of Student Conduct and Academic Integrity investigation. In the end, the court determined that her rights were not violated because the code of conduct policies were not unconstitutional, as she argued (Tatro v. University of Minnesota). The court stated the University was well within its rights to establish and enforce professional standards. The court conceded Tatro's concerns were valid because the school could regulate students' personal expression at any time, but admittedly she had agreed to the program rules and understood she exceeded the limitation of those rules (Tatro v. University of Minnesota).

In other cases, the courts found judgment against the company or institution. Smart (2015) describes Whitham V. Club24Ltd where the termination of an employee was found to be unfair based on workplace policies. Ms. Whitham shared comments about her workplace involving coworkers and working conditions. Although the comments were posted outside of work while using her own computer, her "friends list" included colleagues and superiors. She did not mention anyone by name, but she was terminated regardless (Smart). This case was deemed unfair on the basis that there was no measurable harm to her employer's reputation and the business did not have a specific social media policy.

Although the courts have reviewed many social media cases, the issue has not been clarified. Many of the legal discussions have revolved around institutional policies. It is not a new issue for an employer to attempt to control an employee's private actions or to monitor work place activities (Castagnera & Lanza, 2010). For example, in response to employers encroaching on personal lives of employees, many states have restricted the employer's ability to require a person to provide their social media authentication credentials as a condition of hire or continued employment, and at this time 12 states have pending legislation (National Conference of State Legislatures, 2016). But there are fundamental issues to consider when reviewing these instances of new communication, starting with the expectation of privacy (Strahilevitz, 2005) and the privacy paradox that is presented by social media. Barns (2006) describes the boundaries between private and public social media use as unclear, and our first goal should be to determine if this is a problem. Based on a December ProPublica report, it appears problems are present in healthcare. Ornstein (2015) cites over 37 issues resulting from the actions of nursing home workers since 2012 and these issues can affect everyone involved from the patient to the others employed by the institution. Healthcare providers should be familiar with and understand their employer's policies related to social media.

Professionals need to be cognizant of their social media actions and the possible repercussions. Beyond legal concerns, professions that require public trust are held to a higher standard of professionalism. Quite often in addition to employer guidelines, professional organizations provide guidance to meet these standards. The National Council of State Boards of Nursing (NCSBN) has provided materials to guide the nursing profession titled, A Nurse's Guide to the Use of Social Media (NCSBN, 2011). Other healthcare professionals will find this a valuable resource as well. This practical guide provides useful examples to not only protect the nurse, but also patients by avoiding Health Insurance Portability and Privacy Act violations. The topics that are outlined in this guide include the impact of patient safety, common myths, and potential consequences. Understanding the expectations of a profession in our technology-rich society is imperative and should be a priority for all healthcare professionals.

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