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Ethics in an Age of Information Seekers: A Survey of Licensed Healthcare Providers about Online Social Networking Shannon C. Anderson a & Michelle R. Guyton a a Pacific University , Hillsboro , Oregon
To cite this article: Shannon C. Anderson & Michelle R. Guyton (2013): Ethics in an Age of Information Seekers: A Survey of Licensed Healthcare Providers about Online Social Networking, Journal of Technology in Human Services, 31:2, 112-128
To link to this article: http://dx.doi.org/10.1080/15228835.2013.775901
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Journal of Technology in Human Services, 31:112–128, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1522-8835 print/1522-8991 online DOI: 10.1080/15228835.2013.775901
Ethics in an Age of Information Seekers: A Survey of Licensed Healthcare Providers
about Online Social Networking
SHANNON C. ANDERSON and MICHELLE R. GUYTON Pacific University, Hillsboro, Oregon
The present study explores how licensed health care providers use social media. The researchers utilized a survey to explore 88 licensed psychologists, physicians, and social workers average numbers of Facebook© friends, social groups, and photo albums as well as attitudes toward possible regulation of online social networking by professional organizations. Statistically significant differences were found among groups regarding the degree to which they wanted guidance on ethically managing this new technology, with psychologists and social workers desiring more guidance than physicians. Overall, this study shows that the majority of the psychologists, physicians, and social workers who partici- pated in this study now frequently use Facebook, often providing information on profiles that may include that which is not generally disclosed in a client–therapist relationship.
KEYWORDS ethics, Facebook, health care, social networking, technology
INTRODUCTION
For psychologists, physicians, social workers, and other health care profes- sionals the nature of how one communicates and interacts with clients has changed to incorporate new modes of communication and media resources. With the growing prevalence of online social media networks, some of the prior barriers to self-disclosure by a therapist are weakening, and have
Received October 10, 2012; revised January 25, 2013; accepted February 2, 2013. Address correspondence to Shannon C. Anderson, Pacific University, School of Professional
Psychology, 190 SE 8th Avenue, Suite 260, Hillsboro, OR 97123. E-mail: [email protected]
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Ethics in an Age of Information Seekers 113
impacted the client–clinician relationships in a variety of health professions (Chretien, Greysen, Chretein, & Kind, 2009; Taylor, McMinn, Bufford, & Chang, 2010; Thompson et!al., 2008). The growing presence of health care professionals on online social networks has led to several ethical questions. Can unwarranted self-disclosure on social networking Web sites by health care professionals lead to boundary crossings or ethical violations? What information is appropriate and what is inappropriate for professionals to provide on an online profile? What precautions can they take to protect the information they choose to post online? The present study sought to answer these questions and clarify some of the potential ethical mistakes profession- als should avoid when using online social networks.
Recently, the American Psychological Association (APA) has released a Social Media/Public Forum Policy aimed at guiding mental health profes- sionals when using new technologies like online social media (APA, 2012). Although this policy does not explicitly apply to individuals who wish to maintain private social media pages, it does offer some relevant information for those individuals. This new policy advises those who chose to participate in social media forums to expect that anything they post will be seen and read, and may be used against them by peers, colleagues, and employers. There is general agreement between the American Psychological Association Ethics Committee and several other professional associations (the American Medical Association [AMA], the American Counselors Association [ACA], and the National Association of Social Workers [NASW]) about the ethical consid- erations healthcare professionals should be mindful of when interacting online, such as concerns about confidentiality and unwarranted self-disclosure (ACA, 2005; AMA, 2005; NASW, 2008).
The American Psychological Association’s Social Media/Forum Policy (APA, 2012) provides guidelines for forums created by APA or divisions of APA, but this policy does not necessarily apply to psychologists wishing to participate in individual social media forums. Instead of creating specific policies for individual psychologists who wish to maintain social media pages, the association has attempted to organize the Ethical Principles of Psychologists and Code of Conduct in a way that provides guidance for clini- cians who will need to respond to changes in the field. The APA (2002) Ethics Code covers all areas of professional practice, so confidentiality regu- lations are scattered throughout the document. Standard 4.01 of the APA Ethics Code (Maintaining Confidentiality) mandates the protection of cli- ents’ information. Psychologists are expected to always be cognizant of the limits of their ability to protect client confidentiality when storing client information electronically or discussing a client through computerized tech- nology. It is unclear, however, whether psychologists should be obligated to expand this standard to apply to other potential personal electronic com- munication media, such as social networking Web sites. For instance, a client could post information on a therapist’s personal page if the necessary
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114 S. C. Anderson and M. R. Guyton
privacy settings are not in place, potentially compromising his or her confidentiality.
Psychologists are but one group of mental healthcare professionals who must manage a changing dynamic between client and caregiver. When counselors are faced with ethical dilemmas that are difficult to resolve, they engage in an ethical decision-making process similar to clinical psycholo- gists. The American Counselors Association Code of Ethics (American Counselors Association, 2005) specifically addresses ethical guidelines for counselors who maintain Web sites. Although this section appears to apply only to professional Web sites without addressing personal ones, it helps clarify some of the concerns considered. For example, section A.12.h of the ACA Code of Ethics states that counselors maintaining Web sites must check that electronic links are working and are professionally appropriate, estab- lish ways clients can contact their counselor in the case of technology failures, and establish a method of verifying client identity. According to the National Association of Social Workers Code of Ethics, “social workers should not discuss confidential information in any setting unless privacy can be ensured.” (National Association of Social Workers, 2008, p. 153). The NASW Technology Standards acknowledge that technologies are not infallible, that social workers should be mindful of keeping informed about changing technologies, and that “confidentiality in an electronic medium can quickly evaporate; jurisdiction, liability, and malpractice issues blur when state lines and national boundaries are crossed electronically” (National Association of Social Workers & Association of Social Work Boards, 2005, p. 4).
Similar to psychologists, counselors, and social workers, physicians struggle with how to appropriately engage patients in online forums. Although the American Medical Association Code of Medical Ethics also does not explicitly address how physicians should use (or not use) online media, opinions regarding ethical use of electronic mail and Web sites supplying medical information are provided (American Medical Association, 2005). In addition, the American Medical Association Code of Medical Ethics specifies, “physicians who establish or are involved in health-related online sites that use patient-specific information must use high-level security protections, as well as privacy safeguards” (AMA, 2005, p. 131). The ethical dilemmas doc- tors and other health professionals may run into when using technology according to the AMA code of ethics include lapses in informed consent, risks to medical safety, and harm done to patient confidentiality by a breach in data security.
Although no direct guidelines have yet been established for the per- sonal use of social networking Web sites by the APA, ACA, NASW, or the AMA, these bodies agree on certain areas of importance such as maintaining confidentiality and protecting others from harm. In the absence of specific code language, the guiding ethical principles of each of these organizations
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Ethics in an Age of Information Seekers 115
advise health professionals on how to resolve ethical dilemmas. Overall, the perspectives provided by these different organizations offer roughly the same guidance to professionals who encounter ethical dilemmas in new ter- ritory; carefully consider the situation and act in a way that protects clients, patients, and others from harm to the best of one’s ability. Presently no single document has set forth a clear set of guidelines to help health professionals avoid making ethical mistakes or causing harm via new communications media, such as social networking Web sites. However, several articles, opin- ion papers, and ethics surveys have emerged, detailing the personal experi- ences of many health professionals and offering advice on how to avoid ethi- cal missteps when it comes to maintaining an online presence (Lehavot, 2009; McMinn, Buchanan, Ellens, & Ryan, 1999; Taylor et!al., 2010; Thompson et!al., 2008; Zur, Williams, Lehavot, & Knapp, 2009).
Social Networking Web Sites: The Internet as a Personal and Professional Resource
The Internet can serve as an important professional resource for psychologists and other health professionals. Having an online presence may prove helpful in increasing one’s professional visibility, especially because research shows that clients increasingly seek medical and mental health services online. According to a recent survey of healthcare seeking behaviors by the Pew Charitable Trust, almost half of all adults in the United States have gone online to find health information and 21% have sought mental health information online (Fox & Fallows, 2003). Maintaining a professional Web site is inherently different from maintaining a personal social network page, yet the distinction between personal and professional information is sometimes blurred online.
Although issues of confidentiality are not likely to come up when clini- cians use a Web site designed to inform consumers about their practice or professional credentials, a LinkedIn account, blog, or Facebook profile enables interaction with others and could be the source of some ethical problems. According to Zur (2010), some therapists choose to use a Facebook page rather than a profile, which is composed of relationships with those who “like” the page or business. A client may potentially post therapy related messages, which could be troublesome in regard to confidentiality, privacy, and HIPAA compliance. Even private communications are not foolproof. Communication through electronic means, whether through Facebook, texting, or even e-mail, is never guaranteed to be completely confidential. Web sites such as Facebook detail the limits of their privacy options directly on their Web sites. Privacy policies make clear that online companies cannot guarantee the security of online data, such as the disclaimer Facebook provides to its users:
Although we allow you to set privacy options that limit access to your information please be aware that no security measures are perfect or
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impenetrable. We cannot control the actions of other users with whom you share your information. We cannot guarantee that only authorized persons will view your information. We cannot ensure that information you share on Facebook will not become publicly available. We are not responsible for third party circumvention of any privacy settings or secu- rity measures on Facebook. (Facebook Privacy Policy, 2010)
As psychologists become more comfortable using technology in their professional and personal lives, it is also important that they become more vigilant about privacy policies, security of data, and availability of personal information to the public. The development of program professionalism policies that specifically address Internet use such as blogs and social net- working sites could not only help health care professionals avoid compro- mising client confidentiality; it could also help professionals recognize “slipping” towards violating other ethical standards, such as avoiding mul- tiple relationships and inappropriate self-disclosures. In an article describ- ing the early boundary problems caused by utilizing e-mail and other elec- tronic communication between doctors and their patients, Gutheil and Simon (2005) examine the Internet as a “slippery slope,” a term used to describe the idea that most boundary crossings begin with small deviations that become progressively larger. Several boundary transgressions, includ- ing inappropriate self-disclosure, inappropriate language, and breaches of confidentiality could result from online communication with clients or patients. Developing professionals, who do not yet have a firm sense of their ethical responsibilities, could benefit from guidance when it comes to managing their personal life online in conjunction with a sense of professionalism.
LITERATURE REVIEW
Because the Internet is equivalent to a public place, individuals who post personal information online should have no expectations of privacy. As the APA Ethics Code applies only to a psychologists’ professional life, the American Psychological Association encounters difficulty when profession- als or those in training act in personal roles outside of their roles as thera- pists. However, situations where a psychologist’s personal life interferes with his or her professional life become problematic and in violation of the Ethics Code (Lehavot, 2009). Situations in which students make derogatory com- ments online about clients, advisors, or programs could be seen as unethical or at least unprofessional. Even seemingly harmless information posted online, such as a therapist’s political or religious views, has the potential to affect the client–therapist relationship through self-disclosure (Goldstein, 1994; McMinn, Hathaway, Woods, & Snow, 2009). Psychologist trainees
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Ethics in an Age of Information Seekers 117
thoroughly study the impact of therapist self-disclosure on their therapeutic relationships. Online disclosures can damage the therapeutic alliance between a clinician and client if offhand remarks are made about them or other clients online, whether or not the remarks were intended to be private. Therapists are taught to be mindful about the information they share in public places (Goldstein, 1994), and online social networks constitute public forums.
However, sometimes the Internet can be a useful tool for therapists to use with clients. In a recent article, Lehavot (2009) presented a case study of a client who conducted an online search for her psychotherapist to check her educational background and credentials. The client’s behavior presented a foundation for the client and therapist to explore together how the client attempted to form and maintain interpersonal relationships, as well as exam- ine past difficulties she may have experienced. Similarly, when a client sends a friend request to a therapist on Facebook, the therapist should consider the behavior within the context of the therapeutic relationship. A clinician can address the client’s behavior to obtain “friendship” or information about the clinician via the Internet, and might use this information to inform treatment. However, this does not mean a clinician should accept the request; accord- ing to Lehavot (2009) psychologists should only engage in social networking with clients if it is not contraindicated.
Research thus far has shown that many individuals are increasingly using social networking Web sites to stay connected, meet new people, and establish an online presence (Crawford, 2009; Ellison, Steinfield, & Lampe, 2007). In an anonymous electronic survey of medical school deans of student affairs, their proxies, or their counterparts, Chretien and col- leagues (2009) assessed medical school experiences with online posting of unprofessional content by students, and policies regarding online posting. Sixty percent of respondents reported incidents of students posting unpro- fessional content online. In the past year, 13% reported no incidents, 78% had fewer than 5 incidents, 7% had 5 to 15 incidents, and 2% had some incidents but did not know how many. Violations of patient confidentiality were involved in 13% of these incidents. Further, in 38% of the violations sexually suggestive content was involved, in 40% of violations depicted intoxication was involved, and 48% of violations involved discriminatory language.
Chretien and colleagues (2009) assessed the level of concern among student affairs deans or proxies regarding students posting unprofessional content online as well as whether their school’s current professionalism poli- cies covered student-posted online content. If the professionalism policies covered student-posted content, participants were asked to indicate whether the policy explicitly mentioned Internet use such as blogs and social net- working sites. Only 38% of medical schools reported having policies that addressed student-posted online content. Just 18% of deans surveyed said that their school’s professionalism policy specifically addressed issues of
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Internet use such as blogs and social networking Web sites. Of the 45 schools that reported an incident, 67% gave informal warnings and 7% reported that students were dismissed from their programs. The authors of this study con- cluded that while many of the schools surveyed had incidents of unprofes- sional student online postings, most did not have an adequate wording to address issues of ethics code violations in their professionalism policies.
In another study, the Facebook profiles of all medical students and resi- dents at a large southern university were evaluated for unprofessional con- tent (Thompson et!al., 2008), which was defined as “any material that could be interpreted to illustrate substance abuse, sexism, racism, or lack of respect to patients” (p. 955). Approximately 63% of all participants kept their Facebook profiles public, and medical students had significantly more friends than residents. Use of Facebook was more common among medical students than residents, and most medical student participants chose to keep their profiles open to the public. Medical students also joined significantly more Facebook groups than medical residents. Unprofessional content was seen on several of the students’ profiles. Qualitative analyses of profiles showed that of a random subset (N = 10), approximately 70% had photos displaying alcohol, with 10–50% of those displaying excessive drinking behavior. Several profiles displayed affiliation with groups involving foul language or sexist remarks, such as the group “Physicians looking for trophy wives in training” (Thompson et al., 2008, p. 955).
In a study of 695 American Psychological Association members and doctoral-level psychology students, researchers used an online survey to examine psychologists’ use of social networking Web sites, ethical dilemmas they have encountered when using Facebook, and their belief about the ethics of such use (Taylor et!al., 2010). Because the majority of the sample was comprised of graduate students, findings cannot necessarily be general- ized to the larger population of psychologists or APA members. However, it does give an interesting glimpse into the problems that can develop between therapists and clients due to the blurring of public and private information. The survey included 14 questions about participants’ current use of social networking Web sites and other online activities, feelings about possible regulation of online activities by the APA, and interesting or difficult encoun- ters with clients as a result of online activities. Overall, participants reported that they would reject or ignore attempted client contact via social network- ing Web sites. Seventy-seven percent of the sample reported maintaining a social networking Web site page; of that group, 15% reported that they did not use privacy settings to protect their personal information. A negative cor- relation was found between age and the degree to which participants reported having thought about the ramifications of using social networking Web sites, so younger psychologists and graduate students had thought more about the ethical implications inherent in using online social media than older psychologists.
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The current ethical guidelines established by the APA, ACA, NASW, and AMA have refrained from explicitly regulating online content posted by licensed healthcare professionals. The present study was designed to exam- ine the behaviors of licensed health care professionals pertaining to their use of Facebook and their beliefs about the inherent ethical implications. Based on the literature, the following hypotheses were developed for this study:
1. Psychologists would have significantly fewer numbers of Facebook “friends,” on the average, than both medical doctors and social workers.
2. Psychologists would belong to significantly fewer Facebook social groups and have fewer Facebook photo albums than both medical doctors and social workers.
3. Psychologists would also report having thought about the professional and ethical ramifications of using social networking Web sites more than both medical doctors and social workers.
It was hypothesized that psychologists would be more conservative in the extent of their presence in online public forums due to the traditional psychodynamic recommendation against extensive self-disclosure by thera- pists as well as fact that psychologists are taught to be mindful about the information they share in public places.
METHODS
Participants
The current study was approved and registered with the Pacific University IRB in December, 2010. Data collection began thereafter. Sample participants were recruited from the states of Oregon, California, and Texas. These states were chosen based on the availability of online licensee registers and because surveying licensees from all states would have required more resources than were available to the researchers at the time. Registers of licensed physicians, licensed psychologists, and licensed clinical social workers were obtained from the states’ official Web sites. The names and addresses of potential participants were obtained through the board licensee databases in each state. Through random selection, 50 physicians, 50 social workers, and 50 psychologists in each of three states were selected, totaling 150 names and mailing addresses obtained for each of the three professional groups (psychologists, physicians, and social workers). A total of 150 psychologists were randomly selected from a population of approximately 15,524. One- hundred-fifty physicians were randomly selected from a population of approximately 164,757, and 150 social workers were randomly selected from a population of approximately 29,178 creating a combined total of 450 indi- viduals to whom surveys were sent. Seventy-two surveys were returned at
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the outset. A second batch of 90 surveys (10 to each professional group in each of the three states) was sent out in order to increase the completion rate, making the final total of surveys sent 540. Study participants were sent a cover letter with a brief description of the study and an informed consent document along with the survey. Participants were also given a stamped, preaddressed envelope for the return of the completed survey.
In total 88 individuals returned the survey for a completion rate of 16.29%. Completion rates among groups were 28.6% (N = 43) for psycholo- gists, 19.3% (N = 29) for social workers, and 10.7% (N = 16) for physicians. Sixteen members of the final sample were identified as physicians (18.2%), 43 were psychologists (48.9%), and 29 were social workers (33%).
Of the 88 participants, 43 were men and 45 were women. With respect to ethnicity, 85 (96.6%) identified themselves as White, two (2.3%) as Hispanic, and one (1.1%) as Asian or Pacific Islander. The mean age of respondents was 50.99 years (SD = 11.11) and mean number of years in licensed practice was 17.71 years (SD = 10.35). The mean number of years in licensed practice was also comparable across groups, with psychologists averaging approximately 18 years (SD = 10.90), social workers about 15.5 years (SD = 9.14), and physicians 21 years (SD = 10.40).
Materials
The survey that was sent to participants was developed specifically for the purposes of this exploratory study, although the format used is similar to ethics questionnaires used in past research on the beliefs and behaviors of mental healthcare professionals (e.g., McMinn et!al., 1999; Taylor et!al., 2010). Although it is not included in this article, the survey will be made available to anyone requesting it via an e-mail to the authors. The survey featured 42 questions intended to gather information about participants’ current use of social networking Web sites and Facebook in particular, their beliefs about the ethics of using online social networking Web sites, beliefs about the need for ethics courses in graduate study to address online social networking, and beliefs about need for regulation by professional organizations. The ques- tions were rated on one of two 5–point Likert scales; one scale addressed how often participants engaged in certain behaviors (1 [never] to 5 [always]) and the other rated their level of agreement with specific beliefs and state- ments about the ethics of using Facebook (1 [completely disagree] to 5 [com- pletely agree]). Additional items asked respondents whether they maintained a Facebook profile (yes or no), number of friends in respondents’ Facebook networks, number of Facebook photo albums, and number of Facebook social groups of which they were members. Further items assessed whether respondents provided on their Facebook profile (a) a home address, (b) an office address, (c) a home telephone number, (d) an office telephone number, (e) an e-mail address, (f) a profile photo of themselves, (g) their area of
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Ethics in an Age of Information Seekers 121
practice or field of study, (h) their relationship status, (i) sexual orientation, (j) religious beliefs, and (k) their political affiliations. The survey also included a short demographics section as well as space to provide any further com- ments participants thought were relevant to the topic of ethics and social networking. The survey was mailed to participants through the U.S. Postal Service, and a stamped envelope was provided for the return of the com- pleted survey. No follow-up action was taken if participants failed to return the survey.
RESULTS
An Independent-Samples Kruskal-Wallis Test was conducted to evaluate dif- ferences among the three groups on median number of Facebook friends, Facebook social groups, and photo albums. A nonparametric test was used for this study due to largely unequal group sample sizes, as well as a signifi- cant result when Levene’s test for equality of variance was examined. This test is an extension of the nonparametric Mann-Whitney U Test, for more than two independent groups. With the Kruskal-Wallis test, a chi-square statistic is used to evaluate differences in mean ranks to assess the null hypothesis that the medians are equal across groups. An alpha level of .05 was used for all statistical tests. Comparisons were also made on the level of thought individuals had given to the ethical ramifications of using Facebook, their desire for guidance on how to use Facebook ethically, and their opinions on whether professional organizations should be involved in establishing guidelines for use of online social media. Simple frequencies and descriptive statistics were also calculated for all survey items. Cross-tabulations were completed to compare individuals’ frequencies of endorsement on items by their area of licensure.
The majority of all respondents (59%, N = 52) reported maintaining a Facebook profile. Out of 29 social workers, 18 reported maintaining a pro- file. Out of 43 psychologists, 23 said they maintained a profile, and out of 16 physicians, 11 maintained a profile. The majority of respondents who main- tained a Facebook profile (N = 52) reported utilizing privacy settings so that only their Facebook friends could view their full profile (75%, N = 39). The average number of Facebook friends among all respondents was relatively high, but it varied substantially across individuals (M = 78.51, SD = 135.84), ranging from 0 to 825. The mean number of Facebook social groups was 1.67 (SD = 3.69), and the mean number of Facebook photo albums among all participants was 3.58 (SD = 16.17). Participants were also asked whether or not they provided information such as a home address or telephone number on their Facebook pages. Frequencies of those individuals who reported maintaining a Facebook profile including personal information (n = 52) are broken down by profession and shown in Table 1.
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When asked to rate the level of agreement with the statement, “I have thought about the professional and ethical ramifications of using social net- working Web sites like Facebook,” 69.32% of participants (n = 61) reported that they completely agree (a rating of 5), with an overall mean rating of 4.31. Only five people reported that they had not thought at all about the ramifica- tions of using Facebook. Similarly, most respondents (n = 52) reported that they completely agree with the statement “I take reasonable actions to avoid foreseeable problems with online information.” Only two respondents dis- agreed with the statement. Another eight were neutral. Responses to the last question are displayed in Table 2.
When asked to rate the level of agreement with the statement “I would like guidance on how to ethically manage technological advances like social networking websites,” 60.23% of participants (n = 53) reported that they completely agree or slightly agree (a rating of 4 and 5, respectively). Additionally, when asked to rate the level of agreement with the statement “I believe that professional organizations such as the APA should be involved in establishing guidelines or regulations regarding the use of social network- ing websites,” approximately 70.45% of respondents (n = 62) agreed with a rating of 4 or 5. Fifteen respondents were neutral, and ten responded with a rating of 1 or 2 (completely disagree and slightly disagree). The mean rating was 3.89, indicating an overall moderate agreement with the statement
TABLE 1 Frequencies of Individuals Who Provide Personal Information on Facebook Profiles
(n = 52) Psychologists (23) Social workers (18) Physicians (11) Total
Home address 1 (4.34%) 0 (0%) 1 (9.09%) 2 (3.85%) Home telephone
number 1 (4.34%) 1 (5.56%) 1 (9.09%) 3 (5.77%)
E-mail address 13 (56.52%) 8 (44.44%) 4 (36.36%) 25 (48.08%) Instant messenger 4 (17.39%) 3 (16.67%) 0 (0%) 7 (13.46%) Profile photo of self 19 (82.60%) 11 (61.11%) 10 (90.91%) 40 (76.92%) Relationship status 18 (78.26%) 12 (66.67%) 6 (54.55%) 36 (69.23%) Religious affiliation 6 (26.09%) 2 (11.11%) 3 (27.27%) 11 (21.15%) Political affiliation 6 (26.09%) 4 (22.22%) 2 (18.18%) 12 (23.08%)
TABLE 2 Level of Agreement with the Statement “I Take Reasonable Actions to Avoid Foreseeable Problems with Online Information”
(n = 88) Psychologists (43) Social workers (29) Physicians (16) Total
Completely agree 30 (69.77%) 13 (44.83%) 9 (56.25%) 52 (59.09%) Slightly agree 8 (18.60%) 11 (37.93%) 3 (18.75%) 22 (25.00%) Neutral 4 (9.30%) 1 (3.45%) 3 (18.75%) 8 (9.09%) Slightly disagree 0 (0%) 0 (0%) 1 (6.25%) 1 (1.14%) Completely disagree 1 (2.32%) 0 (0%) 0 (0%) 1 (1.14%) Not Applicable 0 (0%) 4 (13.79%) 0 (0%) 4 (4.55%)
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Ethics in an Age of Information Seekers 123
among all respondents. Finally, respondents were asked to rate the level of agreement with the statement, “I believe graduate ethics courses should dis- cuss the use of social networking websites like Facebook.” An overwhelming majority (84.09%, n = 74) responded with completely agree (a rating of 5).
Simple frequencies were calculated to determine overall differences between the three professional groups regarding age, years in licensed prac- tice, as well as means of Facebook “friends,” Facebook social groups, and Facebook photo albums. As stated above, the average ages were remarkably similar across groups. Table 3 summarizes the mean numbers of Facebook friends, social groups, and photo albums across groups.
The results of the Independent-Samples Kruskal-Wallis Test to evaluate the hypothesis that psychologists would have significantly fewer numbers of Facebook “friends,” on the average, than both physicians and social workers were not significant, !2(2, 88) = 1.60, p = .45. Additionally, the results of the Independent-Samples Kruskal-Wallis Test to evaluate the hypothesis that psychologists would belong to significantly fewer Facebook social groups and have fewer Facebook photo albums than both physicians and social workers were also not significant !2(2, N = 88) = .37, p = .83, and !2(2, 88) = .26, p = .88, respectively. The hypothesis that psychologists would be more conservative in the extent of their online presence due to training about being mindful of what information they share in public forums was not supported.
Significant results were found when the researcher conducted an Independent-Samples Kruskal-Wallis Test to evaluate the hypothesis that psychologists would report having thought about the professional and ethical ramifications of using social networking Web sites more than social workers and physicians. The Kruskal-Wallis Test was again employed and a signifi- cant difference between groups was found, !2(2, 88) = 7.51, p = .02. Follow-up analyses of the data included a Mann-Whitney U test to evaluate pair wise differences among the three groups, controlling for Type I error across tests by using the Bonferroni approach. The results of the test were significant and in the expected direction, with psychologists reporting a higher level of agreement with the statement “I have thought about the professional and ethical ramifications of using social networking Web sites like Facebook” than physicians, z = "2.56, p = .01. Psychologists had an average rank of
TABLE 3 Mean Number of Facebook Friends, Social Groups, and Photo Albums Across Groups
M (SD)
Psychologists Social workers Physicians
Friends 47.84 (75.95) 105.76 (141.95) 111.52 (218.99) Social groups 1.16 (2.15) 2.17 (4.62) 2.13 (4.97) Photo albums 1.37 (1.99) 7.62 (27.78) 2.19 (4.29)
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124 S. C. Anderson and M. R. Guyton
32.66, while physicians had an average rank of 22.84. The mean rank for psychologists of 39.93 did not differ significantly from social workers’ mean of rank 31.41. The mean rank for social workers of 25.53 also did not differ significantly from the mean rank of physicians 22.03.
Another Independent-Samples Kruskal-Wallis Test was conducted to evaluate differences among the three groups regarding desire for guidance on how to ethically manage technological advances like social networking Web sites. The results of the test were significant, !2(2, 88) = 12.18, p = .002. Follow-up analyses were again conducted using a Mann-Whitney U test to evaluate pair wise differences among groups. Type I error was controlled for by using the Bonferroni approach. The results were significant and in the expected direction, z = "3.16, p = .002. Psychologists had an average rank of 34.18, while physicians had an average rank of 18.81. Significant pair wise differences were also found when comparing physicians and social workers, z = "3.04, p = .002. Social workers reported desiring more guidance on how to ethically manage technological advances with an average rank of 27.31, while physicians had an average rank of 15.19. No significant differences were found when comparing psychologists and social workers.
A final Independent-Samples Kruskal-Wallis Test was conducted to evaluate whether there were differences between the three groups regarding the belief that professional organizations should be involved in establishing guidelines or regulations for the use of social networking Web sites. The results of the test were significant, !2(2, 88) = 10.63, p = .005. Follow-up anal- yses were conducted using a Mann-Whitney U test to evaluate pair wise differences among groups, and Type I error was again controlled for by using the Bonferroni approach. Results revealed significant differences between psychologists and physicians, z = "2.78, p = .006, with psychologists having a higher level of agreement than physicians with the statement that professional organizations should be involved in establishing guidelines or regulations for the use of social networking Web sites. Similarly, significant pair wise differences were found between social workers and physicians, z = "2.98, p = .003, with social workers agreeing more that physicians with the statement. Again, no significant differences were found between psy- chologists and social workers.
DISCUSSION
For psychologists, social workers, and physicians, professionalism and ethics are important aspects of their daily work. This study indicates that the majority (59%) of healthcare professionals in this sample, which included psycholo- gists, social workers, and physicians, frequently use Facebook. Further, it reveals that many of these professionals provide personal information on their profiles that would not be found publicly elsewhere. Unfortunately, the
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Ethics in an Age of Information Seekers 125
response rate of 16.29% made cell sizes too small for us to be able to make generalizations about the majority of psychologists, physicians, and social workers. Although most participants reported using privacy settings on their Facebook profiles to protect the personal data that they would not generally disclose in a therapist–client or doctor–patient relationship, many also reported that they would like more guidance when it comes to managing new technology in an ethical manner. Further, the psychologists and social workers who responded to the survey reported considering the potential ethical ramifications of using social networking Web sites significantly more often than physicians who responded. Prevalence of professionals using Facebook did not vary significantly across groups, yet the degree to which participants believed that professional organizations should be involved in establishing guidelines for the use of Web sites like Facebook was signifi- cantly higher for psychologists and social workers than for physicians. As reflected in the current study, the majority of all those sampled believe that they take reasonable precautions when interacting with others online. However, given the findings of this study, many health care professionals may benefit from more guidance on ethically navigating new technological developments like online social networking.
Strengths and Limitations
This study has several limitations. First, this study sampled individuals from only three states. It may be that professionals in other states have different patterns of Facebook use or even different understandings of professional- ism. However, there appears no reason to think that other health care profes- sionals in other states behave differently than those practicing in Oregon, California, or Texas. Second, although this study showed variations in gender, it was limited by the lack of sample diversity in age, race, and ethnicity. Variations in race and ethnicity, as well as variations in age, could yield dif- ferent results. Finally, the low return rate of 16.29% for the overall sample caused the resulting cell sizes to be too small to generalize findings to a larger population. Small cell sizes may also have contributed to some of the null findings. The low return rate may be a result of the methodology used to distribute the survey (e.g., the USPS). A logical next step would be to dis- tribute the survey online to potentially increase response rates.
A strength of this study is related to its sample of older, well-established professionals. Because most research on the use of Facebook and profes- sionals has drawn upon samples of early-career professionals and graduate students, the present study presents a unique look into the behaviors of more established workers in the healthcare field. Taylor and colleagues (2010) predicted that the social phenomenon of Facebook might be under- estimated or overlooked by APA leaders, who tend to be older and more established. Indeed, a survey of APA council representatives and division
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126 S. C. Anderson and M. R. Guyton
presidents indicated their average age to be 58.5 years (McMinn and colleagues, 2009). Yet the findings of this study seem to show that even within an older population that has been in licensed practice for many years, Facebook usage is increasing. Well-established professionals may want more guidance when it comes to navigating difficult issues such as these, especially when the technology is unfamiliar.
Future Research
Although the APA has acknowledged that technology changes too rapidly for the Ethics Committee to possibly keep up with relevant standards for every new technology, the organization has also suggested that psychologists take reasonable steps to ensure the competence of their work and protect others from harm (APA, 2002). Future research could further explore how mental health professionals address online interactions with clients when it comes to social networking Web sites and it may be more effective to conduct such research via online sampling methods, rather than through the mail. Future research could also address how professional organizations can best regulate the social networking behavior of their members. Currently researchers do not know how often clients and patients seek out their therapists and doctors on Facebook, yet this could be important for the development of future guidelines set forth by the APA Ethics Committee regarding members’ online activities.
Implications
Social networking Web sites present unique ethical issues for healthcare pro- fessionals who need to be aware of confidentiality issues, personal safety, and unwarranted self-disclosure. Most health care professionals who responded to the survey reported being aware of the ethical and profes- sional implications involved and actively protect themselves by using privacy settings. It also appears that some professionals would like more guidance on how to ethically manage social and technological advances such as social networking Web sites. Further research is needed to gain a deeper under- standing of how health care workers of all ages relate to and use technology.
As the culture changes and computers and wireless technology become more prevalent forms of communication, the lines may be blurred when it comes to making distinctions between casual online personal communications and other types of interactions, especially if professionals are not cautious in their use of privacy settings on social networking Web sites and if they are not vigilant about protecting confidential client information. As Zur (2009) noted, even if a clinician does not disclose information about clients online, clients can potentially “like” a page or post therapy-related messages, which would be problematic when it comes to confidentiality, privacy, and HIPAA compliance.
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Ethics in an Age of Information Seekers 127
While psychologists sampled in past studies (Taylor et! al., 2010) have expressed ambivalence as to whether or not the APA should have a say in the online activities of organization members, the present study paints quite a dif- ferent picture. Surprisingly, many respondents in the present study expressed a belief that professional organizations like the APA should be involved in establishing guidelines or regulations regarding the use of social networking Web sites. Professionals should always think twice about the information they post in public forums, and it is important to consider the unique situations that can arise on social networking Web sites, especially if they believe incorrectly that they have complete privacy. By being mindful of the way their actions, including online activities, affect others in unanticipated ways, psychologists and other healthcare professionals can better learn to make ethical decisions and navigate a future that will inevitably involve more technological change.
REFERENCES
American Counseling Association. (2005). ACA Code of ethics. Alexandria, VA: American Counseling Association.
American Medical Association. (2005). Code of Medical Ethics: Current opinions with Annotations, 2004-2005 edition. Chicago: AMA Press..
American Psychological Association Social Media/Forum policy. (2012). Retrieved from http://www.apa.org/about/social-media-policy.aspx
American Psychological Association, Washington, DC, US. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57(12), 1060–1073. doi:10.1037/0003-066X.57.12.1060
Chretien, K.C., Greysen, S. R., Chretein, J., & Kind, T. (2009) Online posting of unprofessional content by medical students. Journal of the American Medical Association, 302(12), 1309–1315.
Crawford, L. S. (2009). Medical providers and social networking sites. Medical Malpractice Law & Strategy, 26(11), 1.
Ellison, N. B., Steinfield, C., & Lampe, C. (2007) The benefits of Facebook “friends”: Social capital and college students’ use of online social network sites. Journal of Computer-Mediated Communication, 12, 1143–1168. doi:10.iiii/ j.1083-6101.2007.00367.x
Facebook Privacy Policy. (2010) Privacy Policy 8: How we protect information. Retrieved from http://www.facebook.com/note.php?note_id=10150162293565301
Fox, S., & Fallows, D. (2003). Internet health resources: Health searches and email have become more commonplace, but there is room for improvement in searches and overall Internet access. Retrieved from http://www.pewinternet.org
Goldstein, E. (1994). Self-disclosure in treatment: What therapists do and don’t talk about. Clinical Social Work Journal, 22(4), 417–433.
Guthiel, T. & Simon, R. (2005) Emails, extra-therapeutic contact, and early boundary problems: The internet as a slippery slope. Psychiatric Annals, 35(12), 952–960.
Lehavot, K. (2009). “MySpace” or yours? The ethical dilemma of graduate students’ personal lives on the internet. Ethics & Behavior, 19(2), 129–141. Retrieved from http://dx.doi.org/10.1080/10508420902772728
D ow
nl oa
de d
by [P
ac if
ic U
ni ve
rs ity
], [S
ha nn
on A
nd er
so n]
a t 1
3: 09
0 2
M ay
2 01
3
128 S. C. Anderson and M. R. Guyton
McMinn, M. R., Buchanan, T., Ellens, B. M., & Ryan, M. K. (1999). Technology, profes- sional practice, and ethics: Survey findings and implications. Professional Psychology: Research and Practice, 30(2), 165–172. Retrieved from http:// dx.doi.org/10.1037/0735-7028.30.2.165
McMinn, M. R., Hathaway, W. L., Woods, S. W., & Snow, K. N. (2009). What American Psychological Association leaders have to say about Psychology, Religion, and Spirituality. Psychology of Religion and Spirituality, 1, 3–13.
National Association of Social Workers. (2008). Code of Ethics of the National Association of Social Workers. Retrieved from http://www.naswdc.org/pubs/ code/code.asp
National Association of Social Workers & Association of Social Work Boards. (2005). Standards for technology and social work practice. Washington, DC: NASW. Retrieved from http://www.socialworkers.org/practice/standards/NASWTechnologyStandards. pdf
Taylor, L., McMinn, M., Bufford, R., & Chang, K. (2010). Psychologists’ attitudes and ethical concerns regarding the use of social networking web sites. Professional Psychology: Research and Practice, 41(2), 153–159. doi:10.1037/a0017996
Thompson, L., Dawson, K., Ferdig, R., Black, E., Boyer, J., Coutts, J., & Paradise- Black, N. (2008). The intersection of online social networking with medical professionalism. Journal of General Internal Medicine, 23(7), 954–957.
Zur, O., Williams, M. H., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclo- sure and transparency in the Internet age. Professional Psychology: Research and Practice, 40(1), 22–30. Retrieved from http://dx.doi.org/10.1037/a0014745
ABOUT THE AUTHORS
Shannon C. Anderson, MS, received a Master of Science in Clinical Psychology degree from Pacific University and is currently a doctoral candidate there. Her current clinical and research interests include the treatment of co-occurring substance use disorders and trauma, leadership development, and the inter- section of psychology and technology. Michelle R. Guyton, PhD, received an MA in Clinical Psychology from Sam Houston State University and a PhD in Clinical Psychology from the University of Utah. Dr. Guyton is an associate professor in the School of Professional Psychology at Pacific University.
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