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Social media has become an integral part of today's society. Social networking began to take stride in 2002 and by 2006 social media sites such as LinkedIn, MySpace and Facebook began to flourish.1 Facebook remains the leading global social network with more than 1.9 billion active users.2 With the rise of mobile devices and "fourth screens" such as smartphones and tablets, applications such as SnapChat and Instagram have entered the mainstream of social networking. Each social media platform has specific characteristics that engage users. Fifty-two percent of adults now use two or more social media sites, a significant increase from 2013, when it stood at 42% of Internet users.3 As social media use has increased, the rationale in how it is actually used has also evolved.4 Facebook and Twitter users are increasingly using those outlets to obtain news information.5 The growth of social media has allowed not only personal interactions but informational and professional interactions to occur in this media.
Not only does the general public use social media for communicating with a wide range of contacts, social media provides healthcare professionals with tools to share information, discuss policy and practice issues, and educate and communicate with patients and the public at large. It has been reported that while over 90% of physicians use some form of social media for personal activities, only 65% use these sites for professional purposes.6 While social media has numerous benefits of expanding networks and access to information, healthcare providers encounter a number of risks when interfacing on social media. These risks include poor quality of information, damage to professional image, potential for breaches of patient privacy, violation of patient and healthcare professional boundary, and licensing and legal issues.6 Social media platforms allow the public, including patients and their families, to search out health care providers and students and examine their digital profiles. This open access has the potential to be detrimental to the professional image of the practitioner, the medical institution and the profession in general.7
Zijilstra-Shaw et al indicate that social media professionalism is a needed competency in both undergraduate and postgraduate studies, in order to act effectively and ethically.8 An assessment of surgical residency program directors found that surgical residents are more likely to be dismissed from a program for unprofessionalism rather than cognitive failure.7 In a study of dental and dental hygiene students at one college of dentistry, fourteen instances of unprofessional content were found within the student social media profiles.9 Dental hygiene students were more likely to have a Facebook account as compared to their dental student cohorts. Sixty-one percent had an identifiable profile, with only 4% being entirely public.9
It is vital that health care students and professionals understand that online information, even those accounts with restricted access, is not always private. Milton outlined the ethical obligations for nurses related to social media and indicates that violating these ethical and legal principles may open the door to litigation and distrust of the profession.10 Health care providers should maintain their legal and ethical obligations to patients and the public in any media, including social media.
Because of reported violations and the potential of litigations, social media policies have begun to make their appearance in employee handbooks nationwide. A survey by Proskauer found that 90% of businesses use social media in some aspect.11 As social media increases, there has been a greater need to expand the social media policies for companies and organizations. Social media policies in businesses have increased from 60% to 80%, with more than half of businesses updating their policies with precautions being taken to reduce misuse of confidential information, misrepresenting the views of the business, inappropriate non-business use, and harassment.11 Institutions of higher education are finding the need to implement social media policies as well. A study of U.S. dental schools revealed 35% of dental schools had social media policies and among the respondents, all had an official social media page. As a result of the study findings, dental educators and administrators were encouraged to raise awareness of social media professionalism within their schools, through education and curricular integration.12
In addition to the obligation to protect patients' privacy and trust, health care providers should be aware that actions on social media can negatively affect their own credentialing and licensure. State medical boards have imposed disciplinary action related to social media behavior, including restricting, suspending or revoking licenses.6 An example of this type of social media violation included an emergency medicine physician who was fined after making comments on Facebook regarding a patient. Although a name was not released, pertinent information leading to the patient's identity was enough for the Rhode Island State Medical Board make a judgement on the practitioner's unprofessional conduct.13
Studies of social media use by medical students and physicians have highlighted areas of unprofessional content. Previous research has shown that 60% of U.S. medical school deans had concerns regarding students posting unprofessional content.14 Greysen et al studied online professionalism investigations by state medical boards. Surveys including ten hypothetical vignettes were sent to the medical boards to see what type of scenario would prompt an investigation. Among the highest consensus for investigation were scenarios depicting misinformation on physician practice websites, misleading claims of treatment outcomes, misrepresentation of board certification, patient confidentiality, and inappropriate communication with patients.15
Unprofessional conduct violations and guilty verdicts are made public and are part of the individual's permanent licensure record. In the event that a license is restored to good standing, the disciplinary action may have lingering effects, such as restrictions from certain provider groups. Small outlined that nurses may have difficulty finding employment if they are excluded from a Medicaid provider list. Disciplinary action on a license can prevent a registered nurse from working for employers receiving Medicaid reimbursements. Furthermore, obtaining licensure in another state or in another health care profession could be limited if there are disciplinary actions on the permanent licensure record.16
Guidelines for professional social media behavior and the legal and ethical obligations health care providers have to their patients have been discussed in the literature.15 Medical boards have sanctioned medical professionals due to unprofessional behavior online.15 Currently there is a gap in the literature examining how state dental boards license and enforce their individual dental practice acts relative to social media behaviors. The purpose of this study is to identify how online social media behaviors influence the licensure and enforcement of dental professionals.
Methods
A survey research design was used to evaluate the use of social media, licensure and enforcement practice in dentistry. This study was determined exempt by the Institutional Review Board at The Ohio State University. Email addresses were collected from the American Association of Dental Boards website in conjunction with the individual state dental board websites for the 52 licensing bodies. Permission was granted to use a modified version of the survey, "Online Professionalism Investigations by State Medical Boards: First, Do No Harm," developed by Greyson et al.15 The electronic survey, administered by Qualtrics (Provo, UT), was sent via email to the 52 executive directors of each state dental board and a dental hygiene board. The 19-item survey instrument included multiple choice and open-ended questions related to licensure and enforcement policies regarding the use of social media by dental professionals. An initial email was sent to all 52 dental board directors with follow-up emails sent at two, four and six weeks. Follow-up phone calls were made at week five and eight. One final email was sent to all non-respondents at week ten. Agreement to participate was established with the completion of the survey. Descriptive statistics were used to analyze the results.
Results
Eighteen responses were collected from state dental licensing board directors (n=52) for a 34.6% response rate. Respondents were primarily executive directors, located in a wide geographic range in the United States (U.S.). A majority of the respondents reported that they were not using social media as a communication tool for their licensing board. One respondent indicated use of Twitter by the state dental board while two others indicated using the board's website for communication with their licentiates. Demographics and social media usage by state dental boards are summarized in Table I.
When asked whether online unprofessional behavior of licentiates had been reported to the board, the most frequent behavior reported was online misrepresentation of credentials, clinical competencies or outcomes (n=10). The next most frequent behaviors reported were in regard to inappropriate communication or contact with patients online (n=3). Incidents of online unprofessional behavior came to the attention of the board in various ways, including reporting by another dentist (n=8, 44%) and discoveries during ongoing investigations of another complaint (n=5, 28%). Various actions on incidents of online unprofessional behavior were reported including informal warnings, consent orders and continuing education in ethics and professionalism (Table II). In addition to dentists, similar incidents of online unprofessional behavior were reported among other professionals licensed by the board. Dental hygienists (n=3, 38%) and expanded functions dental auxiliaries (n=3, 38%) were most frequently reported. However, reported incidents also included certified dental assistants, dental radiographers and dental therapists/mid-level providers.
Each licensing board was asked regarding their level of agreement with several statements related to social media and dental licensure and enforcement. Many respondents reported that they are uncertain about first amendment rights that may supersede board actions related to professionalism and privacy violations made through social media (n=8, 47%) and whether the board could effectively deal with issues related to social media use and online unprofessional behavior (n=8, 47%). The majority of dental licensing boards do not have policies to specifically addresses social media, Internet use or online unprofessional behavior (n=15, 83%) (Table III).
Discussion
While social media use is increasing, its impact and effects on licensed dental professionals are still being explored. This study represents baseline data in the area social media and state dental licensing boards. It is evident that there are concerns regarding unprofessional online behavior of licensed dental professionals as well as the strength of the current laws and regulations of the individual board to properly address these issues. In general, this study produced similar results to those of the state medical boards.15 Both types of licensing boards reported uncertainty or did not have policies in place for Internet use by their licentiates; did not utilize social media to communicate with their licentiates or the public; and demonstrated concerns regarding violations of professionalism online.
The high level of consensus regarding cause for investigation by state medical boards matched the most frequently reported behaviors identified by the dental boards. Rationale for board investigations included online violations of patient confidentiality, online misrepresentations, and inappropriate communication or contact with patients.15 Specific consequences for these actions were not discussed in the state medical board study. However, there may be other legal consequences for violations of online professionalism including suspension or termination of employment based on an employer's policy. It is noteworthy that dental boards used social media to communicate with the public and their licentiates less frequently than medical boards.15
Beyond potential violations and consequences initiated by the licensing board, it is the responsibility of dental providers to follow their professional code of ethics both online and offline. Codes of Professional Responsibility and Ethics should be updated to acknowledge social media within the core principles. Greysen et al identify that patients could bring suit for privacy violations under the Health Insurance Portability and Accountability Act and the health care provider may be prosecuted by the Department of Health and Human Services.15 Most social media sites have terms and conditions a user must accept prior to joining. Generally, this agreement states that social media sites own the data, though the content author may retain some rights.17
In a second study by Greyson, it was found that teachers and lawyers have been disciplined and or fired for online behaviors.18 Dental professionals must be aware that their online content may be seen by all, regardless of their privacy levels, and potential ramifications for this content can vary based on the extent. Attitudes towards social media usage for dental office business have also been explored. One study showed that while 73% of patients did not expect their dental practice to have a social media account, 36% had searched for their dentist's reviews via Facebook.19 While these findings are not directly related to licensure, they serve as a reminder to be conscientious of public social media postings.
Despite the concern with online unprofessionalism and current laws, rules, and regulations to address these issues, none of the respondents reported that they were creating social media policy at the time of this study. With the increasing use of social media, dental boards should consider policy in order to protect employees, employers, patients, and the public. Rationales for the apparent lack of social media use policies by state dental boards may be an area for future research.
From results of this study, it is evident that legal issues are easily identifiable and punishable, whereas ethical issues may be more difficult to adjudicate. Other ethical ramifications may be more open to the interpretation of the board without a social media policy in place. An additional reason licensing boards may not have a social media policy may be due to uncertainty regarding the intercession of first amendment rights with online unprofessional behavior. Results from this study indicate that 47% of dental boards have uncertainty about this area and should further examine how social media postings may relate to the role of the dental board in licensure and enforcement. Elevating the awareness of state licensing boards on the increased levels of social media use of the general population could promote future adoption of utilizing social media outlets to connect with professionals and the public. In a study of social media usage by students in U.S. dental schools, students stated that online media is their primary source of information.20 Having state dental boards utilize social media sites could bridge the gap between professional and unprofessional behaviors. Dental boards could act as an example and resource of proper online professionalism for licensees to follow.
Future recommendations include creation of state dental board social media policy. Focus should be made on being professional, being respectful, maintaining confidentiality and privacy, respecting third party content, allowing for subject matter experts to respond and add value, knowing that the Internet is permanent, and separating personal views.21 Policies created should reflect the well-being of all parties involved and clearly define what constitutes a violation of such policies. Additionally, state dental boards could require an ethics and professionalism continuing education course for each renewal period. Currently, only six states require an ethics and professionalism course for dental hygiene license renewal. Other states could allow ethics and professionalism courses to fulfill licensure renewal requirements but do not mandate a specific ethics course.22 If states choose to adopt this suggestion, courses should be evaluated to reflect current and up-to-date information including content related to professionalism on digital media. This uniformity would allow professionals holding multiple state licenses to follow the same guidelines regarding social media since this platform has no boundaries.
This study had several limitations. By sending the survey exclusively to the state dental board executive directors, respondents may not have had access to adequate information to answer the proposed questions. This is most likely validated by the number of uncertain responses to the survey questions. One state dental board executive director commented that many of the questions related to violations were handled by a compliance unit and therefore the information was not readily available. Recognizing this limitation would allow for future research to include enforcement officers or compliance units with more direct involvement in online unprofessional conduct complaints. A similar finding was also indicated in the study of state medical boards where one respondent specified that all complaints must be investigated and referred to a compliance unit as necessary.15 Another limitation was that the survey did not include any potential scenarios or hypothetical vignettes, unlike the study of state medical boards. Vignettes showing hypothetical pictures or comments posted on social media sites could be used in future studies for participants to demonstrate concern for investigation.
Since the original research was completed, there have not been any significant findings in the area of state dental licensing boards and social media. With limited data from dental board studies and online unprofessionalism, comparisons to other health care providers are scarce. As more research continues, studies can further compare oral health care related boards to identify similarities and differences among online unprofessionalism. Finally, this survey had a response rate of 35%, limiting its generalization.
Conclusion
State dental licensing boards are aware of potential online unprofessional behaviors and have implemented various consequences. While this study shows that very few state dental boards communicate via social media with licentiates or the public, dental professionals have been warned or penalized for online behaviors which violate dental practice acts or policies. Although no social media policy currently exists for state dental licensing boards, ongoing continuing education programs should include professionalism on digital platforms. Dental professionals should maintain the highest ethical standards for themselves, the public and the profession in all their activities online.
About the Authors
Shawna Staud, RDH, MDH, is an assistant professor in the Allied Health Department at the University of Cincinnati Blue Ash College, Cincinnati, OH. Rachel C. Kearney, RDH, MS, is an associate professor and Chair of the Division of Dental Hygiene, The Ohio State University College of Dentistry, Columbus, OH.
Corresponding author: Shawna Staud, RDH, MDH; staudsn@ucmail.uc.edu
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