Abstract

Introduction

The use of social media sites (SMS) has increased exponentially since their creation and introduction in the early 2000s. The number of regular users of SMS is estimated at over two billion people worldwide. Ethical and legal guidelines exert an additional responsibility on the behaviour of both graduate and undergraduate dentists when compared to members of the general public with some assumption that life experience can offer some insight into attitudes about online use of social media in relation to professional practice.

Aim

We set out to explore the views of the first year graduate entry programme students at the University of Central Lancashire and their use of SMS together with their opinions on what they consider to be professional online behaviour.

Methods

A mixed-methods approach was adopted with a questionnaire and semi-structured interviews which were designed to elicit the students' opinions.

Results

For this group of students, 100% were using social media sites and some were aware of some of their limitations and possible impact on their careers. There was some rather superficial knowledge of what is and is not professional to post via social media, however, students were not fully aware about the legal and ethical guidelines in place in relation to the topic.

Conclusion

Results from this study present an opportunity and a challenge for educators to incorporate additional details not only about professionalism and ethical and legal aspects within the undergraduate curriculum but more specific emphasis on the use of social media as part of the undergraduate BDS course.

Introduction

The invention of the World Wide Web in 1990 by Tim Berners Lee and other scientists based at Conseil Europeen pour la Recherché Nucleaire (CERN) has significantly changed the way that we communicate with each other.1 One of the ways that the World Wide Web has impacted our lives is demonstrated by the rise in social networking sites (SNS), often referred to as social media sites (SMS), which have a significant impact on millions of people across the world. The number of regular users of SMS is estimated over two billion people worldwide.2 A mere four years after the creation of Facebook, the profiles of undergraduate medical students at the University of Florida were evaluated3 and an unsettling pattern of online behaviour was noticed with 'a significant proportion having subjectively inappropriate content.' It was recognised that the Accreditation Council for Graduate Medical Education (ACGME) counts professionalism as a core competency but that it is a difficult concept to measure and thus to teach.

As the regulator for the dental profession, the General Dental Council (GDC) sets the ethical standards for practitioners,4 which are considered higher than any ethical standards that govern the rest of the population. It is possible for a dental practitioner to breach a professional, ethical standard and be held to account by the GDC when no law has been broken. It is, therefore, important that healthcare professionals are aware of where these boundaries lie and appreciate that the standard of their professional behaviour is significantly different from that expected of a member of the general public. This professional standard does not only apply to graduates but also to those who are studying to join a professional body as detailed in the GDC guidance document, Student professionalism and fitness to practice.5,6

The first GDC advice for registrants was only produced in 2013 and was updated in 2016. This guidance outlines more specific detail on how registrants can use social media in a safe and professional way. For example, maintaining patient confidentiality, suggesting that careful consideration should be utilised before online contact with patients and ensuring that online postings should not damage public confidence in the profession. The GDC's Student professionalism and fitness to practice5 has similar themes with some specific guidelines on how dental students must behave in a professional manner which contrasts significantly with what is expected of undergraduate students studying non-healthcare subjects. Within UK dentistry, specific research among dental students has been relatively recent. Neville and Waylen7 considered that there was little, if any, survey of dental students' use of SMS. Research into the guidelines for SMS use published by the GDC,6 GMC,8 NMC9 and the Health and Care Professions Council concluded that there are broad similarities and recognised that the guidance was useful for an experienced professional but that students needed some practical examples in order for them to appreciate where the boundaries lie.10

Undergraduate dental students are primarily young, inexperienced adults, many of whom are living away from home for the first time. Their concept of suddenly behaving in a 'professional' way is something that they may be unaware of and can result in a sanction from their university. However, it is not clear if students who are part of a graduate entry BDS programme have different views about being professional in relation to using social media, given the fact that they, as a group, are older than other first year BDS students, possibly with more life experience.

In this small study, we explored social media site use among the first year BDS student group at the University of Central Lancashire (UClan) Dental School. The focus was to explore students' level of understanding of the GDC guidance and legal and ethical awareness of issues related to use of SMS.

UClan has a number of policies that the students must adhere to. For example, an email policy,11 a fitness to study12 and fitness to practice policy,13 which governs all undergraduate and postgraduate students and governs the behaviour expected. The dental school also has an annual 'Declaration of good health and good character' that all students must sign. One of the declarations is, 'I intend to comply with the code of professional conduct: GDC Student Fitness to Practice.' In addition to the UCLan policies,11,12,13 the BDS students undertake clinical placements at one of four dental education centres, which are operated by a Hospital Trust and they are considered to be employees and must therefore abide by the Trust policies. Permission to undertake this small study was obtained from the head of the dental school and ethical approval was obtained from the University of Bedfordshire, Institute of Health Research Ethics Committee (ref: IHREC 705) and the University of Central Lancashire (ref: STEMH 600).

Methods

A mixed method of quantitative and qualitative approach was utilised to gauge students' views and perception as well as gather their data usage of SMS.

All first year BDS students (29 students) who were five months into their BDS course were approached using convenience sampling.14 This student group had one brief lecture on the subject of fitness to practice and professionalism (not related to this study). Students were approached before a timetabled lecture and information was given outlining the nature of the study and a request made for their voluntary participation. Participant information sheets and questionnaires were distributed to those who decided to take part (22 students). The questionnaires had no identifying data to ensure participants' confidentiality and to protect students' identity. An invitation for a follow up semi-structured interview was included as part of the research questionnaire to which four students volunteered, students were not offered any reward for taking part in the study.

Results

Thematic analysis was used to analyse the data obtained from the semi-structured interviews and the quantitative data were analysed using a uni-variate approach.14 Semi-structured interviews were conducted by the first author and all interviews were recorded, transcribed and coded. Average time for interviews was 26 minutes.

The age range for students who took part was 21–38 years with the mean age of 23 years old with more female respondents (14) than male (eight) which is proportionate to the trend within UK dental schools.15 As UClan dental school is a graduate entry programme, all those who took part had a Bachelor degree plus four who also have postgraduate degrees.

The questionnaire included demographic data as well as questions about the use of different social media sites, awareness of privacy settings online, views about what constitutes unprofessional behaviour online, accepting patients and university staff as 'friends' on social networks with free text sections included with each question where participants were asked for examples, explanations and/or justifications to expand on their answers.

Responses to questions about what social media sites (SMS) students currently use on a regular basis, for example, at least once per week, are shown in Table 1.

Table 1 Number of students using different social media sites (SMS)

Questionnaires and interviews data

Participants reported use of SMS with WhatsApp, Facebook and Snapchat being the most popular. Only a small number (>6) were using LinkedIn, Twitter, Pinterest and none were using GDPUK, possibly because they were unaware of its existence as it is mainly used by BDS graduates. Participants reported high frequency of use with only one student who reported accessing SMS only once a day and the rest of participants reporting access multiple times during the day, with all participants reporting using their mobile phone as the preferred platform to access SMS. Among the student group who participated in the study, the majority reported awareness of using privacy settings to their SMS with only two students who didn't use these features routinely. There was an interesting split in whether the students view privacy settings as secure with half being of the opinion that the security is only partial or not at all.

When asked if they've observed what 'they consider to be an inappropriate posting, comment or photograph by one of your SMS friends,' nine students had observed a posting that they considered to be inappropriate. The majority commented on postings regarding drunken behaviour, bad language and other rude or vulgar comments and jokes. These were considered to be unprofessional by the students. The majority of the students (17) had seen an inappropriate comment by a 'non-friend' and a similar pattern of behaviour to the 'friend' group was reported in having observed bad language, drunkenness and nudity. However, there were reports of what could be considered extreme postings, which may be illegal (for example, snorting cocaine off a police car, revenge nude photographs after the breakup of a relationship). Extreme far right political views and racism were also observed by a number of participants.

When asked about accepting dental patients as friends or interacting with patients on SMS, only four students considered that interaction to be appropriate. However, they did qualify the parameters in which it may be acceptable:

'If a social media site was developed specifically for dentist-patient interactions, I would. It could enhance rapport with patients and improve recall, compliance etc. I would not accept a patient friend request on Facebook for example (too personal SMS)'

'If I knew the patient socially outside of work – maybe only just joined social media'

'Only if patient is already a family member or a friend.'

These comments suggest that the answer is really, 'no I wouldn't accept a friend's request unless it was on my specific terms,' or in other words, 'I wouldn't accept a friend's request from someone who is only a patient.' The remainder of the students were well aware of the potential problems, and all expressed similar concerns, for example:

'[I] have to maintain professional boundaries – accepting friend request blurs the lines of relationship'

'I want to keep a professional relationship with patients [who aren't friends/family] and therefore share private/personal information that I can't control. I also don't want to form potential negative opinions about a patient based on their postings'

'I feel it's better to have professional relationships, the patient's intent is unknown. It's an inappropriate relationship. Also it's important in “covering” yourself legally. They may use your SM against you.'

When asked about accepting friend requests or interacting in any way on a SMS with a member of the university staff, eight participants considered interacting with a member of the university staff as acceptable, however they did qualify the circumstances:

'Professional relationships aren't necessarily affected by social media friendships.'

'Yes, if I feel I know them well enough and can trust them – perhaps a member of staff who I feel has helped + supported me during my learning and got to know them better'

'My masters [sic] lecturers added me on Facebook. I did feel strange accepting them, but did so out of politeness. I guess it is good to keep in contact with them, as I'm waiting to get back into research.'

Of the remaining participants, the comments were unequivocally negative:

'We aren't friends – it's a professional relationship'

'I believe it should be a strictly professional relationship for the duration of the course'

'While studying NO, after graduation yes!'

'[It] may break the professional barrier.'

Nine participants were unaware of any legal or ethical guidelines that they must adhere to as a member of the public regarding the use of social media. Of the remaining participants, there was some superficial knowledge and some were not correct. None of the students demonstrated knowledge of any laws that are in existence, or examples of cases reported in the media in relation to this topic. However, there was more awareness regarding the guidelines that a dental student must work to, the majority of which were directly related to GDC standards especially patients' confidentiality and anything that might bring the dental profession into disrepute.

Discussion and implications

The use of SMS among this student group is universal with all participants using one or more of the sites. Facebook and WhatsApp are being used by the majority with high usage of Instagram and YouTube. This figure for the number of students using Facebook corresponds closely with other researchers; Kenny and Johnson16 reported 97% use of Facebook among dental students and Garner and O'Sullivan17 reported 96% use among medical students. Other researchers demonstrated slightly lower numbers but some of these results were from several years ago such as Chretien18 who found 35% usage of Facebook but this may be because Facebook was not as popular at the time. The frequency of using social media (more than once a day,) also corresponds with Kenny and Johnson's work16 which showed 97% of respondents accessing Facebook more than once per day. With advancing technology, all students were using their mobile telephones as the primary route to access SMS which facilitate multiple accesses to SMS.

The majority of students commented on postings regarding drunken behaviour and photographs, bad language and other rude or vulgar comments and jokes. These were considered to be unprofessional by the students. However, they've also mentioned freedom of speech and being free to live a normal life. The belief about freedom of speech while commendable could have implications should a friend or colleague need some advice following an unprofessional posting. Participants reported their understanding of the additional responsibility they had as a healthcare professional although some were not aware of available legal and ethical guidance. Surprisingly, half of those who took part considered the security settings on the sites that they were using were secure. Some had a basic level of knowledge about third party access to information on SMS (for example, Facebook). This may be related to the fact that this group are slightly older than students in other studies and have more life experience and personal examples of having observed and experienced inappropriate use by others. However, none of the recent infamous social media cases reported recently in the media19,20,21,22 were mentioned by participants.

This group of mature students demonstrated that they had some knowledge of the existence of legal and ethical guidelines in place but the detail was superficial. This may be because there has been limited teaching in this subject in the early stages of the BDS course and their awareness was more personal. The confidentiality of patients' data and treatment was a subject that all were aware of as an ethical and legal requirement. Professional behaviour was a subject that arose frequently and the majority of the students were aware that having an SMS relationship with a patient was not recommended. The few who did think that this was appropriate were aware that certain parameters would need to be in place before proceeding, for example if the patient was an existing friend. Similarly, interaction with university staff was not considered a good idea as an educational and a professional boundary may be breached. It was not considered appropriate to share your personal life with a teacher and vice versa. This raises the subject of power relation should one party observe something online that they considered unprofessional and use this as leverage in what ought to remain a professional relationship.

Specific reference was not made in relation to the outcome following inappropriate use of SMS within dental school and what it may lead to, for example, a student fitness to practice process. This could be due to lack of information about fitness to practice and for this process not being at the forefront of students' thoughts in their first year of the course. This is significant as dental students, even in their first year, could still be in danger of damaging their reputation by engaging in unprofessional behaviour online. This could be due to the perception that there may be some degree of safety that students may feel as part of 'being a student,' although, in theory, participants identified what could constitute unprofessional behaviour online.

The information gained from this investigation presented some insight into how this group of mature students views professional use of social media. The information gathered shed some light about their views and it has contradicted some of the initial assumption that this group of students may be more aware of guidance, laws and regulations when it comes to social media use compared to the average first year BDS student. Graduate entry programme students in healthcare are reported to be more motivated,23 have better academic results than direct school leavers,24 could experience more anxiety and stress symptoms25 and have a better outlook towards professionalism and personal interactions compared to undergraduate students.26 However, results have also challenged the assumption that this group of students are more in tune with professionalism in the news and current affairs than the average first year undergraduate student. Further studies are always recommended to assess how students change their use of SMS as they progress into their BDS course and as their knowledge about the guidance improves.

The results presented here from this small group of students is unlikely to represent all graduate entry students, however, this study offers an insight into the perception and the views of this small cohort towards what they consider professional behaviour online. The data also shed some light on the need to offer more educational support to this group of students without the assumption that 'they know better'.

Exploring students' views about professional use of social media is important not only to their peers and other student groups but also to educators and regulators to offer more detailed and structured guidance to students. For this mature student group, knowledge of legal and professional regulator guidelines was not as detailed as expected and our view is that this needs to be incorporated into scheduled teaching at a very early stage of the course so that students do not find themselves with a fitness to practice hearing and possibly excluded from their course. The tendency to treat mature or postgraduate students differently due to the fact that they are older and may have more life experience could be seen as mistaken.

It is important to note that for this group, students were invited to take part in interviews after completing their questionnaires to further explore their views about the topic. However, only four students agreed to take part. Perhaps being interviewed to explore their own behaviour with the risk of disclosing information that may or may not be seen as unprofessional was not a good idea from the students' viewpoint. However, anonymous questionnaires allowed students to be as open as possible with their own views about their behaviour and values, safe in the knowledge that their identities are protected. This is paramount for educators who teach ethical and professional practice, as the tendency to agree with what is considered to be 'the right moral answer' is always present when teaching such topics. Students can hardly air a view that will disagree with the GDC standards4 or guidance on ethical and professional practice5 in an open discussion. However, engaging in debate around real life examples, together with exploring case scenarios as part of teaching the guidance and regulations, will assist in developing the moral competencies for some of the professional and ethical real-life issues that students will face in practice. Finding real-life examples of inappropriate behaviour by healthcare students to develop as case studies to use for teaching could be challenging as the student fitness to practice process within dental and medical schools must be a confidential process. Sharing of experiences and knowledge between dental schools concerning this subject and expanding into student fitness to practice in general would be useful.