Professionalism in a digital and mobile world: A way forward for nursing

Professionalism in nursing has long been steeped in controversy. For many years some argued that nurses were only semi-professional due to a lack of university education and qualifications and a knowledge base and skillset that were not distinctly unique (Adams & Miller, 2001). Nurses are now an established profession with clear and robust educational frameworks, codes of professional conduct and standards of practice (Sills, 2000), regulated by an independent agency or governing body. Examples include the American Nurses Association (ANA) and the Nursing and Midwifery Board of Australia (NMBA) which have scope and standards for practice, along with ethical codes, that underpin nursing practice in these countries (American Nursing Association, 2010; American Nursing Association, 2015; Nursing and Midwifery Board of Australia, 2016). These outline the responsibilities and duties nurses have to patients and the public and include values such as caring, compassion and dignity and behaviours such as supporting, empowering and communicating with patients, relatives, colleagues and students. The International Council of Nurses also emphasise that comprehensive regulations are necessary to maintain trust in the nursing profession (International Council of Nurses, 2014). An emerging trend in the professional practice of nurses is that of digital professionalism, which has been defined as: “the attitudes and behaviours (some of which may occur in private settings) reflecting traditional professionalism paradigms that are manifested through digital media” (Cain & Romanelli, 2009, p. 67). Nurses have used health information systems such as electronic health records for many years to help manage the nursing care process and record data for regulatory, fiscal incentive and population monitoring purposes (Topaz et al., 2016). However, the rise of mobile technology has blurred the boundary between professional and private life as they enable digital information to be collected and shared online. Some nurses have embraced these tools and use them in professional ways to support clinical decision-making (Farrell, 2016; Gartrell et al., 2018), education (O'Connor, Jolliffe, Stanmore, Renwick & Booth, 2018) and learning (O'Connor & Andrews, 2018). However, McBride, LeVasseur, and Li (2015) noted that nurses sometimes use personal mobile phones or other communication devices for private reasons such as sending text messages or reading the news during working hours, outside of breaks and meal times. A further worry is the unprofessional behaviour displayed by some nurses online, who post inappropriate images or comments about patients, colleagues or their workplace on social media (Wang, Wang, Zhang, & Jiang, 2019). Despite the potential benefits of mobile technologies to advance professional practice and patient care, there appears to be a lack of trust that nurses can use them appropriately. Some studies have reported resistance to nurses using personal mobile devices in clinical settings, as there were concerns this could be perceived as unprofessional by patients, families or colleagues (Beauregard, Arnaert, & Ponzoni, 2017; Johansson, Petersson, & Nilsson, 2012). In some countries, such as Australia, policies also restrict the use of mobile devices in clinical environments (Mather, Cummings, & Gale, 2018). Furthermore, McNally, Frey, and Crossan (2017) found that some nurse managers were unable to distinguish between private and professional use of personal mobile devices (i.e. smartphones) by nursing students. Hence, they preferred to prohibit this technology in hospital settings as regulating when, where, and how they could be used was challenging. This view of digital professionalism seems to be particularly problematic for nursing students, most of whom have grown up with technology and are keen to use it in their clinical practice to find and retrieve information and apply new knowledge and skills (Lee, Carson, Clarke, Yang, & Nam, 2019). A paradox in relation to digital professionalism is evolving, as district and community nurses are being encouraged in some countries, such as the United Kingdom and Switzerland, to use mobile devices to access and record patient information (Royal College of Nursing, 2017; Swiss Nurses Association, 2019), while their counterparts in hospital settings are not. Although there is better digital infrastructure in acute care, nurses can have limited access to and use of computers (Zadvinskis, Smith, & Yen, 2018). As health services move towards documenting care electronically, a lack of computer availability may restrict the efficiency and efficacy of nurses when working in multidisciplinary teams. One solution, proposed by Parker (2014), would be to equip every nurse with an employer provided mobile device, preloaded with all the required software applications and security features that could be used in clinical practice. This approach is being implemented in some hospitals in the United States (Mobile Heartbeat, 2019), although it is not widespread practice. The landscape of digital professionalism is further complicated by other groups of health professionals such as physicians who also use personal mobile devices in clinical environments. This can create confusion among nurses and nursing students about what is considered acceptable practice. Dimond, Bullock, Lovatt, and Stacey (2016) contend that mobile devices should be as much a part of a junior physician's armoury as a stethoscope, given the wealth of information that is accessible via this technology to facilitate clinical decision-making at the point of care. Furthermore, some health services are developing mobile apps specifically for physicians and nurses to aid decision-making (Davies et al., 2017). And yet, some may not be able to use these apps due to concerns around personal mobile devices and digital professionalism. One could argue not using mobile technology in nursing might be unethical in a sense, if these tools could be used to improve patient care and as many nurses cannot use them, there is limited evidence on whether mobile apps for nurses could have a positive impact. Perhaps the way forward, is a pragmatic one, where the needs of nurses and nursing students are balanced with the perspectives of patients, families, health service managers, and others. More robust research on the effectiveness of mobile devices and apps used by nurses to improve patient and other outcomes is needed. If the benefits of using this technology in day-to-day clinical practice do not outweigh the risks of doing so, then it should be adopted. Hence, a more nuanced approach that considers the values and needs of multiple stakeholders regarding digital professionalism is needed. Educating nursing students and nurses about safe and appropriate use of mobile devices could prepare them to work in more effective ways and avoid some of the risks associated with mobile technology. Best practice guidelines regarding digital professionalism, including how mobile platforms should be used in clinical settings, could be co-designed with all relevant groups. Stakeholder consultation could ensure that all perspectives are considered and agreement can be reached on the values and behaviours that underpin what is acceptable and professional digital practice. These could assist with informing institutional policies and be used to strengthen the training and education of nursing students, nurses and nurse managers and guide leaders in legitimising the use of mobile technology in healthcare. The guidelines could also be displayed in clinical areas to remind staff and students to use technology appropriately and reassure patients and families of this. A global approach, where internationally agreed guidelines on digital professionalism are developed, may also facilitate consistent adoption worldwide. Making these changes could contribute to ensuring nurses and nursing students demonstrate professional use of technology and continue to deliver high quality care in a digital and mobile world. No conflict of interest has been declared by the authors.

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