An assessment of professionalism on students’ Facebook profiles

Abstract

Introduction

With the advent of social media, healthcare professionals not only need to be conscious of professionalism in their face‐to‐face interactions but also in the electronic environment. The aim of this study was to assess the level of online professionalism on Facebook profiles available for public viewing of students from a dental school.

Materials and methods

A search was performed via a new Facebook account of all students in the University Dental School (dental hygiene, dental nursing, dental science and dental technology). Profiles were categorised as ‘private’ or ‘public’. Demographic details and photographs/comments of unprofessional behaviour were recorded for each individual Facebook profile. Each profile was subsequently scored with regard to professionalism based on a previously published score.

Results

There are a total of 287 students in the dental school. Of these, 62% (n = 177) had a Facebook account. Three per cent (n = 6) had a public account (fully accessible) whilst 97% (n = 171) had a private account (limited access); 36% (n = 63) of students mentioned the dental school/hospital on their profile; 34% (n = 60) had questionable content on their profile whilst 3% (n = 6) had definite violations of professionalism on their profile; and 25% (n = 44) had unprofessional photographs on their profile. Of those with unprofessional content, 52% (n = 23) of these had a documented affiliation with the dental school also visible on their profile.

Conclusion

There was a concerning level of unprofessional content visible on students’ Facebook profiles. Students need to be fully aware of their professional responsibility in the setting of social media.

Introduction

Healthcare professionals are expected to act in a professional manner when they are in practice and when they present themselves in public. The General Medical Council in the UK offer guidance regarding ‘Maintaining a professional boundary between you and your patient’; in this publication, dentists are advised to ‘ensure that your conduct, both at work and in your personal life, justifies patients trust in you and the public's trust in the dental profession’ 1. Dental professionalism signifies a set of values, behaviours and relationships that underpins the trust the public has in dentists 2.

With the advent of social media, healthcare professionals not only need to be conscious of professionalism in their face‐to‐face interactions but also in the electronic environment 3. Three‐quarters of medical students use social media regularly; however, they rarely monitor their online presence 4.

With the ever‐expanding use of Internet worldwide, it is common for people to use online resources to seek supplemental information regarding their health 5, up to 75% of people use the Internet for such reason 6, 7. It can be assumed that similar numbers of patients are using the Internet for dental information 8. In addition to learning about their conditions, patients can also find information about their healthcare provider. Previously inaccessible personal information about their physician can now be easily obtained through the Internet by searching popular social networking sites such as Facebook, Twitter, LinkedIn and MySpace 9. Social media, which facilitates interaction and sharing of new ideas, is being utilised to educate students, residents and faculty 10. Interactions between healthcare professionals and patients on social media platforms, such as Facebook and Twitter, can lead to inappropriate or embarrassing situations 11.

With over one billion users in December 2015, Facebook is one of the most utilised forms of social media 12. Facebook allows its users to create a ‘profile’ whereby they can communicate with friends and family through ‘Facebook chat’ or by means of their ‘wall’, where they can post statuses, photos and comments. Facebook allows the general public to access personal information unless viewing restrictions are placed by the individual with the account. Such information may be considered personal, such as comment and photographs 13.

American universities have been faced with issues regarding inappropriate posts on Facebook including those of racial and sexist nature, as well as unacceptable comments and threatening behaviour towards staff members; as a result of this, a number of students have since been suspended and expelled 14. A survey of surgical residency programme directors highlighted an increasing number look at applicants’ social networking sites, and one‐third ranked an applicant lower after viewing their social networking site 15.

The lack of guidance regarding the use of social media in our dental school prompted our study; similar to other schools and published studies, we hypothesise that students’ online profiles may contain unprofessional content. The aim of this study was to assess the level of online professionalism on Facebook profiles available for public viewing of students from a dental school.

Materials and methods

Following approval from the ethical committee of the University Dental School, class lists were obtained from the schools’ secretarial staff for all years of dental hygiene, dental nursing, dental science and dental technology. Authors were blinded to individual student identification numbers.

To view the students’ individual Facebook profiles, the authors (K.N., H.B. and G.N.) created a new Facebook account. It is paramount that a new Facebook account was created, as this allowed the authors to truly analyse what information is available to the general public, including patients, and current or future employers. An account which had affiliations to those involved in the search, or was part of a Facebook group or university domain, would allow for greater access to information on the students being searched, therefore not providing an authentic picture of what is publically visible. The only data which was analysed was the information that students made publically available and did not require special permission from the student.

Every registered student in dental hygiene, dental nursing, dental science and dental technology was searched on Facebook individually by each author using the newly created Facebook account. Names which produced multiple results were narrowed down by network, affiliation, institution or current location to identify the correct profile. If a name produced multiple results, and could not be narrowed down, it was then excluded from the study. Once these applicants were identified, their Facebook profile was categorised as ‘private’ or ‘public’. A private profile was defined as one that contained only basic demographic information that did not extend beyond age, educational history and location. If any additional information (interests, pages, photos, quotes, relationship status, etc.) was provided, it was considered to be a public profile.

Age, name and sex were not recorded as these were features which the authors and ethical committee thought may be identifying factors of certain students in specific courses. Details including educational history, location, relationship status, mention of being a dental student, mention of the dental school and photographs of incriminating behaviour were recorded for each individual Facebook profile.

Each profile was subsequently scored with regard to professionalism, based on the following rating system published by Ponce et al. 9 (Table 1). For example, a score of 2 may have been evidence of public intoxication, whereas a score of 3 may have been a racially insensitive comment.

Table 1.

Rating system for professionalism

Score	Description
1.	Definite violations of professionalism
2.	Questionable content (e.g. Evidence of Public Intoxication)
3.	No professionalism issues (e.g. Evidence of Racially Insensitive Comments)

Results

There are a total of 287 students in the dental school [72% (n = 207) dental science students, 16% (n = 46) dental nursing students, 7% (n = 20) dental hygiene students and 5% (n = 14) dental technology students]. A total of 53 (30%) Facebook users were excluded from the study as multiple results were found for their name that could not be narrowed down to a verifiable account. Demographic details are listed in Table 2. Thirty‐six per cent (n = 63) of students mentioned the dental school/hospital or had an affiliation to it on their profile, and 64% (n = 114) mentioned their specific course (49% dental science students, 10% dental nursing students, 3% dental hygiene students and 2% dental technology students).

Table 2.

Demographic details of the cohort

	Cohort
Total number of students	287
Facebook Profiles (%)	177 (62)
Male:Female	52:125
Private profile (%)	171 (97)
Relationship status (% reported)	18 (10)
Sexual status (% reported)	0 (0)
Nationality (% reported)	92 (52)

Regarding the professionalism score, 62% (n = 110) had no evidence of professionalism issues on their profile, 34% (n = 60) had questionable content on their profile whilst 3% (n = 6) had definite violations of professionalism on their profile and 25% (n = 44) had unprofessional photographs on their profile including alcohol and levels of nudity. Of those with unprofessional photographs, 52% (n = 23) of these had a documented affiliation with the dental school also visible on their profile. There was no identifying patient information on any profile. Unprofessional content was not unique to any specific course; of the 44 students with unprofessional photographs, 19 were dental science students, 13 were dental nursing students, nine were dental hygiene students and three were dental technology students. Regarding the six definite violations of professionalism, these pertained to comments/graphics and posts of racial and sexual nature.

Discussion

Our study found a substantial (62%) amount of students had a Facebook profile. The vast majority had a ‘private’ profile which limits the amount of information available for public viewing. Despite this, basic demographic information as well as a selection of photographs was still viewable. A concerning finding was that approximately one‐quarter had unprofessional photographs visible on their profiles and of these, over half had mention of the dental school or mentioned being a dental student on their profile. Even though some do not mention dental school, it is possible for patients to narrow down profiles in order to access the correct one, by means of viewing the photographs which are easily accessed. This highlights that a number of students are allowing the general public to visualise photographs which portray unprofessional behaviour.

Thompson et al. carried out a similar study on medical students/residents and found 37.3% of their participants kept their Facebook accounts private, compared to 97% of our cohort 16. The presence of unprofessional online behaviour varied greatly between the two studies. An in‐depth analysis of ten students was performed using a random number generator; they noted 30% unprofessional behaviour (unprofessional material was subjectively defined as anything that could be interpreted to illustrate substance abuse, sexism, racism or lack of respect to patients) in their study, compared to 3% having a ‘definite violation’ of professionalism and 34% having ‘questionable’ violation of professionalism in our study. Furthermore, our cohort size analysed 177 student profiles compared to 10 (0.2% of their full sample size) medical students which were analysed for professionalism in that study; our study size is a more representative sample of the multidisciplinary dental team. Henry et al. carried out a similar study, aimed at dental students and dental hygiene students in the United States with 12.8% having ‘private’ profiles 3. They noted similar levels of unprofessional content (unprofessional content was subjectively defined as any illustrations or writings that could be interpreted to be substance abuse, sexism, racism, potential privacy violations and lack of respect for teachers or the university) to our study – approximately 5%. In contrast to previous studies, we used a validated scoring system of professionalism 9.

In 2010, MacDonald et al. reported that 63% of young medical professionals had private security settings on their Facebook profiles compared to 97% of dental undergraduates in our study 17. Worryingly, MacDonald reported nearly 4% of potential breaches of patient confidentiality. It is concerning that there is any form of breach in confidentiality on the Internet available to any member of the public. There were no breaches of patient confidentiality found in our study. Similarly, Barlow et al. reported a substantial level of unprofessional content (34%) amongst Australian medical students – mainly depictions of intoxication (301 students, 34.2%) or illegal drug use (14 students, 1.6%), or posting of patient information (14 students, 1.6%) 18. Kitsis et al. noted significant differences in levels of self‐reported unprofessional (self‐posting of profanity, depiction of intoxication and sexually suggestive material) online conduct between students and faculty at an American university 4, suggesting that graduates have a greater awareness of their online responsibilities. Furthermore, it has previously been reported that use of Facebook decreases as trainees move from residency to fellowship 19, suggesting a possible heightened sensitivity to problems associated with Facebook use as one advances in a professional career. Spallek et al. recognised three developmental stages in a student's path to becoming a competent professional: from undergraduate to dental student, from the classroom and pre‐clinical simulation laboratory to the clinical setting and from dental student to licensed practitioner. They proposed an educational programme to prevent inappropriate use of social media as students are introduced to novel situations 20; a similar endeavour is currently under consideration in our institution based upon the findings of this study. Other possible explanations include a busier working schedule allowing less time for social media use as well as many institutions blocking social media sites in work. The further the students progress in their career, the more professional/personal experience they develop – this maturity may also be a factor.

It is of utmost importance to educate others on how security settings on Facebook operate. The default security setting for Facebook accounts is ‘social’, meaning the general public can access your information and your profile without befriending you. It is the Facebook users’ responsibility to change their privacy setting to maximum security, to limit the amount of information seen by the general public. Regardless of whether an online profile is ‘public’ or ‘private’, healthcare professionals need to be aware of the implications of improper conduct. Improper online activity represents a risk to the reputations of universities, hospitals and teaching programmes, and students/residents should be educated on the dangers of social media. Educational modules regarding social media use have been introduced in some schools as a result of findings similar to ours 4, 21. The challenge facing educators is how to capitalise on the benefits that social media offer, whilst minimising risks and complying with the various forms of legal constraint 22. It has been postulated that healthcare providers need to take control of their online profile; certain sectors use this to enhance interactions with patients 23. However, face‐to‐face interaction with patients remains paramount to the physician patient relationship. Numerous medical societies or medical journals have published guidelines regarding the professional use of social media 24.

The General Dental Council (UK) recently offered some guidance regarding the use of social media – ‘you must consider the potential risks involved in using social media and the impact that inappropriate use could have on your patients’ trust in you and society's trust in the medical profession’ 25. They acknowledge the limitations associated with a private setting on a social media profile in that some information is still visible; they also recommend regularly checking the privacy settings on your profile. Medical professionals are entitled to privacy and private lives; they just need to remain conscious of the impact of any photographs or material they post online as this can be viewed publically.

There were a number of limitations to our study. When analysing Facebook profiles, there is the potential for students to change their privacy settings at any stage during the data collection phase; therefore, this could lead to some discrepancies with regard to the authors’ scoring of professionalism. To minimise this risk, the data collection was kept to a short 2‐week period. The data collection was confined to one dental school. This inevitably limits the ability to generalise the information over a broad population. It would be of interest to carry out this study in other dental schools, to see whether there is a trend in the level of online professionalism amongst different years and courses.

Although Facebook is one of the most used social networking sites, it would be interesting to see whether the results would be different if analysis included other social media sites such as Twitter, LinkedIn and MySpace. It would be of value for a longitudinal study of this topic to be done, to allow us to analyse whether unprofessional behaviour continues or changes as these students graduate.

Conclusion

The use of Facebook is prevalent amongst dental students. Despite the use of standard security settings, a concerning level of unprofessional content was visible. Students need to be fully aware of their professional responsibility in the setting of social media. Based on our findings, the dental school needs to consider an educational module regarding the management of personal profiles in a professional setting.

Conflict of interest

All authors declare there are no conflict of interests in relation to this study. A disclosure statement was sourced from all co‐authors, signed and attached to the submission.

Funding

No funding was sought or received in conjunction with this study.