Scandinavian trade unions’ guidelines regarding nurses’ use of social media: a Fairclough-inspired critical discourse analysis

Introduction: Social media provides nurses with tools to share information, debate healthcare policy and practice issues, and engage in interpersonal interactions. Historically, also in Scandinavia, nurses’ trade unions have taken the lead in defining nursing as a profession and supporting nurses in ‘conducting good nursing’. However, it is unexplored how trade unions guide nurses in social media use.

Aim: To explore the explicitly formulated guidance documents provided by Scandinavian nurses’ trade unions, specifically focusing on how the trade unions guided nurses’ social media use.

Materials and methods: Trade union guidelines for social media use were searched on the Scandinavian nurses’ organisations’ websites. A textual discourse analysis inspired by Fairclough’s critical approach was conducted. The analysis considered three levels: the social practice level, focusing on connections between the texts and the surrounding society; the discursive practice level, focusing on the processes of production and distribution of the texts; and the textual level, capturing how grammatical formulations and single words work in the (re) construction of social structures.

Results: At the social practice level, the trade union documents guiding nurses’ social media uses were embedded in platfomised public communication, laws about confidentiality and data protection, and ethical codes for nurses. At the discursive practice level, the guidelines were constructed to support nurses’ social media uses in adhering to their profession’s ethical principles. The trade unions’ implicit and explicit representations of nurses blurred the distinction between nurses as professionals and nurses as private persons. At the textual level, the guidelines tapped into the potential risks of using social media and how nurses ought to act on social media. Unlike the Danish and Swedish trade unions, the Norwegian trade union did not develop specific guidelines for nurses’ social media use.

Conclusion: The guidelines emphasized risks stemming from social media use that did not adhere to the profession’s politically defined guidelines, norms, and values, although nurses’ conditions are already framed by the national legislations and ethical standards. The study advocates for the development of guidelines that support beneficial uses of social media in relation to nurses and the nursing profession.

Introduction

In recent years, the use of social media in healthcare has grown significantly, partly as a trend in time and partly as policymakers have encouraged the implementation of digital patient-clinician interactions (Hvidt et al., 2021; Sultan et al., 2021). Social media can be understood as social interaction through technology-based tools, where many of those tools are online, such as internet forums, blogs, and networking sites, e.g., Instagram, Facebook, and LinkedIn (Institute of Business Ethics, 2019). Social media platforms have become a versatile tool in many people’s daily life for private, social, and professional purposes. The continuously evolving social media landscape has led to a more digitalized and web-based paradigm of interpersonal communication between people (Mariano et al., 2018). Social media platforms such as Facebook, Instagram, Twitter (rebranded as X in 2023), LinkedIn, and YouTube have an increasing number of individual and organizational users worldwide who use them to communicate, connect, create and share information (Charalambous, 2019; Sultan et al., 2021). Social media is often referred to as “a group of Internet-based applications (apps) that allow the creation and exchange of user-generated content” (Kaplan and Haenlein, 2010, p. 61). All platforms are driven by data and algorithms, which both connect users to each other and control the users’ use of data. Today, five companies dominate these platforms and thus own most of the data users generate when using these platforms, namely Facebook, Apple, Google, Amazon, and Microsoft (van Dijck et al., 2018). As of 2020, social media users have reached over 3.8 billion worldwide (Datareportal, 2020). Overall, as of January 2024, Norway is the Scandinavian country with the highest social media penetration, with 82% of the population using social media, followed by Sweden (80%) and Denmark (80%) (Dixon, 2024). Among social media applications, Facebook has been the most popular mobile application in the Scandinavian countries over the past few years, and other applications, such as Instagram, have also become increasingly popular (Ceci, 2023). As social media becomes more accessible and diverse and takes up a large part of day-to-day activities in the personal and professional lives of individuals and organisations, social media platforms have become pervasive communication channels, making real-life and online reactions increasingly intertwined and converging (Abd-Alrazaq et al., 2020; Farsi, 2021; Kanchan and Gaidhane, 2023). Whether as private or professional initiatives, the use of social media has come to pervade and affect, e.g., health literacy and communication and the delivery of health interventions. The use of applications such as WhatsApp, Instagram and Twitter (X) for sharing clinical information, for instance, has shown to be valuable and potentially lifesaving in critical situations requiring prompt interventions (Farsi, 2021). Social media usage has come to represent a valuable tool for many forms of healthcare delivery, education, and research dissemination, including communication with patients and healthcare professionals and scientific online discussions (Choo et al., 2015; Farsi, 2021; Oliver et al., 2022; Hwang et al., 2024).

The literature demonstrates that social media is used for various purposes in the healthcare field. These include promoting healthcare services, recruiting patients and healthcare professionals (Farsi, 2021), facilitating professional networking and knowledge exchange (Choo et al., 2015; Farsi, 2021), and engaging persons with lived experiences and healthcare professionals in setting research agendas, thereby promoting priority in line with patients’ and professionals’ experienced needs (Hwang et al., 2024). These types of exchange and communication can contribute to knowledge enhancement and tailored interventions. For instance, online support groups hosted by social media platforms may represent a potential venue for addressing distressed populations’ needs in supportive and validating ways (Oliver et al., 2022). Additionally, studies show that social media provides nurses with tools to share information, debate healthcare policy and practice issues, and engage in interpersonal interactions, but that it also poses a threat to professional behaviors and foundational principles of the nursing profession (Wang et al., 2019; Lefebvre et al., 2020; Rukavina et al., 2021). As an example, during the COVID-19 pandemic, also coined as an infodemic (Cinelli et al., 2020; Solomon et al., 2020), a literature review shows that nurses used social media to gain and share information about COVID-19, and to mutually support colleagues (Glasdam et al., 2022a). Social media also functioned as profession-promoting channels, with health professionals sharing heroic self-representations but also displaying critical working conditions, all the while the general public acknowledged frontline professionals’ work throughout the pandemic on social media (Glasdam et al., 2022a). In addition, nurses used social media as a disciplinary tool, educating citizens to adopt ‘right COVID-19′ behaviors (Glasdam et al., 2022a).

Several studies have recognized the growing impact of social media platforms on health promotion, healthcare delivery and their function in health organisations (Belfiore et al., 2020; Chen and Wang, 2021; Pianese and Belfiore, 2021). While health professionals may use digital social networks, including social media, to share experiences or promote their services, patients may use them to obtain health information or exchange support (Pianese and Belfiore, 2021). Organizations, including government health agencies and non-governmental health organisations, use social media primarily for information surveillance, health intervention, and social mobilization, as well as for disseminating health information and combating misinformation (Chen and Wang, 2021). Social media platforms, such as Twitter (X), often can reach a wider audience when disseminating health information, as there is a substantial user presence on these platforms (Diddi and Lundy, 2017). Some researchers warn that nurses must be aware of the impact that social media use can have on the way healthcare information is delivered and the ethical issues related to social media use (Henderson and Dahnke, 2015). Organizational concerns about social media use embody a variety of perspectives but often fall into three related but distinct aspects: reputation issues, privacy issues, and productivity issues, calling for the development of social media policy (Cain, 2011; Surani et al., 2017; Galea et al., 2023).

Nurses’ proper use of social media can be a valuable and progressive means of improving public health, patient education and strengthening the nurse–patient relationship (Henderson and Dahnke, 2015). Aside from the benefits social media brings to nursing work, multiple studies point to the issues of e-professionalization in nursing, referring to the integration of digital technologies and online platforms into nursing practice, education, and professional development (Wang et al., 2019; O'Connor et al., 2021; Rukavina et al., 2021), the challenges and benefits of which were particularly evident during the COVID-19 pandemic (Glasdam et al., 2022b). Policies on the appropriate use of social media can help nurses recognize the potential hazards of blurring social and professional identities and optimize the opportunities that online social networks offer in nursing practice (Henderson and Dahnke, 2015; Surani et al., 2017; Lefebvre et al., 2020). However, due to the variety of applications and levels of use, discussions of social media and nurse practices are rather complex (Jackson et al., 2014). Studies show that many healthcare professionals, including nurses, are unsure about the acceptability of social media use in the workplace in relation to their professional role (Lefebvre et al., 2020; Galea et al., 2023). The lack of awareness of social media guidelines may threaten foundational principles of the nursing profession, such as privacy, confidentiality, nonmaleficence, and professional integrity (Henderson and Dahnke, 2015; Surani et al., 2017; Wang et al., 2019). As social media policies provide protection for individuals, professions, and organisations, it is critical that nurses are properly informed and adhere to the policies (Collings-Hughes et al., 2022).

Historically, the nurses’ trade unions have, and still take, the lead in defining nursing as a profession with a high ethical standard (Breda, 1997; Cake, 2023). The first trade unions for nurses were established in the late 19th and early 20th centuries as part of a broader labor movement aimed at improving working conditions and professional standards. The trade unions fight for the professionalization of nurses and attractive salaries and working conditions. professionalization is, among other things, related to image building regarding autonomy, achieved through public recognition (Forsyth and Danisiewicz, 1985). Scandinavian nurses were among the first to be organized in trade unions, in Denmark since 1899, in Sweden since 1910, and in Norway since 1912. Other trade unions, such as the California Nurses Association was founded in 1903, the Royal College of Nursing (RCN) was founded in 1916 in the United Kingdom, the New South Wales Nurses and Midwives’ Association (NSWNMA) was established in Australia in 1931, and the Canadian Federation of Nurses Unions (CFNU) in 1981. Denmark, Norway, and Sweden share similar overarching cultural values and policy approaches, especially concerning labor rights and social welfare. However they also have unique approaches within their frameworks (Greve and Kvist, 2011). Historically, Scandinavian nursing trade unions can have a significant influence on labor policies and professional guidelines (Pedersen et al., 2018; Szabó, 2022). In many countries, trade unions have issued guidelines and policies regarding how nurses should act on social media and how to enable good ethical social media use. For instance, the American Nurses Association (ANA) offers guidance for nurses on social media use. Its “Principles for Social Networking and the Nurse” document provides recommendations for maintaining professionalism and ethical conduct online (American Nurses Association, 2011). The ICN Code of Ethics for Nurses defines and guides nurses’ professional responsibilities and values and includes the social media usage in ethical nursing practices (International Council of Nurses, 2021). Nowadays, nurses’ trade unions also use social media to promote themselves, their ideas, and ideals, even so Scandinavian trade unions. The question is how they guide their members, the nurses, in using social media to carry out, develop, and promote their practices and profession, and what similarities and differences can be found in these guidelines. This article aimed to explore the explicitly formulated guidance documents for nurses from the nurses’ trade unions in Denmark, Norway, and Sweden through an examination of the articulations of how the unions guide nurses’ social media use. An exploration of such guidelines can generate valuable insights into both effective practices and potential challenges regarding the development of guidelines for nurses managing the intersection of social media and their professional responsibilities.

Materials and methods

This article is a textual analysis of trade unions’ guidelines for social media use among Scandinavian nurses, drawing on Fairclough’s (1993, 2001, 2003) critical approach to discourse analysis. The use of this analytical approach offered the possibility to gain a nuanced and critical understanding of how these guidelines were constructed, communicated and thought-out in a complex social and organizational context. A Fairclough-inspired critical discourse analysis is a methodologically rigorous and critical approach that is well-suited for analysing and improving trade union guidelines by focusing on linguistic details and their social implications. It was an analytical choice among others, where, e.g., a Foucault-inspired analysis could also provide valuable insights into the broader power structures and discourses although being less focused on the practical and linguistic aspects (Frederiksen and Beedholm, 2018).

Collection of empirical material

The search for trade union guidelines for social media use was conducted through the websites of the three Scandinavian trade unions for nurses: Dansk Sygeplejeråd (the Danish Nurses’ Organization, www.dsr.dk), Svensk sjuksköterskeförening (the Swedish Nurses’ Organization, www.swenurse.se), and Norsk Sykepleierforbund (the Norwegian Nurses’ Organisation, www.nsf.no). Through the websites’ search function, open searches were conducted using the three national keywords for ‘social media’, respectively. Inclusion criteria were guidelines in the national language (Danish, Swedish, and Norwegian, respectively), published 2015–2024. Exclusion criteria were guidelines only targeting nursing students. The date for the last search was 20 March 2024. The search yielded 3,411 results on the Danish website, 23 results on the Swedish website, and 45 results on the Norwegian website. All the results from the searches were screened manually by two of the authors [StG and RJAG]. All material not meeting the inclusion criteria or only targeting nursing students were excluded, and all current guidelines were included. The three trade unions in question were also contacted via email to ensure that all relevant materials were included (last search date: 22 March 2022), and there were no additional documents fulfilling the criteria. The empirical material consisted of 5 documents: (1) ‘Brug af sociale medier - at handle med etisk omtanke i sygepleje [‘Use of social media - acting with ethical consideration in nursing]’ (Sygeplejeetisk råd, 2019) (16 pages), (2) ICN’s Etiske Kodeks for Sygeplejersker [ICN’s: The ICN Code of Ethics for Nurses (2021)]’ (Sygeplejeråd, 2023) (31 pages), (3) ‘En etisk kompass för sjuksköterskor i sociala medier [An ethical compass for nurses in social media]’ (Etiska rådet inom Svensk sjuksköterskeförening, 2017) (15 pages), (4) ICN:s Etiska kod för sjuksköterskor [ICN’s: The ICN Code of Ethics for Nurses (2021)] (Svensk sjuksköterskeförening, 2022) (20 pages), and (5) ‘Yrkesetiske retningslinjer for sykepleiere [Professional ethical guidelines for nurses]’ (Norsk Sykepleierforbund, 2023) (6 pages).

Critical discourse analysis strategy

The overall aim of the Fairclough-inspired analysis is to explore underlying mechanisms of commonsense understandings of the trade unions’ guidelines, created through the production and consumption, and disclose possible power relationships within a discursive practice (Fairclough, 1993). People can explicate experiences and interpretations of reality by the use of language. Through language, people create articulations, which can have a causal effect on beliefs, attitudes, actions, social relations, and the material world (Fairclough, 2003). Fairclough (2003) defines any form of language in use as ‘texts’. Language in use is therefore considered an articulation of social practices associated with particular areas of life (Fairclough, 2003). In the current study, trade union guidelines were recognized as language in use, that is, textual representations that formed parts of various social events and practices related to nurses’ views on their profession and clinical practices. According to Fairclough (2001, 2003), social practices articulate discourses. Discourses are closely connected to power as they are social practices in dialectic processes with other social practices, challenging, reproducing, and transforming identities, knowledge, and social relationships (Fairclough, 1993). Fairclough (2003) regards discourse analysis as ‘fluctuating’ between a focus on specific texts and a focus on the ‘order of discourse’. This is the relatively durable social structuring of language, which is itself one element of the relatively durable structuring and networking of social practices (Fairclough, 2003). Through critical discourse analysis, it was therefore possible to identify how discursive practices have a role in defining and regulating social practice (Fairclough, 2001, 2003), here understood as nurses’ uses of social media. The Fairclough-inspired analysis considered three levels. First, an analysis of the social practice level focusing on the connection between the discursive practice and the surrounding society, reflecting both non-discursive and discursive elements and focusing on how the social practice challenged the existing order of discourse (Fairclough, 1993, 2003). Second, an analysis of the discursive practice level focusing on the processes of production and distribution of the texts, forming a link between the text and the social surroundings. And finally, an analysis of the textual level, capturing how grammatical formulations and single words worked in the construction and reconstruction of social structures (Fairclough, 1993, 2003).

Initially, we read the included texts multiple times to grasp how nurses’ use of social media was articulated by the Scandinavian trade unions. Next, the study’s aim guided the analytical questions posed to the texts and the context in which they were created:

– Social practice level: What did the texts express in terms of the historical, social, and political context in which they were created?

– Discursive practice level: How were the texts created and distributed, and for what specific purposes in relation to their context?

– Textual level: How did language articulate social media and nurses, and which literary devices were employed?

The authors proceeded with reading the included texts with the above-mentioned questions as analytical lenses, focusing on the respective questions and analysis levels one at a time. The authors did this at first separately, then jointly by discussing their respective observations. The authors continuously discussed and calibrated their respective interpretations of the text and analytical levels until consensus was reached. The analytical process thus proceeded through mutual dialogs in a consensual process.

The social practice analysis focused on exploring the nature of the social practices within which this discourse belonged. According to Fairclough (1993, 2003), individuals, groups and organizations act conditioned by internalized values and ideologies from the surrounding society. Social practices can be viewed as the relation between social structures in society and events, implying that they ‘control’ certain structural possibilities while disregarding others. To analyze this connection, the analytical process focused on how meaning-making was constructed in the texts. This involved broadening the scope to include reflections on how social media use was perceived and utilized in society and the healthcare field, and how this related to the overall articulations in the empirical material (Fairclough, 2003). The discourse practice analysis focused on the text’s production and distribution (Fairclough, 2003). The texts were analyzed with a focus on how different discourses interact within a single text that encompasses the genres, discourses, and styles utilized by a text and how they are integrated into specific articulations (interdiscursivity), the identification of explicit references to other texts (manifest intertextuality), the tracing of ideas across multiple texts (intertextual chains), and the assessment of the text’s overall coherence. The textual analysis focused on the linguistic aspects (Fairclough, 1993, 2003). This involved a detailed textual exploration of the empirical material, emphasising vocabulary, grammar, modality, and transitivity. First, we explored how different words were used and how these words could represent underlying attitudes, values, and beliefs about social media use in the texts (Fairclough, 2003). This also included an exploration of how modal verbs, such as ‘must’, ‘should’, ‘cannot’, ‘may’, etc., were used to express certainty/uncertainty or possibilities/restraints (Fairclough, 2003, 2013). Lastly, the textual analysis involved transitivity, in which we analyzed how nurses’ roles and tasks were described and how different actors, such as the trade unions, nurses, patients, and relatives, were represented and positioned in the texts (Fairclough, 2003). All quotes were translated from the Scandinavian languages into English by the authors.

Results

Below, the main findings are presented on the three levels of analysis based on the social practice, the discursive practice, and the textual analyses, respectively.

Social practice level

The critical analytical level of social practice focused on how social media use was embedded within broader social practices, including power dynamics, norms, and cultural contexts, considering the historical, social, and political contexts at stake. It also included the ideology and the hegemony that could be discerned through the documents.

Modern society can be described as a platform society, understood as a society where a lot of information is channeled through global online platforms (van Dijck et al., 2018). A platform can be defined as a programmable architecture designed to organize interactions between users (van Dijck et al., 2018). Central to the platform society, including Scandinavia, is that individuals are present both privately and publicly on these platforms. Platforms provide the technical infrastructure for digital services and content, while social media specifically focuses on online platforms for social interaction and content sharing (van Dijck, 2013). However, many social media platforms are built on top of larger technological platforms. In Scandinavia, and many other countries, large parts of public communication, including the social and health systems, are platformised (e.g., Ministry of Health, Ministry of Finance, Danish Regions, and KL, 2018). Here, appointments to the doctor, test results, referrals to specialists, etc., must be found or ordered via a platform. In regards to social media, a large part of the Scandinavian population uses social media privately for multiple purposes, ranging from maintaining relationships to news updates (Dixon, 2024). Hospitals and hospital affiliates also increasingly use social media to educate patients and professionals, to promote themselves as a good workplace and as a good place to be a patient, and to brand their financial performance (Triemstra et al., 2018; Chiang et al., 2019; Pianese and Belfiore, 2021; Al-Hasan, 2024). Nurses’ trade unions also use social media, where social media serves as a powerful tool for the trade unions to amplify their voice, connect with their members and supporters, and advocate for attractive working conditions [e.g., the Danish Nurses’ Organization (dsr.dk), the Norwegian Nurses’ Organization (nsf.no), the Swedish Nurses’ Organization (swenurse.se)]. Today, many individuals, professionals, institutions, and societies present on many platforms to interact with society.

The texts’ ideology was based on laws such as the General Data Protection Regulation (GDPR), authorization and confidentiality laws (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 12, Sygeplejeetisk råd, 2019, p. 10) and ethics codes for nurses (Etiska rådet inom Svensk sjuksköterskeförening, 2017; Sygeplejeetisk råd, 2019; Svensk sjuksköterskeförening, 2022; Sygeplejeråd, 2023). Since Florence Nightingale’s era from the mid-1800s, nursing has also been coupled with demands for good ethical practices (Gallagher, 2020). The International Council of Nurses (ICN), founded in 1899, is an international organization representing nurses worldwide. It developed its first code of ethics for nurses in 1953. Since then, the ICN has revised its code several times to reflect changes in healthcare delivery and societal values. In the latest revision from 2021 (International Council of Nurses, 2021), translated into Swedish in 2022 (Svensk sjuksköterskeförening, 2022) and Danish in 2023 (Sygeplejeråd, 2023), for the first time in history, it included passages on nurses’ uses of social media. The document defined social media in line with the Institute of Business Ethics (2019). Besides defining the concept, it was used three times in the document, as exemplified below:

Nurses respect the privacy and confidentiality of colleagues and people requiring care and uphold the integrity of the nursing profession in person and in all media, including social media (International Council of Nurses, 2021, p. 7).

In 2015, ICN launched a position statement paper noting a positive attitude toward nurses’ use of social media, while always calling for ethical considerations:

The continuously expanding use of social media provides unprecedented opportunities for rapid and wide-reaching communication and information sharing and it is essential that nursing and healthcare communities capitalise on and safely harness the power of social media for global outreach (International Council of Nurses, 2015, p. 4).

In 2017, the ethical council of the Swedish Nurses’ Organization launched a social media guideline for nurses (Etiska rådet inom Svensk sjuksköterskeförening, 2017), and inspired by and based on this, the Danish Council of Nursing Ethics did the same in 2019 (Sygeplejeetisk råd, 2019). Those two specific documents were based on ethical considerations in nursing.

In Norway, nurses’ use of social media was included in a specific document regarding ethical guidelines for nurses (Norsk Sykepleierforbund, 2023). However, the term ‘digital’ (media and judgment) and not ‘social media’ was used, and this only twice:

The nurse protects the reputation of the profession and must, when appearing in public, also in digital media, make it clear whether s/he is acting on behalf of her/himself, the professional group, or others (Norsk Sykepleierforbund, 2023).

The texts represent a potent voice among others in a wider societal context. The texts could thus be regarded as a powerful voice in the hegemonic struggles about nurses’ characteristics as presented in historical and modern images of nurses in healthcare (Heyman, 1995; Petersen, 1999; Teresa-Morales et al., 2022). The hegemonic struggles about nurses’ characteristics referred to ongoing battles or conflicts over the dominant or prevailing ideas, values, and attributes associated with nurses. It pointed to the contestation and negotiation of power and influence in defining what it meant to be a nurse and what qualities or traits were deemed as desirable or acceptable within the nursing profession. In this context, the texts presented distinct expectations on the profession and nurses’ roles as defined in present times, such as:

The nurse takes responsibility for defining and implementing evidence-based, acceptable standards for clinical nursing practice, management, research, and education. Nurses and researchers in nursing are active in developing research-based knowledge that supports knowledge-based practice. The nurse gets involved in social and health policy issues both locally, nationally, and internationally (Norsk Sykepleierforbund, 2023).

As seen in the example above, nurses in modern times can be understood as having more agency in light of their profession, nevertheless, historical structures and expectations that require nurses’ personal dedication to the profession still seem to be the backdrop for expectations on nurses’ role and practices. According to Fairclough (2003), a particular structuring of semiotic differences might become part of the legitimising common sense that sustains and upholds power relations. This meant that the choice of words when describing aspects relating to social media and the nursing profession could be seen as struggles for hegemony, that is, struggles to legitimize claims for one universal perspective on nurses (Fairclough, 2003). The history of nurses is deeply rooted in descriptions of humility, subservience, subordination, and loyalty. Throughout the ages, and still, nurses have often been portrayed as humble caregivers, dutifully attending to the needs of their patients with unwavering dedication (Bridges, 1990; Hallam, 2000; Hoeve et al., 2014; Teresa-Morales et al., 2022). This portrayal reflects the historical context in which nursing emerged as a profession.

Nurses always represent their profession, regardless of whether they are on duty or not, and therefore need to be aware of and relate to this responsibility (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 7).

The relationship between nurses and social media depicts dichotomies that create the impression that social media poses great threats to the nursing profession, as normatively defined by the trade unions. In this way, the language used in the texts constructed a certain dichotomous reality, in which trade unions dictate the definition of what a nurse can and cannot be, can and cannot do, and must and must not do. Studies also show that nurses are characterized by, among other things, the ability to communicate properly (Abedin et al., 2024). The two social media guideline documents made a point of highlighting nurses’ communicative abilities and freedom of speech in relation to social media uses (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 9, Sygeplejeetisk råd, 2019, p. 4). While the texts expressed that employees have a right to criticize their employer, the Danish document also encouraged nurses to act in accordance with the nursing profession’s professionalism, thus maintaining a historical subservience and employer loyalty, such as:

Public employees have far-reaching freedom of expression and the right to criticise and express their opinions, even if such criticism offends the employer to a certain extent. […] However, the attitudes that nurses and nursing students choose to express through social media should be based on the understanding that the norms, rules, and values that apply in a physical meeting also apply when communication takes place on social media (Sygeplejeetisk råd, 2019, p. 4).

Conversely, both documents pointed out that it was important for nurses to use social media to draw attention to societal conditions that create inequality in illness and health (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 9, Sygeplejeetisk råd, 2019, p. 5).

Discursive practice level

While the social practice level explores the broader social context and structures that shaped and were shaped by language use, the discursive practice level focused on the processes of production and distribution of the texts and their contents, forming a link between the texts and the social surroundings. In other words, the discursive practice level focussed on the single text’s genre and style, and how discourses were articulated to trace the (non)coherent ideas across all the texts.

All five texts had nurses as target groups, with the trade unions as the producers and distributors of the texts. The documents’ overall objective was stated as being an important support for nurses toward ethical performance in their uses of social media. This was, for example, described as:

The Nursing Ethics Council (SER) has prepared this guide with the aim of supporting nurses and nursing students when communicating via social media. The document contains several ethical considerations, which are justified in the nursing ethical guidelines (Sygeplejeetisk råd, 2019, p. 4).

The texts were all available online and were shared through the trade unions’ websites and the nursing ethics council’s websites. The Swedish texts (Etiska rådet inom Svensk sjuksköterskeförening, 2017; Svensk sjuksköterskeförening, 2022) were released as pdf ‘books’ with a related unique ISBN number, allowing for efficient identification and cataloguing worldwide. The Danish texts were also released as pdf-books, but without an ISBN number (Sygeplejeetisk råd, 2019; Sygeplejeråd, 2023). However, all Swedish and Danish texts were copyright © detected. The ethical guidelines for nurses in Norway was the only document without a title page and use of refined layout; it had a layout expression like a school assignment written on a piece of white paper with black text and blue headings, but without page numbers (Norsk Sykepleierforbund, 2023). It was also the only document without copyright © and the trade union’s logo; however, it was stated that the Norwegian council board had approved the content of the document in May 2023 (Norsk Sykepleierforbund, 2023).

The Swedish and Danish texts (Etiska rådet inom Svensk sjuksköterskeförening, 2017; Sygeplejeetisk råd, 2019; Svensk sjuksköterskeförening, 2022; Sygeplejeråd, 2023) were presented in a user-friendly layout with the use of pictures, tables, colors, page numbers, and different ways to present the text such as full-page text, columns, and highlights. The language style used in these texts was notably accessible, employing an informal style without difficult concepts or complex phrases. In addition, the guidelines featured practical examples and scenarios to elucidate important key points, enhancing the content’s comprehensibility, where both the lay-outs and the language style uses were intentional to engage all nurses effectively in the guidelines. Moreover, the cover page of the Swedish guideline features a compass, symbolizing guidance in the right direction, while the cover page of the Danish guideline included a whimsical illustration of individuals in white uniforms with recognizable symbols from the social platform Instagram, such as a cell phone, likes, hearts, and hashtags. These symbols were consistently used throughout both documents. The approachable design of these documents had the potential to expand nurses’ perspectives on the use of social media.

Looking at the intertextuality, referring to the presence of other texts within a document, social media was defined in line with ICN (International Council of Nurses, 2021) and their use of the Institute of Business Ethics (2019) definition. The Swedish and Danish ethical guidelines and the country-specific translations of ICN’s Codes of Ethics included a reference list at the end of the document, whereas the Norwegian ethical guideline did not. Additionally, the Swedish guideline on the use of social media only referred to law references, while the Danish guideline referred to websites for laws and data protection/GDPR, as well as the Swedish guideline, which it was inspired by. In addition, the Danish guideline included the Danish Codes for Nursing Ethics (Sygeplejeetisk Råd, 2014) at the end of their text, and throughout the guideline, those codes were used in its advice for nurses’ social media use. The Swedish guidelines provided a list of recommended articles and books, with most of them being references to the Swedish trade union. Despite law references, most part of the content in the five texts did not include references for the statements made throughout the texts. This suggests a presentation of ‘truths’ or undiscussable facts influenced by trade unions.

All over, the texts illuminated how social media challenged some ground principles in nursing, such as good ethical practice, compliance with confidentiality, and safeguarding patients’ interests. For instance, the Swedish guidelines highlighted that the professional nurse role and the private role must be separated when acting on social media due to ethical matters:

However, guidance is needed in healthcare to support nurses and other healthcare staff’s use of social media, where the professional role is clearly separated from the private one. The boundary between working life and private life needs to be clarified so that nurses act based on ethical reflection and awareness (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 5).

However, none of the documents separated those two roles, but only mentioned the professional nurse role - or regarded the nurse as a ‘all-life’ role:

Nurses always represent their profession, regardless of whether they are on duty or not […] (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 7).

Another example was when nurses were personally connected to patients and their relatives through social media, where the two documents warn nurses against sharing information with patients and relatives through the Internet (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 10, Sygeplejeetisk råd, 2019, p. 7). The conditions under which the parties might have been connected before forming a professional-patient relationship are not reflected upon in any of the documents. Nurses were recommended not to (agree to) exchange patient information privately through social media regarding information that is meant to be shared within a healthcare context (Sygeplejeetisk råd, 2019, p.7).

The Swedish and Danish guidelines argued that it was important to discuss the use of social media at the workplace, where nurses were also obligated to follow the applicable guidelines in their workplace.

[…] nurses and nursing students, through critical reflection, shall consciously contribute to maintaining and ensuring their own and colleagues’ professional integrity when they act on social media […] This consciousness has an ethical dimension, which for example involves not accepting abusive or offensive posts on social media or sharing unacceptable posts that go against the Nursing Ethical Guidelines (Sygeplejeetisk råd, 2019, p. 5).

Furthermore, the nurses ought to support patients and relatives in their use of social media, for instance by raising awareness about what information to share or not through social media as caution may be warranted in terms of spreading potentially sensitive and confidential health related information concerning the self or significant others (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 11, Sygeplejeetisk råd, 2019, p. 7). It became visible how nurses were articulated as responsible for their own and others’ actions and social relations on social media. The Danish document made it explicit that nurses were responsible not only for their own but also for their colleagues’ professional integrity (Sygeplejeetisk råd, 2019, p. 5), that is, that they all followed the ethical guidelines. It means that trade unions presented themselves as the judge of what constituted professional integrity, and that failure to abide by the ethical guidelines constituted a breach of professional integrity. They hence defined desirable rules and regulations for nurses’ uses of social media. Furthermore, The Swedish and Danish documents all included ICN’s passage about human rights and nursing:

Nursing care is respectful of and unrestricted by considerations of age, colour, culture, ethnicity, disability or illness, gender, sexual orientation, nationality, politics, language, race, religious or spiritual beliefs, legal, economic or social status (Sygeplejeråd, 2023, p. 3, Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 7, Svensk sjuksköterskeförening, 2022, p. 5, Sygeplejeetisk råd, 2019, p. 5).

The Danish guidelines added that the human rights had implications for nurses’ use of social media:

This should also be reflected in any statements made by nurses and nursing students on social media (Sygeplejeetisk råd, 2019, p. 5).

Hereby, the Danish trade union implicitly articulated that nurses, whether as professionals or as private persons, should not deviate from the view of humanity for which human rights advocate. This stance ought to permeate nurses’ uses of social media. Moreover, the translated ICN code of ethics pointed to the possibilities of using social media to improve public health globally.

Nurses and global health: Nurses, Nurse Leaders and Nurse Managers: Support the ethical and proficient use of social media and technologies to improve population health consistent with the values of the nursing profession (Sygeplejeråd, 2023, p. 23, Svensk sjuksköterskeförening, 2022, p. 15).

Nurses were anticipated to promote and enable the ethical and proficient use of social media and technology, directing their support toward initiatives aimed at improving population health. These efforts were to be in harmony with the fundamental values and ethical benchmarks of the nursing profession. Essentially, nurses were encouraged to champion the responsible and efficient utilization of these tools, thereby making positive contributions to public health outcomes while preserving the integrity and values of their profession. It meant that public health was understood as being consistent with the values of the nursing profession, pointing to the fact that (global) health and nursing were interdependent, with nursing having the right to define values in (global) health.

Textual level

The following section presents the study’s main analytical findings on the textual level. According to Fairclough (1993, 2003), an analysis of words could reveal how individual words contributed to a certain ideology when they were interconnected. The number of times that the terms “social media” and ‘digital *’ was used in the included documents is shown in Table 1.

Table 1

Table 1. The use of the terms social and digital media.

The texts primarily focused on the fact that social media had become an integral part of the lives of nurses, patients, and their families, rather than focus on nurses’ specific uses of social media platforms. Social media was described in the texts as ‘meeting places’ or ‘spaces for social interaction’ facilitated by technology-based tools. It was described as spaces where users strived to create, maintain, and develop contacts and relations through the exchange of information. Furthermore, social media was portrayed as a platform that had simplified and streamlined the exchange of knowledge and dissemination of information (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 4–5). A central point in the texts was that social media use can nurses at risk of not respecting the privacy and confidentiality of both colleagues and patients and thus the risk of not upholding the integrity of the nursing profession (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 7; Sygeplejeetisk råd, 2019, p. 5; Svensk sjuksköterskeförening, 2022, p. 8; Norsk Sykepleierforbund, 2023; Sygeplejeråd, 2023, p. 7). The texts asserted that the ‘rules’ and norms for communication on social media platforms were similar to those in the physical world. However, the texts also stated differences between these types of interactions. These differences included the lack of opportunity to see the person, the inability to accurately gauge the information being received, and the absence of an opportunity to clarify or correct ambiguities (Sygeplejeetisk råd, 2019, p. 4; Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 8).

The texts characterized nurses with words like having responsibility, responsiveness, compassion, ethics, empathy, credibility, dignity, trust, and respect (Etiska rådet inom Svensk sjuksköterskeförening, 2017; Sygeplejeetisk råd, 2019; Svensk sjuksköterskeförening, 2022; Norsk Sykepleierforbund, 2023; Sygeplejeråd, 2023). However, when situations in which nurses’ uses of social media were described, the sentences often had words with negative connotations, mentioning risks, harm, safety threats, and distrust. The texts’ wording signalized the importance of and necessity of and demands for appropriate use of social media among nurses. The texts highlighted that when social media was used by nurses, patients, or relatives within a healthcare department, a form of action or awareness was needed among the nurses. To exemplify this, the Swedish and Danish guidelines presented several (identical) fictional cases in which nurses, patients, and/or relatives, used social media in inappropriate ways. The scenarios presented involved nurses in various contexts. For instance, Kim, a newly educated nurse, received a friend request from Ola, a young patient with a grave ailment (Sygeplejeetisk råd, 2019, p. 8; Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 9). Another example included discovering that a parent had been sharing pictures of their child undergoing chemotherapy treatment on a public blog (Sygeplejeetisk råd, 2019, p. 9; Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 11). At the end of each case, several questions were posed, such as ‘How do you act in your department?’, ‘Do you have guidelines [regarding social media use] in your department, and do you discuss them?’ and ‘How should the nurse act in this situation?’. The questions posed were direct and invited nurses to act regarding what was presented as ethical and moral dilemmas. This aligned with the main aim of the texts, which was to guide and support nurses when they communicated via social media platforms (Sygeplejeråd, 2023, p. 4; Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 5). The texts presented what was perceived as morally and ethically challenging scenarios that needed action, however, they did not offer any solutions to the presented issues.

The texts were generally written in the present or future tense. In some parts of the texts, particularly within the ethical guidelines, the lack of modal verbs and the use of alternative sentence structures was observed. This contributed to the effectiveness of the text in question. For instance, as observed in the Norwegian ethical guideline: ‘Nursing students, nurses, specialised nurses, midwives, nurse leaders, and administrators support ethical and professional use of social media and technology […]’ (Norsk Sykepleierforbund, 2023). In the Swedish and Danish guidelines for social media use among nurses, modal verbs were more frequently used. The use of the modal verb ‘can’ was predominantly used in relation to social media, as exemplified here: “Social media use can reveal a patient’s or relative’s identity.” The use of the modal verbs ‘should’ and ‘must’ was related to nurses and nurses’ uses of social media such as: “Nurses must maintain and ensure their own and colleagues’ professional integrity when engaging on social media.” and “Social media usage should be based on critical reflection.” The use of modal verbs like ‘may’ and ‘should’, on the other hand, reflects a more nuanced and uncertain view of the question at stake. Often, the texts used words like ‘is’ and ‘are’, which could be viewed as a powerful tool for expressing a specific aspect of reality. However, those words were often followed by the words never or always, which turned the phrase into a moral imperative, as for example:

(The responsibility of the nurse and the nursing student is thus to) observe the duty of confidentiality by never commenting on patients on social media, including never passing on information that could reveal the patient’s identity or harm the patient (Sygeplejeetisk råd, 2019, p. 6).

(The nurse’s responsibility is) to always reflect on their actions on social media and what consequences it may have (Etiska rådet inom Svensk sjuksköterskeförening, 2017, p. 6).

When the words ‘never/always’ were used, it led to a ‘truth’ or an undoubtedly accurate statement. The examples provided in the texts showcased the precise responsibilities of nurses, making it difficult to argue against their validity. However, the risks that social media ‘might’ or ‘can’ pose were statements, which were open for discussion. The modal verbs associated with social media, when related to the risks it posed, therefore seemed to be holding a high degree of uncertainty. Despite this degree of uncertainty about the risks that social media potentially inflicted, the authors (trade unions) were specifically clear on what the nurses’ attitudes should be in relation to the use of social media. This illustrated how modality referred to stances and judgments and, thereby, to identification, action, and social relations (Fairclough, 2003).

Discussion

The discussion will focus on three main findings, namely (1) Norway differed from the other two Scandinavian countries by dealing only to a limited extent with nurses’ use of social media, (2) social media was regarded as a potential threat in nursing and healthcare, and (3) nurses were not viewed as private persons but always as representing nurses/the nursing profession on social media.

The results showed that the Norwegian document only used words related to social media twice. Furthermore, the search for guidelines revealed that Norway differed from the other two Scandinavian countries in that it had not developed its own guidelines for nurses’ uses of social media or translated the ICN Code of Ethics for Nurses (International Council of Nurses, 2021) with specific consideration taken toward social media uses. Seen in light of the fact that Norway has the highest social media penetration among the Scandinavian countries (Dixon, 2024), this observation becomes intriguing. It is impossible to determine precisely why this is the case. One explanation could be that the Norwegian Directorate of Health specifically published a ‘Guideline for the use of social media in the health, care and social sector’ (Helsedirektoratet, 2017). The guideline is a supporting document for the health-political norm for information security in social and healthcare settings in Norway, and thereby also includes nurses and their uses of social media. Another cautious speculation might suggest that it is the laws governing nurses’ work, such as authorization and confidentiality laws, along with their associated ethical obligations, that comprehensively dictate what nurses can and cannot do and express, even on social media platforms. In this context, one might argue that a specific guide about warnings and attention points regarding nurses’ social media use is unnecessary, although it may be valuable to concretize, through the use of examples, the application of laws and guidelines within the frame of novel technologies and communication channels such as social media. The findings of this study also support this notion, as all recommendations regarding social media usage were rooted in ethical considerations and confidentiality, where nurses’ conditions are already framed by the national legislations.

The literature on social media and healthcare puts forward both its potential and risks (Geraghty et al., 2021; Jeyaraman et al., 2023; van der Boon et al., 2024). While social media is deemed to represent an immense potential for healthcare, it is necessary to implement policies and regulations for social media uses in line with ethical and professional guidelines to prevent harm for patients/relatives and, e.g., integrity breaches, unprofessional conduct, and misinformation (Jeyaraman et al., 2023). This is in line with what the current study’s documents argue for. The findings nonetheless show that social media uses were mainly addressed in terms of warnings. The pattern of regarding social media as a potential threat is also seen in other countries such as New Zealand (New Zealand Nurses Organisation, 2019), United Kingdom (Nursing and Midwifery Council, 2019); and Canada (College and Association of Registered Nurses of Alberta Council, 2021). Social media per se opens up for nurses’ possibilities to communicate about their abilities and capacities to act independently, make decisions, and actively influence their work environment and heath/patient care. However, the findings pointed to a trade union understanding of social media as a potential threat in nursing and healthcare, risking harm to patients. It showed that nurses’ social media use revealed a risk of damaging nurses’ professional integrity.

The translations of ICN’s codes of ethics were the only documents pointing to positive potentials of social media in relation to improving global public health consistent, however, with the idea of public health being in line with the values of the nursing profession. Moreover, the Scandinavian nursing organisations (the Danish Nurses’ Organization, the Norwegian Nurses’ Organization, and the Swedish Nurses’ Organization) encourage readers to follow and engage in dialog with them on Facebook (www.dsr.dk; www.nsf.no; www.swenurse.se). Conversely, other studies show that social media is perceived to have a positive impact on promoting the healthcare system, while also shedding light on healthcare professionals’ potentially deleterious working conditions (Farsi, 2021; Smailhodzic et al., 2021). Farsi’s (2021) literature review of 73 studies show that healthcare professionals have embraced social media for a multitude of purposes, including promoting health, advancing their careers or practices, recruiting, networking, finding support, accessing medical education, supporting telemedicine practices through added professional communication in social media applications, conducting scientific research, and addressing critical public health issues. Smailhodzic et al. (2021) construct five archetypical interactions on social media between healthcare professionals, in this case doctors, and users. A purposive analysis of 20 social media platforms shows five archetypal types of interactions, namely personal health condition resolution, knowledge-building through teaching, informing on healthcare products, empathising with fellow sufferers, and lifestyle support, where levels of formality and generativity differed. The authors argue that the taxonomy that they put forward can be used to research and understand the effects of social media use on healthcare professionals-patient interactions (Smailhodzic et al., 2021).

Despite the blurred private-professional boundaries that are put forward regarding nurses’ roles, the current study’s documents demanded that nurses stick to professional attitudes and the profession’s norms in their use of social media, and thus to a certain level of formality in their communication on social media. The findings call for future guidelines focusing on the possibilities of social media uses in healthcare in general and in nursing specifically. Additionally, the findings showed that the trade unions’ view of nurses was that ‘nurse’ is not only a professional title but rather a life-duty, meaning that the private person cannot be separated from the professional title and duties. Researchers argue that there are blurred borders between person and professional in highly relational occupations, such as nursing (Callewaert, 2003), placing demands on professionals to beware of what pertains to the professional, respectively private person (Glasdam et al., 2020, 2023). Callewaert (2003) argues that nursing is a job, which demands that the nurses engage with their unique personality in combination with human, social, and professional knowledge. In that light, the Swedish guideline argued for an impossibility by arguing for the importance of separating the professional nurse role and the private role on social media. It also demonstrated this impossibility by not doing the separation in the text. Following the idea of Goffman’s dramaturgical theory (Goffman, 1990), individuals educated as nurses always perform in the role as nurses when they act frontstage, also on social media and here both on work-institutional profiles and private profiles. Trade unions implicitly express a notion of the dissolution of private individuals into an omnipresent role as a nurse with a 24/7 commitment to their profession and their role as nurses, despite an employment relationship on salaried worker conditions. This can be seen as a historical reminiscence about the work as a nurse as a life calling and a way of living (Emerson, 2017).

Another historical reminiscence relates to the finding that nurses rhetorically were given the overall responsibility for their own, patients’ and relatives’, and colleagues’ use of social media, ensuring good ethical practice, including non-offensive behavior on social media. Historically, nurses have been regarded as those who keep order and ensure that everything and everyone in the medical clinic function optimally for doctors, other professional groups, patients, and relatives. In Danish textbooks from 1870 and 1956, for example, nurses are depicted as embodying the ideals of orderliness, grounded in knowledge, patient care, physician requirements, and moral principles, encompassing professional needs and ethical-aesthetic standards (Frederiksen, 2010). Also, in relation to social media, the trade unions hold nurses accountable for maintaining orderliness and ethically reflected use, on behalf of all. From trade unions’ perspectives, nurses should always consider human rights (United Nations, 1948). If the private and professional roles are not distinguished and nurses are expected to be nurses ‘at all times’, it implicitly means that nurses, even as private individuals, should not express themselves in ways that stride against human rights. A consequence of the ICN’s ethical codes for nurses (International Council of Nurses, 2021), and the conflation of professional and private roles, is that nurses cannot express themselves politically, religiously, or in other ‘not-comme-il-faut’ ways on their private social media. This means that, realistically, in their private social media use, they must not express attitudes that contradict the equal value of all people, as it goes against their professional values. In that light, the trade unions implicitly treat the nurses’ right to freedom of expression, including the freedom to hold opinions and to impart information and ideas without interference by public authority and regardless of frontiers (European Union Agency for Fundamental Rights, 2007, article 11). From the Scandinavian trade unions’ perspective, nurses are expected to appear exemplary, also in terms of human rights, both in their official capacity and as private persons. It could thus be argued that every nurse must possess a thorough comprehension of the guidelines and also of how to use social media professionally to maintain the profession’s reputation in society. Only through this can nursing uphold its professionalism, as expected by the trade unions. Hence, it becomes evident that social media is still an area where ‘good practice’ is discussed; nevertheless, with unclear borders of how to behave as a professional, which calls for future studies.

The current study has strengths and limitations. The strength of conducting a Fairclough discourse analysis of social media guidelines made by Scandinavian nurses’ trade unions lies in its ability to uncover the underlying power dynamics and ideological positions embedded within the discourse. Fairclough’s approach allows researchers to systematically analyze the language used in these guidelines, identifying how power relations are constructed, negotiated, and maintained within the context of desired professional communication forms on social media platforms. However, choosing a specific method or a specific theoretical, analytical perspective always has limitations. Other methodical choices and theoretical perspectives could present different understandings of the analyzed texts. The current study’s strength lies in the transparency of the analyses, allowing readers to see how constructed ‘truths’ about the texts have emerged (Glasdam et al., 2024). The text analysis also included a broader discourse practice surrounding the guidelines’ creation and implementation and the sociocultural context in which they operate. This comprehensive approach enables a deeper understanding of how social media guidelines reflect and reinforce particular professional norms, values, and power structures within the nursing profession. The authors have described the search and analysis processes in detail and developed the analysis in a consensual analysis process amongst the authors. Throughout this process, the researchers performed a dialectic process to strengthen the study’s confirmability and credibility (Stahl and King, 2020). Quotes were included to enhance transparency and facilitate alternative interpretations of data, also strengthening the study’s confirmability and credibility (Stahl and King, 2020). However, the current study cannot answer whether the documents are being used by its targeted audience, that is nurses that operate in Scandinavian contexts. There may be discrepancies between the prescribed norms in the guidelines and the actual practices and interactions occurring on social media, limiting the effectiveness of the analysis in capturing real-time dynamics and the differences between visions and real practices, although this is beyond the scope of the current article. This calls for future research about nurses’ uses of social media, both as professionals and as private persons.

Conclusion

Through a Fairclough-inspired analysis of the Scandinavian trade unions’ guidelines with focus on nurses’ social media uses, the current article illuminated the embedded social practice level, discursive practice level, and textual level of the named guidelines. This gave an idea of the trade unions’ commonsense understandings of social media and nurses obligations in terms of their social media uses in relation to their profession. The findings showed that the guidelines were embedded in a modern, digitalised society, laws about confidentiality and data protection, and ethical codes for nurses, and that the trade unions’ implicit and explicit representations of nurses made the distinction between nurses as professionals and nurses as private persons blurred. These representations could also be seen in the light of nursing’s historical background, with nurses being viewed as acting out of a personal ‘call’ and being identified as subservient to other healthcare professions. The guidelines indicated that nurses ought to always comply with the profession’s ethical and moral guidelines on social media, that is both in private and professional contexts. The findings showed differences between the Scandinavian countries, with Norway as an exception to having translated the ICN Code of ethics for nurses. Furthermore, Norway did not have a separate document with guidelines focusing specifically on nurses’ social media uses. While the literature on social media and healthcare shows that social media uses can represent both a threat and a valuable resource in healthcare, the current findings showed that the guidelines tended to highlight risks that could ensue social media uses that did not comply with the profession’s politically defined guidelines, norms, and values, although nurses’ conditions are already framed by the national legislations. The study advocates for the development of guidelines to support beneficial uses of social media pertaining to nurses and nursing, while still acknowledging associated risks. The current findings did however not shed light on nurses’ actual uses of social media and on the discourses related to this, which calls for further research on the subject.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author contributions

StG: Conceptualization, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing. HX: Writing – original draft, Writing – review & editing. RJAG: Formal analysis, Methodology, Writing – original draft, Writing – review & editing. SeG: Formal analysis, Writing – original draft, Writing – review & editing. SS: Formal analysis, Methodology, Writing – original draft, Writing – review & editing.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

Abd-Alrazaq, A., Alhuwail, D., Househ, M., Hamdi, M., and Shah, Z. (2020). Top concerns of tweeters during the COVID-19 pandemic: Infoveillance study. J. Med. Internet Res. 22:e19016. doi: 10.2196/19016

PubMed Abstract | Crossref Full Text | Google Scholar

Abedin, S., Khademi, Z., Kamalzadeh, H., and Broujeni, R. B. (2024). Characteristics of a good nurse as perceived by nurses. Nurs. Ethics 31, 79–88. doi: 10.1177/09697330221147895

PubMed Abstract | Crossref Full Text | Google Scholar

Al-Hasan, A. (2024). Social media marketing and hospital brand equity: an empirical investigation. Inf. Dev. doi: 10.1177/02666669241236199

Crossref Full Text | Google Scholar

American Nurses Association (2011). ANA’s principles for social networking and the nurse guidance for registered nurses. Amer. Nur. Associ. Available at: https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/social-networking.pdf

Google Scholar

Belfiore, P., Sarnacchiaro, P., Sorrentini, A., and Ricchiuti, R. (2020). New social media for health promotion management: a statistical analysis. Soft. Comput. 24, 13853–13862. doi: 10.1007/s00500-019-04664-2

Crossref Full Text | Google Scholar

Breda, K. L. (1997). Professional nurses in unions: working together pays off. J. Prof. Nurs. 13, 99–109. doi: 10.1016/s8755-7223(97)80010-5

PubMed Abstract | Crossref Full Text | Google Scholar

Bridges, J. M. (1990). Literature review on the images of the nurse and nursing in the media. J. Adv. Nurs. 15, 850–854. doi: 10.1111/j.1365-2648.1990.tb01917.x

Crossref Full Text | Google Scholar

Cain, J. (2011). Social media in health care: the case for organizational policy and employee education. Am. J. Health Syst. Pharm. 68, 1036–1040. doi: 10.2146/ajhp100589

PubMed Abstract | Crossref Full Text | Google Scholar

Cake, S. (2023). Framing unions and nurses. Work Employ. Soc. 38, 579–595. doi: 10.1177/09500170221144525

PubMed Abstract | Crossref Full Text | Google Scholar

Callewaert, S. (2003). “Profession og personlighed–to sider af samme sag?[profession and personality–two sides of the same question?]” in Person og profession–en udfordring for socialrådgivere, sygeplejersker, lærere og pædagoger [person and profession–a challenge for social workers, nurses, teachers and pedagogues]. ed. P. F. Laursen, Frederiksberg: Billesøe og Baltzer. 259–277.

Google Scholar

Ceci, L. (2023). Daily usage of social media apps in the Nordics 2016–2019, by app [Infographic]. New York: Statista. Available at: https://www.statista.com/statistics/878557/daily-usage-of-social-media-apps-in-the-nordics/

Google Scholar

Charalambous, A. (2019). Social media and health policy. Asia Pac. J. Oncol. Nurs. 6, 24–27. doi: 10.4103/apjon.apjon_60_18

PubMed Abstract | Crossref Full Text | Google Scholar

Chen, J., and Wang, Y. (2021). Social media use for health purposes: systematic review. J. Med. Internet Res. 23:e17917. doi: 10.2196/17917

PubMed Abstract | Crossref Full Text | Google Scholar

Chiang, A. L., Rabinowitz, L. G., Kumar, A., Chan, W. W.-Y., and Rabinowitz, L. G. (2019). Association between institutional social media involvement and gastroenterology divisional rankings: cohort study. J. Med. Internet Res. 21:e13345. doi: 10.2196/13345

PubMed Abstract | Crossref Full Text | Google Scholar

Choo, E. K., Ranney, M. L., Chan, T. M., Trueger, N. S., Walsh, A. E., Tegtmeyer, K., et al. (2015). Twitter as a tool for communication and knowledge exchange in academic medicine: a guide for sceptics and novices. Med. Teach. 37, 411–416. doi: 10.3109/0142159X.2014.993371

PubMed Abstract | Crossref Full Text | Google Scholar

Cinelli, M., Quattrociocchi, W., Galeazzi, A., Valensise, C. M., Brugnoli, E., Schmidt, A. L., et al. (2020). The covid-19 social media infodemic. arXiv pre-print arXiv. doi: 10.1038/s41598-020-73510-5

Crossref Full Text | Google Scholar

College and Association of Registered Nurses of Alberta Council (2021). Social media and e-professionalism: Guidelines for nurses. Edmonton: College and Association of Registered Nurses of Alberta (CARNA) Council.

Google Scholar

Collings-Hughes, D., Townsend, R., and Williams, B. (2022). Professional codes of conduct: a scoping review. Nurs. Ethics 29, 19–34. doi: 10.1177/09697330211008634

Crossref Full Text | Google Scholar

Datareportal (2020). Digital 2020: Global digital overview. Singapore. Available at: https://datareportal.com/reports/digital-2020-global-digital-overview

Google Scholar

Diddi, P., and Lundy, L. K. (2017). Organizational twitter use: content analysis of tweets during breast cancer awareness month. J. Health Commun. 22, 243–253. doi: 10.1080/10810730.2016.1266716

PubMed Abstract | Crossref Full Text | Google Scholar

Dixon, S.J. (2024). Share of active social media users in the Nordic countries as of January 2024 [Infographic]. Statista. Available at: https://www.statista.com/aboutus/our-research-commitment/3088/stacy-jo-dixon

Google Scholar

Emerson, C. (2017). Calling to nursing: concept analysis. Adv. Nurs. Sci. 40, 384–394. doi: 10.1097/ANS.0000000000000185

Crossref Full Text | Google Scholar

Etiska rådet inom Svensk sjuksköterskeförening (2017). En etisk kompass för sjuksköterskor i sociala medier [An ethical compass for nurses in social media]. Stockholm: Swedish Nurses’ Organization.

Google Scholar

European Union Agency for Fundamental Rights (2007). EU charter of fundamental rights. Official journal of the European Union C 303/17–14.12.2007. Vienna: European Union.

Google Scholar

Fairclough, N. (1993). Discourse and social change. London: Polity Press.

Google Scholar

Fairclough, N. (2001). Language and power. 2nd Edn. London: Pearson Education.

Google Scholar

Fairclough, N. (2003). Analysing discourse: Textual analysis for social research. London: Routledge.

Google Scholar

Fairclough, N. (2013). Critical discourse analysis and critical policy studies. Crit. Policy Stud. 7, 177–197. doi: 10.1080/19460171.2013.798239

Crossref Full Text | Google Scholar

Farsi, D. (2021). Social media and health care, part I: literature review of social media use by health care providers. J. Med. Internet Res. 23:e23205. doi: 10.2196/23205

PubMed Abstract | Crossref Full Text | Google Scholar

Forsyth, P. B., and Danisiewicz, T. J. (1985). Toward a theory of professionalization. Work. Occup. 12, 59–76. doi: 10.1177/0730888485012001004

Crossref Full Text | Google Scholar

Frederiksen, K. (2010). A discourse analysis comparing Danish textbooks for nursing and medical students between 1870 and 1956. Nurs. Inq. 17, 151–164. doi: 10.1111/j.1440-1800.2010.00487.x

PubMed Abstract | Crossref Full Text | Google Scholar

Frederiksen, K., and Beedholm, K. (2018). “Michel Foucaults og Norman Faircloughs tænkning: forskelle og ligheder [the thinking of Michel Foucault and Norman Fairclough: differences and similarities]” in Å tenke med Foucault: En bok for masterstudiene i helse- og socialfagene [thinking with Foucault: A book for master's studies in the health and social sciences]. eds. C. Øye, N. Ø. Sørensen, and K. Martinsen (Bergen: Fagbokforlaget), 43–67.

Google Scholar

Galea, G., Chugh, R., and Luck, J. (2023). Why should we care about social media codes of conduct in healthcare organisations? A systematic literature review. J. Public Health 32, 1205–1217. doi: 10.1007/s10389-023-01894-5

PubMed Abstract | Crossref Full Text | Google Scholar

Gallagher, A. (2020). Learning from Florence nightingale: a slow ethics approach to nursing during the pandemic. Nurs. Inq. 27:e12369. doi: 10.1111/nin.12369

PubMed Abstract | Crossref Full Text | Google Scholar

Geraghty, S., Hari, R., and Oliver, K. (2021). Using social media in contemporary nursing: risks and benefits. Br. J. Nurs. 30, 1078–1082. doi: 10.12968/bjon.2021.30.18.1078

PubMed Abstract | Crossref Full Text | Google Scholar

Glasdam, S., Ekstrand, F., Rosberg, M., and van der Schaaf, A. M. (2020). A gap between the philosophy and the practice of palliative healthcare: Sociological perspectives on the practice of nurses in specialised palliative homecare. Medicine, Health Care, and Philosophy. 23, 141–152. doi: 10.1007/s11019-019-09918-2

PubMed Abstract | Crossref Full Text | Google Scholar

Glasdam, S., Sandberg, H., Stjernswärd, S., Jacobsen, F. F., Grønning, A. H., Hybholt, L., et al. (2022a). Nurses’ use of social media during the COVID-19 pandemic—A scoping review. PLoS ONE. 17:e0263502. doi: 10.1371/journal.pone.0263502

PubMed Abstract | Crossref Full Text | Google Scholar

Glasdam, S., Jacobsen, F. F., Hybholt, L., and Stjernswärd, S. (2022b). Scandinavian nurses’ use of social media during the COVID-19 pandemic - A Berger and Luckman inspired analysis of a qualitative interview study. Healthcare. 10:1254. doi: 10.3390/healthcare10071254

PubMed Abstract | Crossref Full Text | Google Scholar

Glasdam, S., Karidar, H., Lundqvist, P., and Stjernswärd, S. (2023). Unity strengthens and inhibits development: A focus group interview with volunteer adults in support programs for bereaved children and their family. Death Studies. 1–11. doi: 10.1080/07481187.2022.2160521

PubMed Abstract | Crossref Full Text | Google Scholar

Glasdam, S., Xu, H., and Gulestø, R. J. A. (2024). A call for theory-inspired analysis in qualitative research: Ways to construct different truths in and about healthcare. Nurs Inq. doi: 10.1111/nin.12642

PubMed Abstract | Crossref Full Text | Google Scholar

Goffman, E. (1990). The presentation of self in everyday life. London: Penguin.

Google Scholar

Greve, B., and Kvist, J. (2011). Has the Nordic welfare model been transformed? Soc. Policy Adm. 45, 146–160. doi: 10.1111/j.1467-9515.2010.00761.x

Crossref Full Text | Google Scholar

Hallam, J. (2000). Nursing the image: Media, culture and professional identity. London: Routledge.

Google Scholar

Helsedirektoratet. (2017). Veileder i bruk av sosiale medier i helse-, omsorgs- og sosialsektoren [Guideline for the use of social media in the health, care and social sector]. The Norwegian Directorate of Health. Oslo. Available at: https://www.manuellterapi.no/wp-content/uploads/sites/65/2017/09/Veileder-sosiale-medier-versjon-1-0.pdf

Google Scholar

Henderson, M., and Dahnke, M. D. (2015). The ethical use of social media in nursing practice. MEDSURG Nursing Journal 24, 62–64.

Google Scholar

Heyman, I. (1995). Gånge hatt till… Omvårdnadsforskningens framväxt i Sverige: sjuksköterskornas avhandlingar 1974–1991 [hats off to… The rise of nursing research in Sweden: nurses' theses 1974–1991]. Stockholm: Daidalos.

Google Scholar

Hoeve, Y., Jansen, G., and Roodbol, P. (2014). The nursing profession: public image, self-concept and professional identity—a discussion paper. J. Adv. Nurs. 70, 295–309. doi: 10.1111/jan.12177

PubMed Abstract | Crossref Full Text | Google Scholar

Hvidt, E. A., Grønning, A., Brøgger, M. N., Møller, J. E., and Fage-Butler, A. (2021). Multilevel structures and human agency in relation to email consultations: a strong structuration theory analysis of the Danish general practice setting. Soc. Sci. Med. 282:114155. doi: 10.1016/j.socscimed.2021.114155

PubMed Abstract | Crossref Full Text | Google Scholar

Hwang, K., Sivaratnam, S., Azeredo, R., Hashemi, E., and Jibb, L. A. (2024). Exploring the use of social media and online methods to engage persons with lived experience and healthcare professionals in creating research agendas: lessons from a pediatric cancer research priority-setting partnership. PLOS Digital Health 3:e0000181. doi: 10.1371/journal.pdig.0000181

PubMed Abstract | Crossref Full Text | Google Scholar

Institute of Business Ethics. (2019). The ethical challenges and opportunities of social media use. Business Ethics Briefing. Available at: https://www.nedaglobal.com/assets/files/ibe_social_media_briefing.pdf (Accessed May 2, 2019).

Google Scholar

International Council of Nurses (2015). Nurses and social media, position statement. Geneva: International Council of Nurses.

Google Scholar

International Council of Nurses (2021). The ICN code of ethics for nurses. Geneva: International Council of Nurses.

Google Scholar

Jackson, J., Fraser, R., and Ash, P. (2014). Social media and nurses: insights for promoting health for individual and professional use. Online J. Issues Nurs. 19:2. doi: 10.3912/OJIN.Vol19No03Man02

PubMed Abstract | Crossref Full Text | Google Scholar

Jeyaraman, M., Ramasubramanian, S., Kumar, S., Jeyaraman, N., Selvaraj, P., Nallakumarasamy, A., et al. (2023). Multifaceted role of social media in healthcare: opportunities, challenges, and the need for quality control. Cureus 15:e39111. doi: 10.7759/cureus.39111

PubMed Abstract | Crossref Full Text | Google Scholar

Kanchan, S., and Gaidhane, A. (2023). Social media role and its impact on public health: a narrative review. Cureus 15:e33737. doi: 10.7759/cureus.33737

PubMed Abstract | Crossref Full Text | Google Scholar

Kaplan, A. M., and Haenlein, M. (2010). Users of the world, unite! The challenges and opportunities of social media. Bus. Horiz. 53, 59–68. doi: 10.1016/j.bushor.2009.09.003

Crossref Full Text | Google Scholar

Lefebvre, C., McKinney, K., Glass, C., Cline, D., Franasiak, R., Husain, I., et al. (2020). Social media usage among nurses: perceptions and practices. J. Nurs. Adm. 50, 135–141. doi: 10.1097/NNA.0000000000000857

Crossref Full Text | Google Scholar

Mariano, M. C. O., Maniego, J. C. M., Manila, H. L. M. D., Mapanoo, R. C. C., Maquiran, K. M. A., Macindo, J. R. B., et al. (2018). Social media use profile, social skills, and nurse-patient interaction among registered nurses in tertiary hospitals: a structural equation model analysis. Int. J. Nurs. Stud. 80, 76–82. doi: 10.1016/j.ijnurstu.2017.12.014

PubMed Abstract | Crossref Full Text | Google Scholar

Ministry of Health, Ministry of Finance, Danish Regions, and KL (2018). “A coherent and trustworthy health network for all” in Digital health strategy 2018–2022 (Copenhagen: Ministry of Health).

Google Scholar

New Zealand Nurses Organisation (2019). Social media and the nursing profession: a guide to maintain online professionalism for nurses and nursing students. New Zealand Nur. Organis.

Google Scholar

Norsk Sykepleierforbund (2023). Yrkesetiske retningslinjer for sykepleiere [Professional ethical guidelines for nurses]. Norsk Sykepleierforbund.

Google Scholar

Nursing and Midwifery Council (2019). Guidance on using social media responsibly. Nursing Midwifery Council.

Google Scholar

O'Connor, S., Zhang, M., Honey, M., and Lee, J. J. (2021). Digital professionalism on social media: a narrative review of the medical, nursing, and allied health education literature. Int. J. Med. Inform. 153:104514. doi: 10.1016/j.ijmedinf.2021.104514

PubMed Abstract | Crossref Full Text | Google Scholar

Oliver, D. P., Washington, K. T., Benson, J., White, P., Cruz Oliver, D., Smith, J. B., et al. (2022). Facebook online support groups for hospice family caregivers of advanced cancer patients: protocol, facilitation skills and promising outcomes. J. Soc. Work End Life Palliat. Care 18, 146–159. doi: 10.1080/15524256.2022.2046236

PubMed Abstract | Crossref Full Text | Google Scholar

Pedersen, A. W., Hippe, J. M., Grødem, A. S., and Sørensen, O. B. (2018). Trade unions and the politics of occupational pensions in Denmark and Norway. Transfer 24, 109–122. doi: 10.1177/1024258917748873

Crossref Full Text | Google Scholar

Petersen, K. A. (1999). Sygeplejevidenskab - myte eller virkelighed. Om genese og struktur af feltet af akademiske uddannelser og forskning i sygepleje i Danmark [nursing science - myth or reality. On the genesis and structure of the field of academic education and research in nursing in Denmark]. Dissertation. Viborg: Viborg Amt.

Google Scholar

Pianese, T., and Belfiore, P. (2021). Exploring the social networks' use in the health-care industry: a multi-level analysis. Int. J. Environ. Res. Public Health 18:7295. doi: 10.3390/ijerph18147295

PubMed Abstract | Crossref Full Text | Google Scholar

Rukavina, T. V., Viskić, J., Poplašen, L. M., Relić, D., Marelić, M., Jokic, D., et al. (2021). Dangers and benefits of social media on E-professionalism of health care professionals: scoping review. J. Med. Internet Res. 23:e25770. doi: 10.2196/25770

PubMed Abstract | Crossref Full Text | Google Scholar

Smailhodzic, E., Boonstra, A., and Langley, D. J. (2021). Social media enabled interactions in healthcare: towards a taxonomy. Soc. Sci. Med. 291:114469. doi: 10.1016/j.socscimed.2021.114469

PubMed Abstract | Crossref Full Text | Google Scholar

Solomon, D. H., Bucala, R., Kaplan, M. J., and Nigrovic, P. A. (2020). The “Infodemic” of COVID-19. Arthritis Rheumatol. 72, 1806–1808. doi: 10.1002/art.41468

PubMed Abstract | Crossref Full Text | Google Scholar

Stahl, N. A., and King, J. R. (2020). Expanding approaches for research: understanding and using trustworthiness in qualitative research. J. Dev. Educ. 44, 26–28.

Google Scholar

Sultan, M., Brown, E. M., and Thomas, R. H. (2021). Clinicians embracing social media: potential and pitfalls. Epilepsy Behav. 115:106462. doi: 10.1016/j.yebeh.2019.106462

PubMed Abstract | Crossref Full Text | Google Scholar

Surani, Z., Hirani, R., Elias, A., Quisenberry, L., Varon, J., Surani, S., et al. (2017). Social media usage among health care providers. BMC. Res. Notes 10:654. doi: 10.1186/s13104-017-2993-y

PubMed Abstract | Crossref Full Text | Google Scholar

Svensk sjuksköterskeförening. (2022). ICN:s etiska kod för sjuksköterskor [ICN’s: The ICN code of ethics for nurses (2021)]. Stockholm: Swedish Nurses’ Organization.

Google Scholar

Sygeplejeetisk Råd (2014). De sygeplejeetiske retningslinjer [The Nursing Ethics Guidelines]. Copenhagen: Dansk Sygeplejeråd.

Google Scholar

Sygeplejeetisk råd (2019). Brug af sociale medier - at handle med etisk omtanke i sygepleje [use of social media - acting with ethical consideration in nursing]. Copenhagen: Dansk Sygeplejeråd.

Google Scholar

Sygeplejeråd, D. (2023). ICN’s etiske kodeks for sygeplejersker [ICN’s: The ICN code of ethics for nurses (2021)]. Copenhagen: Dansk Sygeplejeråd & ICN.

Google Scholar

Szabó, I. G. (2022). Professionals on the road to contention: social movement unionism in healthcare labour disputes across Europe. Econ. Ind. Democr. 43, 410–430. doi: 10.1177/0143831X20903090

Crossref Full Text | Google Scholar

Teresa-Morales, C., Rodríguez-Pérez, M., Araujo-Hernández, M., and Feria-Ramírez, C. (2022). Current stereotypes associated with nursing and nursing professionals: an integrative review. Int. J. Environ. Res. Public Health 19:7640. doi: 10.3390/ijerph19137640

PubMed Abstract | Crossref Full Text | Google Scholar

Triemstra, J. D., Poeppelman, R. S., and Arora, V. M. (2018). Correlations between hospitals’ social media presence and reputation score and ranking: cross-sectional analysis. J. Med. Internet Res. 20:e289. doi: 10.2196/jmir.9713

PubMed Abstract | Crossref Full Text | Google Scholar

United Nations (1948). The universal declaration of human rights. Paris: Universal Declaration of Human Rights | United Nations.

Google Scholar

van der Boon, R. M. A., Camm, A. J., Aguiar, C., Biasin, E., Breithardt, G., Bueno, H., et al. (2024). Risks and benefits of sharing patient information on social media: a digital dilemma. Eur. Heart J. Digital Health 5, 199–207. doi: 10.1093/ehjdh/ztae009

PubMed Abstract | Crossref Full Text | Google Scholar

van Dijck, J. (2013). Facebook and the engineering of connectivity: a multi-layered approach to social media platforms. Convergence 19, 141–155. doi: 10.1177/1354856512457548

Crossref Full Text | Google Scholar

van Dijck, J., Poell, T., and de Waal, M. (2018). “The platform society as a contested concept” in I: The platform society. (Oxford: Oxford University Press), 7–46.

Google Scholar

Wang, Z., Wang, S., Zhang, Y., and Jiang, X. (2019). Social media usage and online professionalism among registered nurses: a cross-sectional survey. Int. J. Nurs. Stud. 98, 19–26. doi: 10.1016/j.ijnurstu.2019.06.001

PubMed Abstract | Crossref Full Text | Google Scholar