Editor Comment
In the September issue of the Journal of Paramedic Practice, we published a ‘comment’ (i.e. opinion) article by ambulance service communications directors on guidance for the use of social media, and their views on its value within the ambulance services.
In response, we received several email messages and ‘Tweets’ about why some readers found the comment to be unfair, and asking why the journal published it, particularly as it was not referenced (with the exception of a link to the guidance) and we are a peer-reviewed journal (i.e. our longer clinical and research articles are subject to double-blind peer review prior to acceptance for publication).
Comment allows the expression of opinion from varied sources, with the potential to engage readers and stimulate discussion on contentious topics, facilitate the sharing of honest ideas, and encourage debate—all of which can lead to further learning and growth.
We routinely publish editorials, comments and columns, which are not peer-reviewed. In fact, we believe that to subject an opinion to peer review would threaten its authenticity. Opinions are not factual and cannot be ‘corrected’ based on the opinions of others.
Comments include only key citations as they are brief opinion articles in contrast with longer clinical and research articles which require full referencing (although we are aware of the rationale for authors' views and welcome a full list of references for our records). Readers can decide how much weight to place on an opinion and any presented key evidence (or lack thereof), as well as of detecting any potential bias. Articles are clearly marked with author titles and article type to aid this process.
Furthermore, if guidelines are produced for use, and controversial views are held by influential people within the ambulance services, is it not favourable to share them to open up discussion and stimulate change or provide clarification if needed?
All articles can be challenged and each perspective provides valuable insight. These pages feature letters from our valued readers, as well as a response from the lead author of the original comment and Chairs of the authors of the guidance it discusses. Articles that spark debate encourage the evolution of thought and practice, and counter-arguments allow for a more balanced view, ultimately encouraging the forward movement of the profession.
Dear Editor,
I read with interest the article by Cotton et al (2019) and would like to respond to some of the contentious points made in their comment article.
I don't think there has ever been an argument made that ambulance services should not use social media, the question has always been about how they should use social media. The authors cite four reasons for their use of social media: education, public health messages, sharing knowledge and supporting research in out-of-hospital care. If used correctly, I don't think many people would raise any concerns in any of those domains. However, the Twitter storms against certain corporate twitter accounts suggest that not everything has been perfect in the world of corporate ambulance tweeting so guidance is long overdue.
Cotton et al are highly critical of those of us who have raised concerns about corporate tweeters and the rise of the parody accounts, but they provide an unbalanced perspective. The parody accounts came into being because those in control of corporate accounts were taking little, if any, notice of individuals who were raising concerns, and corporate tweeters were blocking dissenting voices. The parody accounts served to highlight some very important issues and reached a far broader audience than I could, but I do agree that some occasionally over-stepped the mark of what would be considered acceptable.
My personal experiences of raising concerns have been largely negative. One corporate tweeter was providing information about drugs that was open to misinterpretation so I suggested a change of punctuation to make it clearer. I then contacted the individual by private message in order to keep the discussion out of the public domain. My reward—accused on Twitter of being a Troll and told that if I knew my drugs better, I wouldn't have been confused. It's not often that I've been accused of not knowing my drugs so I considered it both a personal and professional affront, especially as I teach paramedic students about pharmacology at University. I complained to the employing Trust who saw nothing wrong with it and this perhaps explains why the authors argue that no complaint is ever upheld. There were several occasions where this individual put incorrect drug information into the public domain and on all occasions his employing Trust did nothing. There is irony that Cotton et al accuse dissenting voices of insulting behaviour but don't tackle the issue when it is directed from within their own corporate social media accounts.
The argument that no complaint has been upheld is of course not quite true either. One Trust received complaints after a corporate tweeter posted a picture of a child in the back of an ambulance on the way to hospital. This was breaching confidentiality, publishing patient-identifiable information and, quite simply, wrong. The Trust removed the post following a host of complaints, which suggests that those complaints were upheld. I'm not sure if they took action against the individual concerned and I'm not even sure that action was necessary; the fact that they took the complaints seriously and made changes shows those complaints were upheld. Their actions probably also prevented people from raising the issue with the HCPC.
The article by Cotton et al is very heavy on criticism of those who hold a contrary view and this is unhelpful. It is shifting the blame to those who have complained about corporate ambulance tweeters and I have inferred from this that the authors perceive that their corporate tweeters are always right and those who raise concerns are invariably wrong (also implied when stating that no complaint is ever upheld). Instead of criticising those who hold a different view, engage with them to understand why they hold those views and perhaps we can contribute positively to the guidelines.
I was also disappointed to read that the authors wanted to address the criticism against ‘live tweeting’. As far as I can see, there is no value to live tweeting for the patient or the public and it seems destined only to distract clinicians from their responsibilities. The statement that live tweeting is acceptable as long as clinical care has been completed misses the wider point of what paramedic care is about. Care is more than the clinical management of a patient, it is about the social and psychological support, and it is about giving your total commitment to that patient at that time. I would be very disappointed if my GP started to tweet about my condition part way through a consultation! As a patient, I would want to know that any health professional is focused on me and not seeking an opportunity to tweet about my condition on social media. Perhaps the authors can respond and highlight how the patient and wider public can benefit from live tweeting.
The authors go on to discuss the development of the guidelines but the discussion is brief and there is little detail about the process. What I did note was the lack of service user involvement and a lack of involvement from paramedics outside of those who are already involved in corporate tweeting. I think we will have to draw our own conclusions regarding the absence of those important voices but it does add a limitation to the development of the guidance.
I use social media to tweet about research, promote my university work and challenge my local MP (always very politely) so I do not have a problem with paramedics and ambulance Trusts using social media. I can see the benefits of social media when used well but I reserve the right to call it out when it's used badly. Cotton et al suggest that people like myself are villains when in reality we raise concerns because we care about our patients and our profession.
I have been a paramedic since 1992 but I don't live in the past. I'm not a modern-day Luddite and I welcome the promotion of our profession through whatever means available; however, we need to do it responsibly and communications directors need to engage with the dissenting voices as well the voices of those who agree with them. Debate is healthy and invariably brings improvements where all parties are open to dialogue.
Dear Editor,
I am writing in response to your article on Storytelling via social media in the ambulance services. This article left me annoyed, I'm afraid. I am a Paramedic who uses social media. I do not live tweet.
The title talks about storytelling—whose story are we telling? I'm not sure we should be telling ‘stories’ about patients on what, for many, is the worst day of their life.
As a Paramedic, ask yourself if a bystander knocked on the door of your ambulance and asked for rough details of what was going on, how would you react? I'd venture to say you would politely tell them it was nothing to do with them and you weren't at liberty to say. Yet by live tweeting, are you not doing the opposite?
In the article, it mentions that none of the complaints made against staff/trusts using social media have been upheld; who investigated these complaints? It's not clear.
The article talks about trusts having a combined total following of over 356 000. I'm not sure how successful social media is as we are busier year on year. If tweeting is so successful in patient engagement, why does our call rate rise year on year when we tweet all the time about ‘inappropriate’ calls and when to call/not to call us?
The article talks about messages being appropriate, relevant and never breaching patient confidentiality. I'm not sure how posting the below helps our profession:
These are their ‘stories’ to tell—not ours. Other health professionals don't tweet/post anywhere near the detail that we seem to; as a young profession, we will rightly be scrutinised by other professions and patient-related posts show us in a negative light.
Paramedics never gain written permission to post and I would question whether getting permission to post a photo of a new mother with her newborn after undergoing birth minutes before would hold stead if complained about? My own partner—a GP—struggled with what to have on her toast after childbirth, let alone whether strangers could take her photo and post it.
The article talks about receiving compliments from patients and patients' families. It is of course nice to know patients and their relatives are pleased with their treatment and care, but the whole point of this, is that it's the patients who have decided to talk about it publicly, not us.
The article rightly talks about an adverse effect on staff's mental health when they have received negative posts but doesn't seem to consider patients' mental health when they are negatively posted about?
The article talks about speaking to staff who tweet about why they do it and its benefits but was there any approval of the guidelines from the people who the tweets concern the most: the patients?
Trusts will use social media for many aspects of our work, but as paramedics, our focus must remain on the patient. Part of the clinical care we should be striving to achieve includes patient confidentiality—ANYTHING that could compromise this needs to stop.
Dear Editor,
I recently read the paper ‘Storytelling via social media in the ambulance service’. I noted a number of ethical and factual areas of concern within the paper I thought I should raise with you.
The comment appears to demonstrate a lack of understanding of the universal principles of human research ethics, which all academic journals should adhere to. I note that the comment states that the authors have spoken with ‘frontline staff’ to ‘hear why they do it and the benefits—not just to them, but to patients and others.”, and ‘spoken to the HCPC’ and this conversation—not referenced, nor supported in any way by ethics or method—was supposed to hold some persuasive weight.
Any work that appears in a peer-reviewed academic journal that interviews human participants and makes claims about findings should go through an ethics committee. This is because ethics in research is a fundamental cornerstone of good academic practice and something that should be promoted in academic journals.
The publication of a ‘comment’ piece that contains not one single reference in a peer-reviewed journal is disappointing. Rather than the authors having a ‘conversation’ with the regulator, they could instead have referenced any number of documents published by that agency. This would have not only increased the value of the piece by offering the reader a reference to an actual regulatory document, and in so doing been instructive, but it would also have acknowledged the fact that publishing any piece in a journal has the power to be persuasive. It is imperative that those who have some persuasive power by virtue of their position (like academics or directors of corporate media units) use that power responsibly. One way in which this can occur is by ensuring that the material published is ethically sound and factual. If the choice is made to publish a piece such as this with no references at all, it should only ever be on a matter that is uncontroversial.
The matter of social media use by paramedics is anything but. There are real harms that can be caused to patients, paramedics and the health system more broadly by the inappropriate use of social media. The introduction of new guidelines has certainly improved the behaviour of the worst offending services and ‘corporate tweeters’; however, there have been egregious examples in the past of poor behaviour. This suggests that there is some confusion over what behaviour is okay and what is not; this paper does not help to clarify this. Instead, the authors fail to acknowledge any potential harms associated with bad social media behaviour; ‘the HCPC…had no issue with them live tweeting’ and worst still, attempt to suggest that there is no bad behaviour at all: ‘complaints have not been upheld after investigation.’ As the claimants of a statement of fact, the onus lies with the authors to provide evidence for this statement but evidence is lacking from this point as it is with others. I am aware of at least three cases where I believe paramedics have been disciplined in the UK and these cases are publicly available (Teeside Live, 2009; HCPC Tribunal Service, 2015; 2017). The article does not include cases where health professionals have been sanctioned for similar behaviour and it does not mention cases that may have arisen in other countries where the JPP is available. This claim also does not take into account the instances in which an organisation (including those that the authors have worked for) have removed content from social media after complaints were made by professionals and members of the public prompting internal investigations. The outcomes of these investigations are not publicly known but the removal of these posts could serve as an admission of their inappropriate nature.
Worse still, the authors appear to dismiss legitimate and substantiated concerns raised by others about the potential harms associated with inappropriate social media use by paramedics, including a paper written by myself and Aidan Baron and published in this journal, ‘Live Tweeting by Paramedics: a growing concern’ (Vol 9, Issue 7). The authors have framed the legitimate concerns raised by academics and concerned paramedics with the actions of ‘keyboard warriors, bullies, and trolls’ as if to suggest that any legitimate and substantiated criticism of the unethical, unprofessional, and potentially patient-harming practices of health professionals on social media is unwarranted, hyperbolic, ill-informed or self-interested. This is concerning. It is the job of academics and health professionals to advocate for the public good and patient interest. Any suggestion to the contrary should be retracted.
This piece also conflates the effective use of social media by ambulance services for recruitment and compliments about staff performance with ‘storytelling via social media.’ Using social media for recruitment is not the same as storytelling and despite the title of the piece, there is only one section of the entire paper that talks about ‘storytelling’ as ‘staff tell[ing] their own story, in their own words, through a series of posts…[to] engage, inspire and connect with others’. Staff telling their own story is quite different from using patient information to tell a story that provides no benefit to the patient. There is nothing wrong with individual paramedics wanting to share their story, as long as their story does not include details about their patients, unless their patient has consented. Unfortunately, there have been countless examples of patient information being used without consent, that have promoted the interests of the ambulance service and possibly even the corporate tweeter, but does nothing to benefit the patient whose information has been used to create the ‘story’. This article seems to support this use of patient information by stating that ‘as long as staff had completed their care, they had no issue with them tweeting’. Last year, the HCPC (Timms, 2018) issued this advice about the use of patient information:
‘In providing health and care services, HCPC registrants' primary consideration should be their service user; raising the profile of their profession should only ever be a secondary consideration, and should not impact the service user's privacy or dignity. They should post in a modest manner; only providing the information the public needs to understand the role, and they should ensure any additional information, in particular service user identifiable information, isn't included.’
Identifiable information goes beyond information like name, address, treatment. As the HCPC (Timms, 2018) notes: ‘…. identifiable information goes beyond that and can include details about a service user's personal life, health or circumstances, or images relating to their care.’
A person's healthcare is identifiable information and neither paramedics nor ambulance services have the right to use such information without the express consent of an individual/patient. The fact that this piece suggests that it is okay, indeed that it is actively encouraging paramedics to share their stories with their ‘356 000’ followers so as to ‘improve how patients, the general public and other health professionals engage with us’ is frankly worrying. The justification given for this action is that there is a ‘statutory and legal duty’ to engage with the public.
Apart from there being no reference to the law that is referred to, there also seems to be a misunderstanding of what is meant by suitable ‘engagement’. Engaging with the public is answering the phone when it rings for help, and sending an ambulance. It is not tweeting about the patient's condition and what the paramedics did to the patient.
This piece reads like a public relations exercise, written by non-paramedics, for the corporate interests of the authors' employers, and would be more appropriately found in a trade magazine rather than a peer-reviewed journal on paramedic practice. Social media use by ambulance services and paramedics can be done safely and with good effect. However, this piece does nothing to educate staff about the right and wrong ways of using social media, nor the risks that exist for patients and paramedics when they use social media inappropriately. The flaws with the ethics and content of this piece have the potential to cause harm to patients, paramedics, the profession, and the reputation of this journal.
Dear Editors,
I was interested to read Cotton et al's completely unreferenced opinion piece, regarding social media use within ambulance services in the last edition of the Journal of Paramedic Practice.
I was specifically intrigued to see their bold statement that no complaints ‘have ever been upheld after investigation’. I would be happy to supply the editor with a complaint response from one of this paper's authors regarding a Twitter post containing a photograph of a paediatric patient, in an ambulance, with accompanying clinical information. The response highlighted that: the tweet had been deleted, and that trust guidelines were reviewed and modified in response to this tweet. Specifically, it stated that ‘We have made it clearer that taking a picture of a patient in the rear of an ambulance while care or clinical monitoring is on-going is not appropriate’. To me, this is a clear example of a complaint being upheld, with policy changes resulting and raises questions around the pervasive nature of social media use for some clinicians, such that they considered taking photographs of a patient while at work was a normal practice.
Perhaps there is still the need for an honest, open discussion about the pros and cons of social media use in the paramedic profession, and further inquiry into why we appear to be the only health professionals using social media in this way. To my knowledge, no other branches of medicine, nor other groups of allied health professionals, are live-tweeting photographs of patients from their clinical areas and I do not believe the paramedic profession should be pioneering such behaviours.