Let's see Nursing differently...

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*Disclaimer - this video is endorsing the use of samsung and T-mobile, this is the view of the company BAYADA not of the individual reposting this video*  The intent behind posting this video is to show the benefits of having technology that is used outside the acute care setting, and the benefits it is able to have on overall client care. It also shows the potential technology has in assisting health care to continue into the future with a client-centered care mentality, as has been discussed in recent lectures. 

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Week 9 - Technology outside the Acute Care Setting

             In recent years, a Canadian trend that seems to continually be on the rise is spending on healthcare.  In 2011 it was predicted that health costs would rise to a total of $200.5 billion dollars, an increase of 4 % from 2010 (Health Care Spending to top $200B in Canada, 2011). Another common theme in the health care system recently has been the increase of work load for nurses (Callaghan, 2003).  These two trends, as well as changes in the way services are provided, and an aging baby boomer population are not only predicted to continue into the future but also are factors that need to catalyze change (Health Canada,2012). These different factors are all leading to the realization that our system can no longer function as it once did, and that changes have to be made.

                One possibility for this change could be through implementation of a type of electronic health technology called the eShift. “Electronic health technologies are significant drivers of innovation, sustainability and efficiency in the health care system by improving access to services, patient safety, quality of care, and productivity” (Health Canada, 2012).  The primary purpose of eShift currently is to be able to take care of palliative care patients in their own home, supporting them through their sickness as well as supporting their primary care takers (South West CCAC, 2013). EShift allows for PSW’s to remain in the home overnight caring for the patient. The PSW is in constant contact via an eShift iPhone app with an overseeing RN who can manage up to 4 cases simultaneously (eShift Helps Patients and South West CCAC, 2012). This allows for more patients to receive improved around the clock care, and remain in their own homes. This technology is also helping to overcome some of the barriers to care such as distance, restricted number of staff and budget (Tiaki, 2013).

             EShift technology cuts back on the overall health care budget because it decreases the number of beds being used in an acute care setting, as well as decreasing the number of emergency admissions (Kouli et al., 2013).  This decrease in patient numbers will mean that more patients are being cared for in their homes. Patients who are cared for in their homes are recipients of continuing care, and are better able to build relationships with their care provider. This continued care and relationship both add to the independence of the patient and decrease the adverse effects of sickness or disability (Kouli et al., 2013). “Home care takes advantage of the positive influence of the family environment and gives the patient the ease and tranquillity needed, reducing the feelings of powerlessness and fear associated with a progressive and terminal illness” (Kouli et al., 2013). Home health care with the assistance of eShift has the ability to overcome barriers to health such as geographical distance and access (Tiaki, 2013).

             Overall, allowing patients to have the ability to remain in their own home during their illness is a great asset to the entire health care system. It also provides different opportunities for RNs. Because of the way eShift is set up, the RN is the overseeing care taker and the RPN or PSW is in the home with the patient. This provides a different set of opportunities for RNs to adopt roles as team leaders and managers. This could also open up doors for opportunities in areas such as policy writing, research and technology advancement, all while still being connected to a patient (Canadian Nurses Association, 2009). As nurses we are called to be impactful leaders in all rolls and domains of practice (Canadian Nurses Association, 2009). Through the opportunities that are becoming available because of advancements such as eShift it is important that nurses remain in touch with the client and their needs. It is also important that we adapt and develop as a profession to accommodate the changes in health care. These modalities are coming, it is important for us to see how they will affect us but also how we are going to affect them.

  References

  Health Care Spending to top $200B in Canada (Nov 3, 2011). CBCnews Politics. Retrieved from http://www.cbc.ca/news/politics/health-care-spending-to-top-200b-in-canada-1.1042170

  Health Canada (2012). Canada’s Health Care System. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php

  Kouli, E., Patiraki, E., Kalokerinou, A., Liaropoulos, L., Galanis, P., & Kaitelidou, D. (2013). Economic Evaluation of Home Care Versus Hospital Care for Patients with Terminal-Stage Malignant Neoplasms. Home Health Care Management & Practice. 25(5), 229-235. doi: 10.1177/1084822313489831

Callaghan, M. (2003). Nursing Morale: what is it like and why?. Journal of Advanced Nursing. 42(1), 82-89.  

Tiaki, K. (2013). Ehealth – nurses must embrace the technology. Nursing New Zealand. 19(6).

South West Community Care Access Centre [CCAC] (Jan 23, 2012). [Video file]. Retrieved from http://www.youtube.com/watch?v=M6rSJYhYmLE

eShift Helps Patients and South West CCAC. (2012). South West LHIN Exchange. Retrieved from http://www.southwestlhin.on.ca/newsletter.aspx?id=60

Canadian Nurses Association. (2009). Nursing Leadership. Position Statement. Retrieved from http://www.cna-aiic.ca/~/media/cna/page%20content/pdf%20en/2013/07/26/10/52/ps110_leadership_2009_e.pdf

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Week 8 - How Nurses affect Informatics

       As we have been discussing over the duration of this class, informatics is affecting the way nurses provide care, it is affecting a nurse’s work load and the way he or she manages a client’s care. A perspective that was brought on by discussion this week was, “How can Nurses affect informatics?”, What are the things we can do to bring change to the world of nursing and how informatics is used in health care. The discussion this week was directly linked to how nurses can affect the use of Electronic Health Records Systems (EHRS), however this is not the only way nurses can affect change in informatics.

       One of the questions posed was: “Should nurses be involved in the change of ERHS, if so why?”  Based on discussion in class, I, alongside strong scholarly-based evidence, believe that nurses must be involved in the development and change of EHRS.  Nurses are responsible for gathering, synthesizing and sharing data presented by the client to the health care team; this is often a responsibility for the nurse because they spend the most amount of time with the client (Sassen, 2009). Nurses act as advocators for the patient and in order to advocate for them using our ability to decrease the gaps in care (Howell, 2013), we must be able to get the appropriate information to the rest of the care team.

       If we are not consulted in the changes made to the EHRS, then we will have no input as to what the records contain, how it is presented or what the focus of the record is. Imagine the affect it would have on your role as a nurse to use a system that is simply biomedically based, it would take away many aspects of your practice that are very important. As individuals who work as “care coordinators, health coaches, disease managers and community liaisons” (Howell, 2013) it is very important that the system you are using to document on is one that includes facets of your profession that are important. Nurses have different scopes of practice than other health care providers - some social, emotional and psychosocial data - that we gather could go unnoticed in a system that doesn’t accommodate for that type of information (Sassen, 2009).

       Nurses facilitate, advocate for and are the main users of EHRS. Nurses are the people who will determine their success, and a system is only as good as its users. Appropriate care and leadership amongst the nursing staff and all others involved are dependent on the configurations of people, resources, processes, and technology (Mitchell, 2012), therefore we as leaders must facilitate the use and development of ERHS. In Payne’s article “The implementation of electronic clinical documentation: Using Lewin’s change management theory”, it is suggested that by using Lewin’s models of “unfreezing, implementing change, and refreezing” we can affect the outcome of EHRS (2013). It is suggested that we use techniques such as identifying barriers to change and driving forces to assist change, obtaining opinions and suggestions of others, and making appropriate changes are all effective in implementing change in a nursing environment (Payne, 2013).

       Since nurses are the front line workers and know best how technology can help patients and themselves.  It is important that nurses be involved in all aspects from the planning to the implementation of ERHS and other technologies to ensure our patients get the best type of care possible and that they remain the center of our work (Doran, Reid-Haughian, Chilcote & Bai, 2013). 

  References

Doran, D., Reid-Haughian, C., Chilcote, A., & Bai, Y. (2013). A formatice evaluation of nurses’ use of electronic devices in a home care setting. Canadan Journal Of Nursing Research, 45(1), 54-73.

Howell, J. W. (2013). The Changing Role of Nurses. Hospitals and Health Networks. Retrieved from: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2012/0312HHN_FEA_movingforward&domain=HHNMAG

Payne, S. (2013). The implementation of electronic clinical documentation: Using Lewin's change management theory. Canadian Journal of Nursing Informatics, 8(1).

Sassen, J. E. (2009). Love, Hate, or Indifference How Nurses Really Feel About The Health Records System. CIN: Computer, Informatics, Nursing. 27(5). 281-287

Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, E., Rohrbach, V., & Von Kohorn, I. (2012). Core Principles & Values of Effective Team-Based Health Care. Institute of Medicine. Retrieved from https://www.nationalahec.org/pdfs/VSRT-Team-Based-Care-Principles-values.pdf

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This video was added as a resource to help gain a general understanding of the ideas and concepts of eHealth and how technology is intersecting with healthcare on a basic level.  

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Week 7 - Canadian Electronic Health Records

In order to progress and continue moving forward in the area of health informatics, serious consideration is being given to the potential that Electronic Health Records (EHR) could provide both the client and the clinician with a better system of care.  Electronic health records are the area of health information technology that has the potential to help create a more sustainable health care system.  In order to fully understand an electronic health record we first have to look at what it is, and what it contains. An electronic health record differs from an electronic medical record in that it focuses on total health. An electronic health record tends to go beyond clinical data towards broad view of care, and is designed to share information with other health care providers. Their purpose is to “be created, manages, and consulted by authorized clinicians and staff across more than one health care organization” (Garrett & Seidman, 2011). Conversely, an electronic medical record is used to track data over time, and monitor/improve overall quality of care within the practice. In essence, it is a digital version of paper charts in the clinician’s offices (Garrett & Seidman, 2011).

According to The Canadian Health Infoway (2013), health information technologies have the potential to help create a more sustainable health care system in the areas of: Healthy Living, Person-Centred Care, Quality Improvement, Access to Services, Continuity of Care, and Efficiency Improvement.  One of the health information technologies that have the potential to assist in the improvement of these areas is electronic health records.

The importance of creating a more sustainable overall health care system is something that cannot be ignored and the need for change is imminent. In 2012 the totally health care cost in Canada was expected to reach $207 billion dollars, roughly $5,948 per person, and 29.2% of that $207 billion were costs relating to hospitals which accounted for the largest share of health dollars (2010). Although the Canadian Institute for Health Information has shown that our growth pace is slowing it is still at a level that is not sustainable. Therefore as the Canadian Health Infoway suggests, making changes in the six “prioritiy” areas (ie: Healthy living, person-centered care, quality improvement etc.) with the use of health information technologies is a way to help create our system into a sustainable one. As stated before one of the ways this could be achieved is through the proper implementation of Electronic Health Records.

The benefits of the electronic health record are linked to things such as a reduction in medical errors by providing a clear and comprehensive display of test results, improved population management through registry generation, and improved patient and colleague communication (Ryan, Bishop, Shih, & Casalino, 2013). Other benefits of an Electronic Health Record include empowerment of the patient and better, more effective communication between care providers (Born & Laupacis, 2011). In a study entitled “Effect of Electronic Health Records on Health Care Costs: Longitudinal Comparative Evidence From Community Practices,” it was found that that EHR reduced the cost of health care by a magnitude that if sustained for a longer period of time would have resulted in substantial savings (Adler –Milstein, 2013).

                In touching on the benefits of the electronic health records the drawbacks also have to be presented. Some care providers worry about the data privacy and security with in the health records system, as well as the accuracy and reliability. Another main issue with the electronic health records system is that “the disruption caused by EHR adoption [can make] it difficult for providers to learn how to use EHRs to monitor population health, better coordinate care, or engage in more sophisticated use” (Adler –Milstein, 2013).

                Ultimately, the EHR has the potential to vastly affect our health care system, helping to achieve a more sustainable health care system which in turn will create a healthier population. However, this will only occur with the correct implementation and use of the EHR to the fullest extent. This is something I believe has to occur in order to achieve a sustainable healthcare system that has a positive impact on the population it serves.  

  References

Adler-Milstein. J., Salzberg. C., Franz. C., Oray. J., Newhouse. J. P., & Bates. D.W. (2013). Effect of Electronic health Records on Health Care Costs: Longitudinal Comparative Evidence From Community Practice. Annals Of Internal Medicine, 159,(2). 97-104

Born, K., & Laupacis, A. (March 30, 2011). Should patients have better access to their medical records?. Retrieved from http://healthydebate.ca/2011/03/topic/innovation/deliveringonthepromiseoferecords

Garrett, P., & Seidman, J. (Jan 4th, 2011). EMR vs HER – What is the difference?.Retrieved from http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/

N.a. (2010). Canada’s health care spending growth slows. Retrieved from http://www.cihi.ca/CIHI-ext-portal/internet/EN/document/spending+and+health+workforce/spending/release_30oct12

Ryan, A., Bishop, T., Shih, S., & Casalino, L. Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records. Health Affairs, 32, no.1 (2013):53-62

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Whose information is it?

            As the world of technology changes at the most rapid pace in history logically you would think many other things would be advancing as well. As it turns out our Health Care world, although evolving doesn’t quite have the speed and gusto of its technology counterpart at least in terms of information access. In a world where I can access my online banking and finances, contact a colleague in another part of the world, or purchase something as big as a car in a matter of minutes, it is shocking that I would have to wait days possibly weeks to have information about my own health. The process of obtaining one’s own health information is an onerous one and one that many people do not want to have to go through.

That being said there are two sides to every story, so let’s uncover some of the pros and cons to giving patients access to their health information in the form of an electronic health record.

For the sake of discussion we will begin with looking at a few of the negative side effects of health information be accessible online. One of those side effects being that the information could be found to be quite confusing. Not everyone has a medical background so giving someone access to information such as charts, diagrams and SOAP notes with scribbled short forms and medical jargon would not be solving any problems(Born & Laupacis, 2011). It would be similar to taking a hockey fan and dressing them for an NHL season opener. Just because they know what the sport is doesn’t mean they really know how to play the game. The dangers of having information misinterpreted could be detrimental to the individual’s health. The potential for health information to be skewed in highly possible, as the general public would be more likely to take offense to phrases and comments they may not fully understand (Chen-Tan & Stephen, 2013). Another main concern of those opposing electronic health records is the safety of the system. The possibility of information being leaked is a legitimate one and the concern is valid as the internet isn’t always a safe place. A fully secure system has yet to be created and the potential for that information to be accessed by someone other than the clients themselves makes some people wary. 

The flip side to this argument is that patients should have full online access to their health records. Many believe that access to their health information will empower patients, improving their care and allow for more effective communication with their care providers (Born & Laupacis, 2011). It has also been said that “Patients who share responsibility for decisions about their care often enjoy better health than those whose doctors act out a traditional paternalistic role” (Millenson, 2013). Many also feel that not having direct access to information about themselves is a violation of their rights. With the growing number of hospital beds needed and the short stay times we need Canadians to maintain their health, not only will it help the patient; it will help and improve the care provided wherever they are (Born & Laupacis, 2011). This will occur not only because the patient has access to their medical information but also because with an online format any health professional taking care of the patient can have immediate access to the pertinent information they need. Meaning that people can get healthy and stay health, creating shorter wait times, increased autonomy on the part of the patient and a decrease of financial pressure on the health care system as a whole. These are all things that are needed in order to sustain and improve the health of our country; many see electronic health records as one of the first steps in meeting this goal.

Depending on where your opinion lies, you may have found yourself agreeing or disagreeing with the information presented above. Where ever on the scale you stand I challenge you to expand your thinking, the first step in that is going to be by watching the following youtube clip - http://www.youtube.com/watch?v=2vejkD0Rl3o

How do stories like the one of E-patient Dave change the perspective of health information and the way it is presented to the patient? If you were in a similar situation would you want access to your information? As a supporter of the electronic health record, I would say that having easy access to my information is not only a privilege but a right. The information contained in that record would be my information, information that would help me better understand my health and therefore it would be advantageous to have better access to in order to continue living a healthy and productive life. 

  References

Chen-Tan, L., & Stephen, E. R. (2013). The Effects of Promoting Patient Access to Medical Records: A Review. Journal of the American Medical Informatics Association. 10 (2). 129-138. (Chen-Tan & Stephen, 2013)

  Born, K., & Laupacis, A. (March 30, 2011). Should patients have better access to their medical records?. Retrieved from http://healthydebate.ca/2011/03/topic/innovation/deliveringonthepromiseoferecords

  Millenson, M., L. (2013). The Long Wait For Medical Excellence. Health Affair. 32 (10). 1757-1760. 

[lveets93]

An interesting look at the potential that a paperless hospital has to offer both patients and practitioners 

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GUEST Blog – Jacqueline Hanley

Jacqueline has been a paediatric nurse at SickKids for three years, working in the Transplant/Nephrology/GI & Nutrition/Rheumatology/Endrocrinology/GIFT unit. She is the founder and co-chair of her unit’s Pain Resource Group and a member of the SickKids Pain...

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An interesting perspective on the day to day struggles and joys of Nursing 

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Lorenzo's Oil (1992) a movie based on the true story of one family and their search for a cure to their son's adrenoleukodystrophy - an interesting perspective on what client can accomplish when given access to their personal health information and health information on a larger scale. 

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Week 5 - consumer Health Information 

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Retrieved from http://iconsinmedicine.wordpress.com/2011/02/14/finding-health-information-online/  

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Technology helping in providing client centered care

<blockquote class="twitter-tweet"><p>Mobile devices help reduce medication errors in nursing homes, doctors say – McKnight’s Long Term Care News: L... <a href="http://t.co/Kpl2tz2osP">http://t.co/Kpl2tz2osP</a></p>— Senior Splash (@SeniorSplash) <a href="https://twitter.com/SeniorSplash/statuses/388283429608882176">October 10, 2013</a></blockquote>

<script async src="//platform.twitter.com/widgets.js" charset="utf-8"></script>

Take a look at the 8:42 AM - 10 Oct 2013 tweet!

[lveets93]

“What’s in your bubble?”

            If you log onto facebook what is the first thing that pops up in your news feed? Is it a comment on the latest Jay-Z album? A profile picture that has over one hundred “likes”? Or is it an article that a “friend” shared about the US Government shutdown? All of what shows up on your newsfeed depends on who you are, what your preferences are, what sites you typically visit and what areas of the web you spend the most time on.

            It is almost embarrassing that I would have considered myself a fairly well educated individual on things of global importance. I learned of the US government shut down almost two full days after it occurred, l wasn't even remotely aware that there were two Canadian men being held hostage for the past 7 weeks in Egypt and I was completely oblivious of the typhoon that has had half a million Chinese citizens evacuated from their homes. Needless to say none of this popped up on my facebook or instagram feed over the last week.  Why is it that none of this information seemed to have made its way into my “bubble”? That would be because my algorithmic “gate keeper” decided this information wouldn't be important to me based on my browsing history. This “gate keeper” of sorts is essentially deciding for me what I will and will not have direct access to throughout my internet query. One of the major issues with this model is that the algorithm has no sense of reason or civic responsibility. “Our society requires civic engagement to realize the potential of its citizens and its communities”(Ehrlich, 2000) , however if we are receiving our information from a source that it’s self has no sense of responsibility or engagement how then, are we to know what kind of information we are receiving?

            If we take a step back and look at this through a different lens we can see that web personalization has its downfalls, however this is not to say that there is no benefit to personalization. One of the benefits is that you are presented with information that “historically” speaking you are more likely to want, and at a very rapid pace as well. There is much to be said for the fact that you do not have to scroll through pages and pages of hits on your google search to find the one thing you are interested in. In a society and culture that is driven by success, if you can complete tasks quickly than you can complete more tasks and therefore produce/receive/come closer to your goal faster. Thus leading almost directly to becoming more successful, as the saying goes “time is money”, and personalized web browsing definitely saves time. However if time saving and money making are the only two things that power our society there are going to be many problems.

            One of the major problems that are going to be run into, especially in terms of health care, is going to be the accuracy of information available to the general public through the internet. As future practitioners we have access to “obtain empirical evidence about the efficiency of diverse interventions by electronic searches of existing databases or other bibliographic devices.” (Nevo & Slonim-Nevo, 2011). This means that we have access to reliable and up-to-date information that can be used to influence our client care. This is a privilege not extended to the general public, and therefore they are at risk of finding inaccurate health care information without knowing it is inaccurate. If totally relied upon, mistaken health information from the internet could have serious back-lash to the user.  In theory if you were someone who made a lot of online purchases, and you were to look up health information the likelihood of you coming across a health supplement or something of that nature to buy would be very likely. Again, if you didn't know much or anything about the product from an unbiased stand point the supplement may cause you more harm than good.

            So after all is said and done, the questions remain should technology companies personalize internet searches? How can this affect the health, well-being and development of our society in both positive and negative ways? How can knowing about your “bubble” make you a more informed citizen, and does it matter

            An ending thought and potential warning as you continue to surf the web is from Lihi Raviv (2012)  “We [have gotten] so used to living in our bubble that if we're not careful, we will end up not wanting to go outside.” My suggestion – got take a walk on the wild side it might be more fun over there. 

  References

              Ehrlich, T. (Ed.). (2000). Civic Responsibility and Higher Education. Westport, CT: Greenwood Publishing Group, Inc.

Nevo, I., & Slonim-Nevo, V. (2011). The Myth of Evidence-Based Practice: Towards Evidence-Informed Practice. British Journal of Social Work, 41, 1176-1197. doi:10.1093/bjsw/bcq149

Raviv, L. (2012). Filter Bubbles on the Internet and Social Media. Retreived from http://premium.docstoc.com/article/89094621/Filter-Bubbles-on-the-Internet-and-Social-Media

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http://www.cbc.ca/player/News/Canada/ID/2410938210/

A video of public interest, not directly linked to health care, however could be linked to overall health and well being of our country.

[lveets93]

[Untitled comic]. (n.d.). Retrieved September, 2013, from            http://home.messiah.edu/~se1191/images/internet%20and%20sources%20cartoon.gif

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Social Media and Health Care – a Dynamic Combination

Is it ethical? Is it legal? Where to go from here…

Ethics is defined by the Oxford Dictionary as the “moral principles that govern a person’s behaviour or the conducting of an activity”. The Oxford Dictionary also defines law as being “the system of rules which a particular country or community recognizes as regulating the actions of its members and which it may enforce by the imposition of penalties” (Oxford Dictionary, 2012). So then would it be possible to come across situations which are ethical however illegal? Or legal but unethical? The short answer to the previous questions is yes, you can have situations that are ethical but illegal and legal but unethical. The more applicable portion of this however is how you chose to proceed in those situations and what course of action you choose. This was the topic that fueled discussion in lecture this past week.

Another aspect of this discussion involved the use of technology and social media in the health care field, and how that becomes more of a grey area when intertwined with the questions of legalities and ethics.

In the Youtube clip http://www.youtube.com/watch?v=i9FBEiZRnmo  (National Council of State Boards of Nursing, 2011) there is a situation in which the nursing student is expelled because of something she posted online about a patient. The intent behind the post was not a malicious one, so in theory the post was not unethical. However because it breached patient confidentiality it was deemed illegal and the nursing student was reprimanded. The outcome was an unfortunate one for the nursing student, maybe she was unaware of the social media policies, or perhaps she never took an informatics class during her education. So if the incident was completely her fault is potentially in question but she will pay the price for it because someone has to take the fall. The moral behind this and my opinion on the matter is to be careful what you post. What you say and do in the virtual world can have huge real world impact “Even when using it for personal purposes, nurses should pay particular attention to how their online conduct can impact their professional image, employer reputation and collegial relationships” (CNO, 2012).

  Technology: a pavement for the future

After the previous post warning against the material in which you post online, which I still feel is valid, I would like to highlight an opposing view of the uses of technology (specifically social media). This view is in support of social media and the benefits of having social media outlets to increase the client base in which a health care worker can reach.

As Bill Gates said “The Internet is becoming the town square for the global village of tomorrow.”( quote, 2012 ) And if the global village of tomorrow is going to have adequate resources to accurate health care information, health care professionals better be in the forefront of this movement. Most people would agree that social media is one of the most widely used communication mediums; approximately one in four people around the world use social media (eMarketer, 2013). Meaning that the opportunity for provision of health teaching and promoting to the public is readily available. The RNAO is a good example of a health association that is currently using social media in a positive way. They have both a facebook page as well as a twitter handle (https://twitter.com/RNAO) which they use to promote many different kinds of current health information. The ability to become connected to different health resources via social media is becoming easier and easier as our technology world advances. The opportunities to change the face of healthcare to create a positive impact are numerous and can no longer be ignored. Welcome to the future Canadians. 

    Reference

College of Nurses of Ontario. (2012). Survey says … Nurses weigh in on social media and professionalism. The Standard, 37 (2), 14 – 15.

Ethics. (n.d.). In Oxford Dictionary Online. Retrieved from http://oxforddictionaries.com/definition/english/ethics

 National Council of State Boards of Nursing. (Dec 9, 2011). Social Media Guidelines for Nurses. Retrieved from http://www.youtube.com/watch?v=i9FBEiZRnmo

Bill Gates. (2012). Brainy Quotes. Retrieved from http://www.brainyquote.com/quotes/authors/b/bill_gates.html

eMarketer. (June 18, 2013). Social Networking Reaches Nearly One in Four Around the World. Retrieved from http://www.emarketer.com/Article/Social-Networking-Reaches-Nearly-One-Four-Around-World/1009976