key: cord-0883459-kzpy6xs0
authors: O'Leary, Lisa; Erikainen, Sonja; Peltonen, Laura‐Maria; Ahmed, Wasim; Thelwall, Mike; O'Connor, Siobhan
title: Exploring nurses’ online perspectives and social networks during a global pandemic COVID‐19
date: 2021-10-22
journal: Public Health Nurs
DOI: 10.1111/phn.12994
sha: 15662854ce390e6745affc58a1404b80ecb264d7
doc_id: 883459
cord_uid: kzpy6xs0

OBJECTIVES: Examine the online interactions, social networks, and perspectives of nursing actors on COVID‐19 from conversations on Twitter to understand how the profession responded to this global pandemic. DESIGN: Mixed methods. SAMPLE: Ten‐thousand five‐hundred and seventy‐four tweets by 2790 individuals and organizations. MEASUREMENTS: NodeXL software was used for social network analysis to produce a network visualization. The betweenness centrality algorithm identified key users who were influential in COVID‐19 related conversations on Twitter. Inductive content analysis enabled exploration of tweet content. A communicative figurations framework guided the study. RESULTS: Nursing actors formed different social groupings, and communicated with one another across groups. Tweets covered four themes; (1) outbreak and clinical management of the infectious disease, (2) education and information sharing, (3) social, economic, and political context, and (4) working together and supporting each other. CONCLUSION: In addition to spreading knowledge, nurses tried to reach out through social media to political and healthcare leaders to advocate for improvements needed to address COVID‐19. However, they primarily conversed within their own professional community. Action is needed to better understand how social media is and can be used by nurses for health communication, and to improve their preparedness to be influential on social media beyond the nursing community.

Infectious diseases pose a serious threat to human health. The SARS-CoV-2 virus, commonly known as COVID-19, was identified in China towards the end of 2019 (Wang et al., 2020) . A pandemic was declared by the World Health Organization (WHO) on March 11, 2020. As of June 8, 2021, over 172 million cases of the infection have been reported, with more than 3.7 million deaths worldwide (World Health Organization, 2021) . Public health measures such as testing, contact tracing, and travel restrictions were introduced to control the disease and minimize its impact on population health, the economy, and wider society (Heymann & Shindo, 2020) . Mass vaccination programs to protect the public are now underway. However, low-and middle-income countries are lagging behind due to a lack of investment and infrastructure (Thanh Le et al., 2020) .

The public health crisis led to significant challenges with healthcare systems globally. This included a shortage of Personal Protective Equipment (PPE) that endangered healthcare workers such as nurses (World Health Organization, 2020) , and additional stress and anxiety leading to burnout among nurses from working in hazardous conditions (Gennaro, 2020; Jun et al., 2020) . Nurses working in community settings also experienced verbal and physical abuse from people who saw them as a virus-spreading threat (Gilroy, 2020) . Furthermore, many healthcare workers were infected with and lost their lives from COVID-19 (Erdem & Lucey, 2021) . These challenges were especially acute during the early stages of the pandemic, which was characterized by scientific, governmental, and social uncertainty. Studies have looked at specific aspects of nursing during COVID-19 such as working in palliative care (Kates et al., 2021) , preventing delirium in critically ill patients with the virus (Ozga et al., 2020) , or reacting to hero narratives attributed to nurses during the pandemic (Halberg et al., 2021 ).

Yet, none have taken a comprehensive overview of the challenges faced by the nursing profession and how it responded to this public health emergency.

Nursing communication has traditionally focused on face-to-face interactions with patients, families, and other healthcare professionals or written forms of communication documented in patient notes or electronic medical records (McCabe, 2013) . Numerous conceptual models and theories explaining these processes exist such as

Peplau's Theory of Interpersonal Relations (Peplau, 1991) , the Humanistic Nursing Theory (Paterson & Zderad, 1976) , and more recently the Contac-d model (van Manen et al., 2021) . As contemporary society embraces digital technologies, ways in which nurses communicate using digital media are being proposed. Nonetheless, this tends to focus on conventional stakeholders, that is, patients and healthcare professionals (Wagg et al., 2018) . Alternative models of communication may be necessary when nurses need to reach out to influence patients, the public, or policy makers, particularly in times of crisis when the situation is changing fast, and information is rapidly evolving. Nurses are increasingly using digital media for real-time health communication and promotion (Gabarron & Wynn, 2016) . Hence, communication theories and frameworks from other disciplines may be useful to employ to understand the complexities of this process. Hasebrink and Hepp (Hasebrink & Hepp, 2017) proposed a new conceptual framework called communicative figurations, to further our understanding of the relationship between media-related communicative practices as an individual and as a collective configuration of actors within a particular social domain. This is explored through three concepts. Firstly, the "constellation of actors" which is the network of individuals who communicate with each other about a related interest.

Secondly, the "relevance frames" which defines the topic of interest and the characteristics of this social domain. Thirdly, the "communicative practices" are the tools and techniques, intertwined with other social practices, that form the basis of generating and sharing information about the social domain. This framework allows for a more holistic appreciation of mediatization theory which argues that the media, particularly mass media, can shape the processes and dialogues of political and social communication that influence present-day society (Corner, 2018) . It is particularly useful when examining social media, where both individual and collective communicative practices converge in digital spaces. Here, communities of users create, share, and engage with media content to make sense of and take action on various issues (Lutkenhaus et al., 2019) , but the communicative figurations frame-

work has yet to be employed in nursing. The term nursing "actor" is utilized in this study to refer to the various stakeholder groups within the profession that perform distinct roles in clinical practice, education, research, policy, and regulation, and therefore have unique perspectives on nursing.

The online perspectives of nurses from around the world, and with 

A mixed methods study utilizing a sequential explanatory design was employed (Bowen et al., 2017) . This comprised two phases: (1) a quantitative analysis of Twitter data about COVID-19 posted by nursing actors, and (2) a qualitative exploration of tweets related to COVID-19 made by the nursing profession. The qualitative phase elaborated on the quantitative data by providing a more detailed analysis of the most common topics and perspectives discussed by nursing actors in the early stages of the pandemic. The sample was drawn from English language tweets, posted from March 10, 2020 to May 10, 2020, to reflect how nursing actors used social media as a new means of communicative practice to rapidly respond to a public health emergency in its early stages.

A software program called Mozdeh (http://mozdeh.wlv.ac.uk) was used to access the Twitter application program interface to collect Englishlanguage tweets using four keywords (coronavirus, "corona virus", Covid-19, and Covid19). These were filtered to remove duplicates and near-duplicates, giving 7,427,918 unique English-language COVID-19

tweets. The tweets were processed to identify those containing the words "nurse" or "nurses". The term "nursing" was not included because it is often used to refer to activities not by nurses, for example, nursing a hangover, baby, or cold. This subset of data was searched for the term "nurs" in the Twitter username, as it was more likely these accounts were related to people that self-identified as nurses or nursing related organizations. This final dataset comprised 10,574 tweets which were exported to Microsoft Excel (http://www.microsoft.com) for further screening (see Figure 1 ).

Twitter usernames were sorted and associated tweets counted.

Those with less than five tweets were removed (n = 5771) for the qualitative study, as it was hypothesized these were less likely to be nurses or nursing organizations and the quality of the online content posted could be less relevant. In addition, the resources available for qualitative coding were limited, so a pragmatic decision was taken to focus on what was perceived to be the best quality Twitter data. This subset of data contained a manageable number of unique usernames.

These were cross-checked manually against the Twitter account profile to determine the geographic location of each user and gauge the type of nursing actor. In some cases, the geographic region was not listed.

In others, the Twitter profile descriptions were too vague to allocate them to a specific nursing actor role and so these tweets (n = 660) were also removed. Therefore, the final dataset for qualitative analysis comprised 4143 tweets (39%).

For the initial quantitative phase, the full Twitter dataset (10,574 tweets) was imported into the professional version of NodeXL (https://nodexl.com/, release code: +1.0.1.428+) (Ahmed & Lugovic, 2019) . Social network analysis was performed to produce a network visualization. The users were grouped using the Clauset-Newman-Moore algorithm (Clauset et al., 2004) which shows clusters of users who communicate with each other frequently, forming a unique group within a network. The betweenness centrality algorithm (White & Borgatti, 1994) was also used. This is a measure from graph theory that indicates a person's role in enabling information to pass from one part of a network to another via the shortest path. This allowed for the identification of key nursing actors in the social media network who were influential in COVID-19 related conversations on Twitter. The most frequently occurring hashtags were also examined.

For the qualitative phase, inductive content analysis was used on tweets posted online to explore the perspectives of nursing actors on COVID-19. The three phases of preparing, organizing, and reporting were followed. Only manifest content was used given the challenges of interpreting latent content [hidden meanings] from social media data (Elo & Kyngäs, 2008) . The unit of analysis was any term related Excel were employed to facilitate the analyses.

Screening and analysis of the quantitative social network data was undertaken by WA using NodeXL. This was checked and validated by SO and LO. NodeXL is used extensively in health research and clearly discloses the algorithms, assumptions, and techniques it uses to analyze data (Ahmed & Lugovic, 2019; Probst & Peng, 2019; Riddell et al., 2017) . The four dimensions of qualitative rigor (i.e., trustworthiness)

were adhered to (Lincoln & Guba, 1985; Noble & Smith, 2015) . Robust data collection and analysis methods, examination of negative data, and periodic peer debriefing were used. Coding clinics were also held to cross-check the qualitative analysis. Data were triangulated via different types of nurses and nursing organizations discussing COVID-19 on Twitter. Open social media datasets and freely available software programs also enhanced the study's rigor. Researcher reflexivity was heightened as data analysis was undertaken, discussed, and crosschecked by multiple authors from different scientific disciplines (Palaganas et al., 2017).

Ethical guidance specific to social media research was followed (Townsend & Wallace, 2016) . Favorable ethical opinion was obtained from a university ethics committee (reference ID: Staff179).

A total of 10,574 tweets on COVID-19 posted by 2790 individuals or organizations were extracted from Twitter. The network visualization in Figure 2 represents nursing actors that were tweeting about the infectious disease. Each colored circle represents a unique Twitter user within the social network, and the lines connecting users indicate interactions such as a reply or mention. This shows nurses formed several different groups, and communicated with one another across groups. Twitter users, and their top tweets, words, and word pairs, who were most influential in the early stages of COVID-19 conversations amongst nursing actors are illustrated in Table 1 , ranked by betweenness centrality. Individuals who ranked highly, such as those located in the United States or the United Kingdom, with some representation from Switzerland, Australia and Nigeria, may be information gatekeepers in the social network. National and international nursing organizations were highly represented along with nurse leaders, educators, and a learning disability nurse as some of the most influential users. The top hashtags across all Twitter users, excluding target hashtags (#covid19, #covid_19, #covid, #pandemic, #nurses, and #nursing), were "#ppe" (25 tweets), "#protectnurses" (30 tweets), and "#getmeppe" (25 tweets).

The qualitative phase analyzed 4143 tweets (39%). The majority came from individuals or organizations positioned in the United States (53.1%) and the United Kingdom (22.4%) (see Table 2 ). Almost onethird of the tweets analyzed were posted by Twitter users selfreported to be registered nurses (30.1%), another third by nurse and patient organizations (14.3%), nurse specialists and consultancy services (11.7%), and informal nursing networks (10.4%).

Four overarching themes emerged from the discussions that nursing actors had on Twitter about COVID-19. These were: (1) outbreak and clinical management of the infectious disease, (2) education and information sharing, (3) social, economic, and political context, and (4) working together and supporting each other. Each theme had a number of sub-themes, detailed below. Tweets to support each theme and subtheme can be found in Table 3 .

Here, three sub-themes emerged: (a) prevalence and spread, (b) testing for, and (c) clinical disease management of COVID-19 infections.

Many tweets focused on sharing statistical information on regional

prevalence of cases and deaths connected with COVID-19. Tweets about the international spread of the virus were accompanied with commentaries on controlling its transmission via social distancing, staying at home, and washing one's hands.

The development and implementation of COVID-19 testing, including the progress and delivery of public testing programs, in different national contexts were discussed. Many tweets expressed concerns about testing effectiveness. Tweets relating to strategies for prevention, treatment, cure, and management of COVID-19 symptoms and patient outcomes were also posted. The impact of the infectious disease on hospitalizations, morbidity, and mortality was expressed, as was the need to provide holistic care, and the right to be treated with dignity and die with comfort.

Many tweets concerned generic changes to care delivery that were provoked by the global pandemic. This included nurses adapting their practice to meet patients' needs and work in more challenging environments. For instance, managing relationships between healthcare professionals, patients, and their families where close physical contact and social interaction was identified as high risk. The move to more digital forms of healthcare was another notable change. Digital platforms such as mobile apps, social media, telehealth, and virtual clinics were rec-ognized as potentially beneficial to healthcare delivery and the patient experience during COVID-19.

This theme had two subthemes: (a) sharing information and resources, 

"From the start of the crisis (nursing organisation) has been calling for govts to prioritise the support", Our nurses are reporting to work every day knowing that their lives are at risk because federal agencies gave the green light to substandard protection" (Nursing and patient organisation, USA) "We should've embraced humanity after Hitler. Instead, #COVID19 is the ruthless guard, & the lack of vents is a death chamber march. No disrespect meant.

We learned NOTHING" (Registered nurse, USA) "The preventive measures about #COVID19 is quite low, by now they should have imposed a travel ban." (Nursing network, Nigeria) "Yesterday I wrote to .. to ask @. . . to share some ventilators with NY and 140 were sent today. So proud to live in a caring state, where we look out for our fellow humans. Thank you . . . for your leadership" (Registered nurse, USA)

"tell President Trump: Healthcare Workers Need PPE NOW." (Nursing and patient organisation, USA) "the impossible choices we will be faced with when there are two #COVID19 patients in our care who need ventilators, but there's only one ventilator" (Registered nurse, USA) "As#Nurses we're shocked to find out that any #NHS Trust is refusing to pay their outsourced workers sick leave and is putting #PatientSafety at risk" (Nursing and patient organisation, UK) "It is outrageous for the (name of organisation) to tell hospitals that nurses and other health care workers don't need the maximum protective gear to prevent them from getting sick during this pandemic" (Nursing and patient organisation, USA) "Unfortunately, the employer has decided to continue disregarding basic health and safety precautions" (Nursing and patient organisation, Canada)

(Continues)

"Covid19 knows no boundaries as we are all in this together as we battle this pandemic" (Nursing network, Nigeria) "To all the healthcare workers putting service above self, I thank you, your patients thank you, the whole world thanks" (Nurse specialists and consultants, France) "From the health care workers and first responders at the forefront of #COVID19",care to all of those staying home to save lives, we thank you. Together we're dedicated to getting through this global health crisis." (School of Nursing, USA) "Thanks to all the nurses who have reached out to help with the #COVID19 pandemic" (Regulator, Canada) "President (name of organisation) urges the world to listen to our #nurses on the frontline and follow @Dr.. ' Nursing actors also commented on shortages of ventilators and intensive care beds, with some raising the ethical dilemmas this caused.

There were mentions of how the health system focused on profit over people, referring to nurses' deaths or sickness, or instilling fear, and limiting nurses' capacity to tackle the virus. The deployment of nursing students, retired nurses or others who had left the profession was noted as an organizational strategy to overcome resource limitations. However, some strategies conflicted with employment rights and health and safety standards such as nurses being expected to work during annual leave and unpaid overtime. In addition, tweets mentioned employers disregarding basic health and safety precautions in certain countries and that sometimes nurses were expected to relinquish their rights to follow clinical guidelines during the pandemic.

Nursing actors also discussed how COVID-19 exacerbated existing social inequalities such as the inability of homeless people to follow shelter at home mandates, putting them at a disadvantage. The lack of equitable access to new and emerging healthcare treatments and digital platforms was also identified.

The final theme included three sub-themes: (a) strategies for building resilience and coping skills, (b) a sense of "we're all in this together", and (c) healthcare volunteering and donations. Strategies for building resilience and coping with the pandemic encompassed the practical and emotional challenges of providing care to patients and families.

Tweets provided explanations on normal emotions, stress, and how to cope with these. Staff retention and suicide was also recognized as an issue within the nursing profession during COVID-19.

The courage of frontline healthcare workers and the importance of auxiliary staff in care provision was acknowledged in tweets. There were calls for more financial reward and recognition for them. Healthcare workers were labelled as "warriors" and "unsung heroes". The clap for carers tradition and tokens such as free parking, free meals, and other personal and collective gestures were used to applaud health professionals for their work. Tweets endorsing the view of "we're all in this together" and calls for "all hands-on deck" were dominant, voicing empowerment by sharing the burden of the pandemic. The loss of nursing and other colleagues due to the virus was also acknowledged online.

Nursing actors shared tweets on fundraising for healthcare equipment or advertised vacancies for health professionals, volunteering, and donations to support the healthcare workforce such as providing money, PPE, and other supplies. In particular, nurses tweeted calls for masks and hand sanitizer to be donated to hospitals and frontline workers. Many also reported contributions by private businesses who gave money, PPE, and equipment such as ventilators.

This study showed the social networks and interactions of nursing actors on Twitter during the early months of COVID-19. It highlighted discussion hubs, containing nine of the most influential users in the network, as well as smaller more disconnected groups. A number of key perspectives on COVID-19 from nursing actors were also revealed.

Nurses recognized a lack of preparedness and control on a macro-level in terms of how governments handled the crisis, highlighting failures in contact tracing systems and lack of PPE. The capacity of healthcare organizations to protect the safety and rights of nurses and other professionals at work was also questioned. Nursing actors reached out through social media to political and nursing leaders to advocate for change such as using more technology to identify and manage COVID-19. Nurses also critiqued the quality of information available on the global pandemic, reflecting the scientific uncertainty that characterized its early stages. They emphasized the need to distinguish between misleading information versus emerging scientific evidence to inform the public health response. Furthermore, nursing actors used Twitter to voice their pride in the profession and advocate for greater recognition of their role in responding to public health emergencies.

A mixed methods approach was adopted that included robust methods of data collection and analysis. Although, the quantitative and qualitative findings were not wholly integrated, the themes and sub- tive practice for nurses. The study was conducted by an experienced research team from a variety of scientific disciplines including nursing, sociology, computer science, and social care, who discussed and agreed the interpretation of data. However, as this study focused on the early stages of the pandemic, the data are not representative of later phases or tweets outside of the English language, which may constrain the generalizability of the findings. Self-reported data in Twitter account profiles may be unreliable (Jensen, 2017) , hence the categorization of nursing actors and the results should be interpreted with caution. Most Twitters users were from high-income countries whose experiences of COVID-19, digital media access, and social media culture may be different from those in low and middle-income nations.

This study found a lack of preparedness on a macro and meso level by government and healthcare organizations. Hence, some nursing actors took control on a micro-level, adopting creative strategies to protect themselves against the virus such as making their own versions of PPE and calling for donations of equipment from private providers. Similar strategies were found in a study of front-line healthcare staff in the United Kingdom during COVID-19 (Hoernke et al., 2021) . Previous studies also identified how limited organizational readiness can affect nurses' capacity to cope with a crisis and lead to burnout and high staff turnover (Corley et al., 2010; Fernandez et al., 2020; Hu et al., 2020; Wood et al., 2021) . These mental health concerns emerged in the current study, because suicidal ideation and a desire to leave the nursing profession were mentioned. This has been emphasized in other recent studies on this global pandemic Liu et al., 2020) .

The study's findings are also supported by nursing informaticians who called for nurses to embrace digital technologies during the pandemic (Atique et al., 2020) . This study added insights into digital practices nurses employed during COVID-19 such as electronic medication management, remotely monitoring patients at home, and providing virtual forms of support to patients. Misinformation on social media and mass media about COVID-19 was also raised by nurses in this study, which was noted previously (Lee et al., 2020) . In addition, this study highlighted that nursing actors recommended reliable sources of information and stressed the importance of generating and utilizing scientific evidence. They also encouraged others to share credible information to counteract fake or misleading claims about the virus. In keeping with the findings of this study, others have discussed the changes needed in higher education to prepare nursing students with the knowledge and skills to care for patients with COVID-19 (Dewart et al., 2020) . The voices of nursing students who expressed anxiety about working in clinical practice and continuing academic studies was highlighted in this study.

This study uncovered several implications for nursing research. Firstly, the experiences of nursing actors in low-and middle-income countries needs further exploration as their experiences of COVID-19 may be different. This could be due to prior exposure of other infectious disease outbreaks (Mboussou et al., 2019) , poor healthcare infrastructure (Oleribe et al., 2019) , and limited access to digital media and online forms of communication (Mutsvairo & Ragnedda, 2019) . Secondly, nursing students and nurses working in care homes with older adults were underrepresented in this study. Hence, further research into their perspectives could aid our understanding of the challenges they faced, their response to COVID-19, and how they utilized social media during the pandemic. Thirdly, it could be beneficial to research later phases of the pandemic to identify how nurses responded via social media to changes in scientific evidence, the availability of vaccines (Khubchandani et al., 2021) , and other social and political changes that affected the public health response (Jaffe, 2021) . Finally, more research could explore how nursing actors use other social media platforms to communicate during times of crisis, as Instagram and Tik-Tok are becoming popular avenues for online health promotion (Basch et al., 2021; Niknam et al., 2021) .

While social media research and practice in nursing is gaining momentum, this study showed that nursing actors tended to remain within their professional community when communicating online. This could limit their ability to advocate for change and reach key stakeholders such as policy makers and the public. As social media platforms like

Twitter are becoming an increasingly central tool for health promotion, they open up new possibilities for communicative practices that have the potential to reach and influence large audiences (Niknam et al., 2021 ). Yet, the restricted scope of nurses' sphere of influence suggests that the ability of nurses to fully leverage the potential offered by social media platforms like Twitter remains limited. This has notable implications for the future of nursing as a digitally engaged health profession capable of informing and shaping public health debates and communication in the digital age (Booth et al., 2021 As public health nurses are closely involved with their local communities (Vessey & Betz, 2020) , they could use social media to reach out to key community groups, particularly those who are vulnerable, to ensure public health advice about controlling infectious diseases such as COVID-19 is widely shared. They could also work with these groups to use various social media platforms to influence local politicians and healthcare leaders to invest in the right infrastructure and resources to limit the transmission and spread of infectious disease. National, regional, and local public health campaigns on social media may also benefit from the expertise of public health nurses, who are attuned to the needs of the different populations in their locality.

This study demonstrated how social media enables global health communication and promotion, as it clearly identified how nursing actors communicated using an online platform as an international public health crisis unfolded. It also showed how a range of nursing actors used social media to urge political and nursing leaders to invest in areas of nursing education, research, and practice to help manage the infectious disease. Nurses' contribution to tackling COVID-19 were acknowledged on Twitter and tweets also offered support to the profession. However, nursing actors mainly conversed within their own community on Twitter, potentially limiting their reach and influence during the pandemic. Nurses need to take a more active role in online discussions on healthcare issues, targeting health service and political leaders to advocate for change. More education is also needed to improve nurses' knowledge and skills about how to be influential on social media to help enact positive change.

We would like to dedicate this study to nurses everywhere who are helping tackle the coronavirus pandemic, particularly those who have lost their lives from this infectious disease.

The authors declare no conflicts of interest.

S.O. conceptualized and designed the study will assistance from L.O.,

S.E., and L.P. M.T. aided data collection. W.A. led the quantitative analysis, while L.O., S.E., L.P., and S.O. led the qualitative analysis. All authors contributed to the final data analysis, interpretation, and drafting of the manuscript.

Open access funding provided by IReL.

The raw data used in this article is freely available in the public domain 

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