Searching for private patient information in Internet resources (patient-targeted Google)—experiences of nurses and nursing students

The evolution in access to and use of Internet resources has changed people’s perception of the nature of communication and the rules for sharing personal information, as well as the boundaries of privacy and anonymity [1‐3]. Using social networks and publishing various materials on them often blurs the line between private and social or professional life. The sense of anonymity on the Internet is apparent, as these data can also be quickly found by people who were not directly addressed.

The Internet and social networks leave no doubt about their important role in modern healthcare [1, 3, 4]. Medical personnel also have the possibility to access various types of data posted on the Internet [2, 5‐9], and the phenomenon of searching the Internet resources to obtain private information about patients is known as Patient-targeted Googling (PTG) [5, 10, 11]. The development of communication technologies and the transformations that modern medical care undergoes may cause PTG to become an informal part of daily medical and nursing practice [5, 9, 12‐15].

The possibility for medical personnel to obtain information shared by patients on the Internet may involve potential risks and benefits [4, 5, 9, 10, 16]. There is a belief that the data obtained by analyzing publicly available content posted on the Internet do not require the consent to be obtained. This belief is based on the assumption that a person posting information on social media and publishing photos and footage is aware that the data are available to outsiders. However, treating these data as public property can lead to the misconception that seeking information online about patients does not require their consent [5, 14, 17, 18]. The ease of obtaining private patient information via the Internet may lead medical personnel to initiate and conduct PTGs without the necessary consideration and justification [5]. The process of obtaining patient information is relatively simple, but the consequences can be unclear and difficult to predict. The ethical aspect of this activity should be primarily related to the evaluation of the motivations and goals to be achieved by the search undertaken [12]. The purpose should be broadly understood as the willingness to help the patient, not to satisfy curiosity or to look out for the patient's own interests [9, 11, 12]. PTG may raise concerns about maintaining the principles of privacy, confidentiality, informed consent, professionalism, therapeutic relationship and standards of communication and patient protection, and maintaining impartiality and objectivity in the therapeutic relationship [5, 6, 8, 10, 12‐14, 16, 18]. Other concerns relate to the reliability of the information obtained through this route and its usefulness in the therapeutic process (actions taken on the basis of this information may be inadequate to the actual condition and needs of the patient) [1] and the risk of misinterpreting this information [2, 8, 10]. It can also be difficult to determine the identity of patients online due to similar or the same personalities, pseudonyms, or impersonation [9, 10]. Additionally, information posted by a patient intentionally or unintentionally can mislead Internet users [2, 12, 19].

Potential benefits of using PTG in clinical nursing practice include the possibility of better understanding the patient, obtaining relevant information for the therapeutic process and not previously disclosed by the patient, and verifying the data [1, 10, 13]. In addition, data obtained from Internet resources often reveal different aspects of the patient’s life than those addressed during a face-to-face interview [4], which allows one to get to know the person in many dimensions of his functioning [12].

The use of Internet resources today is a common phenomenon, but there has not been much research on patient-targeted Google by medical personnel [11, 20]. However, the results of available studies indicate that this phenomenon exists [1, 5, 7, 10‐13, 21‐34]. The percentage of medical personnel who confirmed patient targeted searches based on available research varies widely, and was 5.1% in the study by Bosslet et al. [25]; 14% in the study by Ben-Yakow et al. [22]; Similar results were obtained by Jent et al. – 13.0% [23]. The results showing a higher percentage were presented in the paper by Chester et al. – 16.7% [10], Ginory et al. – 18.7% [24], Deen et al. – 20% [27]. The frequency of conducting PTG indicated in the study by Eichenberg et al. was 39.6% [13], and in the study by Harris et al. [28] was 33.2%. The performance of PTG by analyzing social networks and blogs in a study by Tunick et al. [30] revealed 32.0% of the respondents. In a study by Ommagio et al. [7], 33.0% of the participants reported that they searched the Internet for patient information. The highest percentages were shown in the studies of DiLillo et al. [21]—97.8% and Trub et al. [33]—86.0%. In Poland, according to the information available to the authors, to date there have been no studies on the conduct of PTG by medical personnel and medical students. This is the first Polish study to describe the prevalence of PTG along with its determinants.

The aim of this study was to evaluate the prevalence of the phenomenon in which private patient information is obtained from publicly available online resources (patient-targeted Google) among active nurses/midwives and undergraduate nursing and midwifery students.

Having an account in the Facebook app was reported by 91.39% and in the Instagram app by 60.71%. The results obtained showed that the students were more likely to use Facebook and Instagram (p < 0.01). Students also indicated using the X social network (formerly Twitter) (p < 0.05). The daily use of social networks was confirmed by 81.24% of the respondents, and they were more often students (p < 0.0001).

Table 1 illustrates The reasons of the respondents for considering searching for patient information on the Internet.

Respondents also indicated what in the patient’s behavior was the reason they considered patient-targeted searching. For 60.78% it was the display of unusual or weird behavior and for 41.7% it was the crossing of boundaries in contact with medical personnel. Nurses significantly more frequently indicated crossing boundaries in contact with medical personnel, cheerfulness, enmity to the environment, aggressive behavior (p < 0.01). On the contrary, the students significantly more often declared that the reason for seeking information was not the behavior (p < 0.01) (Table 2).

The patient’s physical appearance was also a reason to consider the patient's targeted search. 37.81% indicated an unusual hair-style or makeup. Active individuals were significantly more likely than students to indicate inappropriate clothing for the season (p = 0.0031) and time of day (p = 0.0087), dirty (p = 0.0005), eccentric (p = 0.0032) and unusual hairstyles or makeup (p = 0.0010) and tattoos (p = 0.0007). Respondents confirmed that they most often considered seeking information about patients treated in non-invasive treatment wards – 63.50%, surgical wards 19.64% and those receiving community care and long-term care 3.15% each. Statistical analysis did not show differences between the study groups (p = 0.0508).

More than half of the respondents (59.82%) claimed to have ever searched for patient information on the Internet, eg, using web browsers, browsing social media profiles. The result was not statistically significant between the study groups (p > 0.05). When conducting searches, the most frequently used applications were Facebook 81.55% and web browsers, eg. Google 70.11%, Instagram apps 22.88%. Students were significantly more likely to use the Instagram app (p < 0.01). Such searches 'several times a year' were confirmed by 55.72%, 'once a year and less often' by 29.89%, and daily by 1.85%. The results were not statistically significant, with no significant relationship between the respondent groups (p > 0.05).

For 79.34%, curiosity was the reason for the patient's targeted search, the willingness to get to know the patient better was the reason for 52.03% while for 50.18% it was to understand the patient’s behavior (Table 3).

For 63.1% of the respondents, unusual or weird behavior of the patient was the reason for seeking information about the patient, for 48.34% inappropriate behavior in the situation, and for 43.91% crossing boundaries in contact with medical personnel. Nurses and midwives significantly more frequently indicated unusual/weird behavior of the patient (p < 0.05) as the reason for the search for information (Table 4).

For 37.64% of the respondents, unusual hairstyle or makeup, and for 35.06% eccentric clothing and tattoos – 32.47% were the reasons for seeking information about patients. Nurses were significantly more likely to indicate eccentric clothing (p = 0.0126), inappropriate clothing for the season (p = 0.0163) and unusual hairstyles or makeup (p = 0.0112) as reasons. This group also indicated that dirty clothes (p = 0.0014) and tattoos (p = 0.0026) were significantly more often. Respondents searched most frequently for information about patients receiving care in non-invasive treatment and surgical units. Statistical analysis did not show significant differences between the respondents' groups (p = 0.2303).

More than half of the respondents, 54.53%, answered affirmatively that they thought that other healthcare professionals were searching the Internet for information about patients. The answer 'no' was indicated by 14.79%, while 'don't know' was indicated by 30.58%. Statistical analysis showed that students responded significantly more often 'I don't know' than nurses, and the latter were more likely than students to indicate the answer 'no' (p = 0.0268). The respondents were also asked whether medical students seek information about patients on the Internet. Among them, 63.36% answered in affirmative. The students were significantly more likely to give an affirmative response (p = 0.0006). Less than half (40.96%) admitted providing information, but only information considered relevant to the treatment process for selected members of the treatment team, while 36.16% of the respondents stated that they never provided this acquired information. Statistical analysis showed that The students were significantly more likely not to share the acquired information (p = 0.0009).

Patient-targeted Google was classified as unethical by more than half of the respondents (54.06%), indicated responses of 'rather disagree'—26.71% and strongly disagree – 14.35%. More than 35.1% had no opinion and 23.84% rated these activities as ethical, of which 2.65% agreed strongly and 21.19% disagreed rather. There were no significant differences between the study groups (p = 0.2736). In response to the question of whether the ethical standards in force in Poland allow searching for patient information on the Internet, the predominant response was lack of knowledge in this regard. The answer 'I don't know' was given by 65.12%. There were no significant differences in the answers given between the groups (p = 0.2102).

Almost half of the survey participants (48.79%), were not of opinion on whether information about patients obtained on the Internet could affect the subsequent nurse – patient relationship in the therapeutic process. For 19.21% it did not matter, while 17.44% indicated a negative influence. There were no statistically significant differences between the groups (p > 0.05). If the patient found that data about him was sought on the Internet, this information would negatively affect further relationships in the therapeutic process in the opinion of 36.87%, for 4.86% it would have a positive impact. Meanwhile, in the opinion of 18.89%, such information would not affect any further relationships in the therapeutic process. Statistical analysis of the responses to the question of what effect obtaining information about such a search by the patient would have on future relationships in the therapeutic process is highly significant (p < 0.01) and depends on the group of respondents. Students indicated a negative impact on further relationships in the therapeutic process more frequently (p = 0.0058).

Statistical analysis showed a relationship between the place of providing patient care and the reason for seeking information about the patient on the Internet. A highly significant relationship (p = 0.0255) was found between the verification of the patient’s functioning and the non-invasive treatment wards, and a significant correlation (p = 0.022) was found between the confirmation of the presumption that a patient has a mental disorder and the non-invasive treatment wards and surgical wards. Detailed analysis of the data also revealed a relationship between the place of care provided by the patient and the behavior of the patient. A highly significant (p < 0.01) correlation (p < 0.01) was found between the behavior of a patient under the influence of alcohol and drugs and non-invasive treatment wards. A significant (p < 0.05) correlation (p < 0.05) was also found between the excessive cheerfulness of the patient and the non-invasive treatment wards. Other significant relationships were also confirmed between the place where patient care was provided and the appearance of the patient. A highly significant (p < 0.01) correlation was found between inappropriate clothing for the season and non-invasive treatment ward, and a significant (p < 0.05) correlation was found between inappropriate clothing for the time of day and incomplete, eccentric and unusual hairstyle or makeup.

Access to Internet resources is a part of everyday life, and it is hard not to notice that the digital revolution has also extended to the field of medical care [1, 14, 36‐38]. Information on the Internet allows medical personnel to search for information not only on the health of patients, but also on their private affairs [5, 38].

The subject of patient-targeted googling (PTG) among healthcare providers is not a foreign phenomenon, as evidenced by studies published to date [7, 10, 11, 13, 21‐34, 38]. However, it is noted that their scope in this area is still limited and, according to the information available to the authors of this publication, no studies on the PTG phenomenon have been conducted in Poland so far.

The research results take into account various aspects of the PTG phenomenon, and although all of them do not address PTG in groups of nurses or students in these fields, as assumed in our own research, it is worth comparing them with other results. Lavahot et al. [29] evaluated the online activity of the subjects, and the conclusions of this study confirmed the search for information about the patients, and the main reason for PTG was mainly curiosity. Harris et al. [28] pointed out the search for patient information and informed consent, and Tunick et al. [30] assessed the online activity of professionals and the prevalence of browsing social media and patient blogs. Eichenberg et al. [13] studied professionals’ experiences with the PTG relationship, similar to Trub and Magaldi [33]. Furthermore, Eichenberg et al. [13] studied the circumstances that justify the conduct of PTG, and ethical aspects were also important for Deen et al. [27], Ben-Yakow et al. [22] and Wu et al. [31]. Determining the prevalence of the PTG phenomenon was the objective in studies conducted by Gershengoren et al. [11], Thabrew et al. [32] and Dililo et al. [21]. The study by Chester et al. [10] addressed PTG in terms of social media use, while the study by Ommagio et al. [7] focused on the use of social networks and web browsers. However, Jent et al. [23] focused their research not only on evaluating the prevalence of social media use and conducting PTG, but also on how this practice is perceived by professionals. A slightly different approach to research, as Bosslet et al. [25] used the mediation of social networks in patient interactions. The use of electronic communication and social networks by psychiatrists in their interactions with patients was of interest for Koh et al. [34]. The focus of research on the role of social networks in psychiatric practice in the context of professionalism was presented by Ginory et al. [24]. Intentional or incidental interactions with patients on the Internet were studied by Kolmes et al. [26]. In comparison, the area of our own research included not only the prevalence of PTG in Poland, among professionally active nurses and midwives, as well as students of these majors, but also analyzed the phenomenon of PTG through the prism of ethical aspects, legal aspects, circumstances under which the respondents undertook PTG and considerations for its undertaking. This fits in a similar scope of research to that presented above, although, a comparison of the results obtained is not fully possible.

Available reports indicate that the prevalence of PTG behaviors among healthcare personnel varies [7, 10, 13, 21‐25, 27, 28, 30, 33], which may result from differences in the studied groups and the use of different research methods. In our own research, the percentage of professionals admitting to this practice was 59.82%, showing that these results rank higher in the compared studies. Furthermore, more than half (54.53%) of the respondents confirmed that they were aware of other healthcare professionals searching the Internet for patient information. In comparison, nearly 40.0% of the respondents to the study conducted by Eichenberg et al. [13] knew colleagues who had such practices.

The decision to seek private information about patients from medical personnel can have many reasons. Our own research found that the most common were curiosity and willingness to get to know the patient better and to understand his behavior. Other reasons included willingness to help the patient, inability to obtain data from other sources, verification of the patient’s truthfulness and confirmation of mental disorders, as well as checking compliance with the recommendations and functioning of specialists after hospitalization. Other authors have shown that this type of search is a reason for conducting this type of search in their studies for collecting data on patient care [7], curiosity [11, 13, 24, 27, 29, 30, 33], improving care [7, 13, 24‐27, 29, 30, 32], therapeutic concern [30], putting the patient at risk to himself or others [13], his safety or his place of residence at risk [26], risk reduction [32], monitoring health status and progress of treatment [13, 24, 26], obtaining the necessary information for treatment [30], warning the patient of potential harm [7]. Some other reasons have included verification of the patient’s truthfulness [7, 27, 29, 33], monitoring the patient’s well-being and coping [26], clarification of information obtained from history or inconsistencies with medical records [7]. Other motives include contacting the patient and warning him of possible harm [7], requests from the patient or family [11, 13, 30], verification of formal data, verification of online activity and therapy-related content [13], and obtaining information in medical emergencies [10]. The possible reasons why the respondents choose to perform PTG indicate their diversity and it can be concluded that they are dictated by the patient’s well-being in the broadest sense. Differences in the results of various studies are probably due to differences in the research methods used and the professional education and specificity of the professional activity of the study participants.

Studies on PTG also included evaluation of possible benefits. According to professionals, the reasons for carrying out this activity argued in favor of protecting the patient [13, 23], reducing the patient’s crisis or emergency situation [13, 26] and getting to know the patient from a different perspective [13, 29], as well as improving communication [25]. Compared to other studies, our own research has shown such benefits as getting to know the patient’s social environment, better understanding the patient, obtaining information quickly, and getting to know the image created by the patient. In the available publications, arguments against the practice of PTG pointed to the cross of the private space of patients [24], depriving them of autonomy [10], dignity [22], informed consent [22, 23], and the right to express information [13] and confidentiality in the relationship [22, 25]. However, our own research found that, for more than half of professionals and students, seeking information about a patient without informing him involves violating the principles of informed consent (56.07%) and privacy (55.19%). In the patient relationship, violation of professional boundaries [24], the risk of prejudice [30], impaired impartiality, countertransference [13] and professional discomfort [24] have been highlighted. Almost half of the participants in our study had difficulty determining whether seeking information about patients could affect the subsequent nurse-patient relationship in the therapeutic process. It seems interesting that it was the students who significantly more often indicated an answer confirming that such an action is a violation of professionalism. Perhaps, being aware of what characterizes professionalism in the profession, they will not undertake such activity on the Internet in the future. Other arguments against PTG included the risk of obtaining unreliable information and drawing inappropriate conclusions based on it [10, 26] as well as the lack of credibility of the Internet as a source of information [13]. Compared to other studies, our own research showed that more than 40.0% of the participants found the data obtained from the Internet to be reliable.

Some of the studies conducted so far have also included ethical evaluations of aspects of PTG. In Ommagio’s study [7], most of the respondents felt that searching for patient information on the Internet should not take place or is rarely acceptable, similar to the study conducted by Ben-Yakow et al. [22]. Ethical doubts were also present among most of the participants in the study by Eichenberg et al. [13] and Bosslet et al. [25], for whom the motivational purpose to perform PTG was irrelevant, and in the study by Wu et al. [31] the above activities were considered unquestionably unethical by 31.0%. In contrast, the results obtained by Deen et al. [27] showed that the majority of the respondents considered conducting PTG ethically. Kaslow et al. [38] address ethical issues related to conducting PTG by proposing guidelines in this area addressed to people providing psychological care (psychologists).

The flow of patient information is an extremely important and desirable phenomenon among the therapeutic team, allowing, for example, to make appropriate interventions or to determine a common understanding of the patient’s condition. The question can then be posed: Should the information obtained online also be shared with other members of the treatment team? Our own research showed that 41.0% of the respondents shared information of their choice with other members of the treatment team. In comparison, 83.0% of the personnel in the study by.

Ben-Yakow et al. [22] communicated information gained during PTG to colleagues and supervisors. These differences may result from the specific professional activity of the studied persons; the study by Ben-Yakow et al. [22] was conducted among emergency medicine personnel, where rapid flow of information is invariably important.

In our own study, the vast majority of participants, 80.79%, indicated that maintaining appropriate relationships in the Internet space was not subject to education as part of training and at the same time expressed their belief that such training was necessary. The need to address PTG issues in the course of education is also confirmed by the results obtained by other researchers [10, 11]. This proves that issues related to maintaining appropriate relationships by medical personnel in the Internet space are important regardless of the country in which the research was conducted.

The analysis of available studies and the results of our own research encourage the development of recommendations for PTG-related activities aimed at nursing, medical and psychological care professionals, as well as the inclusion of patient-targeted search issues in the basic as well as postgraduate training of medical personnel. The constant changes faced by activity in the Internet space, the emergence of new applications, the implementation of innovations in this area or the presence of new media, as well as transformations in the perception of privacy, public data, and therapeutic boundaries require addressing the above phenomenon.