Nurses And Web

Nurses and the Web: Staking Out Your Territory as an Expert in Health Care
Christine Gorman
Oct. 6, 2009
American Journal of Nursing conference
Chicago, Illinois

[Title slide] Thank you very much for inviting me to Chicago and to share some ideas
and experiences about staking your claim on the web.

[next slide: Web Sites] Here is a list of the places you will most easily find me on the
Web. I have also posted the PowerPoints on slideshare.net so that if you are following the
talk via the audiocast or you just want to refer to it later, you can do so. I will also post a
write-up of what I say on my blog at globalhealthreport.com.

There are basically two main points I would like you to take away from today’s talk.

[Next slide: Platform shift] The first is summed up in this slide.

The world of media—all the ways that we get information, that we are entertained, that
we interact with and respond to others at a distance—is going through a major shift in
platform. The delivery system if you will. We are transitioning from a broadcast platform
to a network platform. The often satirized “Voice of God” message that gets delivered to
the masses is being replaced by what you might call “the Big Hum” — the constant
murmur of many conversations amongst many much smaller groups.

[Next slide: Implicit to Explicit] And the second major point I want to make has to do
with the soaring value of taking what you know implicitly and making it explicit.

Providing context has always been important. But its value increases dramatically in a
world where we get bombarded by information and voices and opinions all vying for our
attention with very few built-in filters to help us separate what is real from what is
fantasy.

Now you might expect a lot of how-to guidance and cool technology tips from a talk
about how nurses can stake their claim on the Internet. Something like Christine’s top
five tips for getting other people to listen to you. Or 7 ways to profit from the social
media revolution. Lists are so easy to grasp that they are a popular way to boost your
circle of influence on the web—whatever the topic.

And the truth is, you can find many good introductory how-to instructions about lists and
other attention-getting devices on the Internet after a couple of searches or by asking
questions in various forums.

But I think it is important to have a theoretical framework to understand these issues so
that you can adapt them to your own situation. Otherwise, you spend most of your time
boosting somebody else’s influence and credibility without building up your own. A little

theory makes it easier to evaluate which shiny new tool on the Web you should be paying
a lot of attention to—or even helping to build. And which you can avoid wasting your
time on.

So the first part of my talk is going to give a fair amount of background. And then we
will get into some guidelines and rules of thumb for staking your claim on the Web.
Finally, there will be time for questions at the end.

[Next slide: Influences] A lot of the ideas in this talk are inspired by my own experiences
on the web and in journalism. But I have also been helped a great deal in my thinking and
understanding by the work of a number of Internet thinkers and practitioners. Here are a
few of the key ones who have influenced me.

• Yochai Benkler – Berkman Center at Harvard
• Mindy McAdams – University of Florida
• Persephone Miel – Internews
• Clay Shirky – NYU
• Matt Thompson –University of Missouri
• Michael Wesch – Kansas State University
• Ethan Zuckerman – Berkman Center

[Next slide: Literary Heroes] I’ll also admit taking inspiration for this talk from some
American literary giants as well, particularly Mark Twain and Upton Sinclair. Mark
Twain for his wry insights into the world as it is and how we might like it to be. And
Upton Sinclair for his righteous anger and passion for addressing injustice.

Any mistakes, however, are my own.

[Next slide: Platform shift] So back to this platform shift, which starts off as a technical
shift—“How are news, entertainment and information created and delivered?” This
technical shift has also become a cultural shift, a change in the way we organize our
thoughts and ourselves.

Most of us, myself included, grew up in a world where broadcast media dominated.
Whether you’re old enough to remember Walter Cronkite or Woodward and Bernstein or
you get most of your news from Jon Stewart, you didn’t think much about the fact that
this was a one-way conversation. One message to millions of people—hence the “Voice
of God” tone.

Listeners, viewers and readers absorb the message, maybe even talk about it with their
friends, but what they have to say won’t have much of an impact on the newscaster
--unless of course they are already a powerful figure – like a President, a talk show host,
a CEO or a celebrity.

This mostly one-way conversation has its advantages and disadvantages but the point I
want to make here is that it was not set in stone somewhere. It is actually a function of the

enormous costs of production and distribution. Costs which weren’t necessarily there at
the beginning but that grew over time.

If you look at the early days of radio, you find a lot of amateurs, enthusiasts, small
community groups –like churches – and even lectures by the U.S. Public Health Service
on the airwaves. Broadcasters transmitted from low-power stations over a very limited
range.

There is a finite amount of electromagnetic spectrum over which you can transmit radio
waves, however. Two radio stations trying to transmit over the same frequency from
nearby locations would end up interfering with each other’s signals. Eventually the U.S.
government started assigning different spots on the spectrum through various licensing
arrangements.

Scarcity and regulation favored more powerful transmitters. The amateurs and small
groups were priced out of the market. The escalating lawyers’ fees and the cost of
building and maintaining powerful transmitting stations eventually meant that, with
notable exceptions here and there, only large commercial interests could afford to be in
the radio business.

Similarly for newspapers and magazines, the capital required to reach a large
metropolitan audience – not to mention a national one – meant tremendous expenditures
for presses, distribution trucks and mailing costs – and all the people to keep the process
flowing.

But once these initial startup and distribution expenses were met, the cost of adding each
additional customer was rather small in comparison. So you could create and deliver huge
audiences. And those big audiences were exactly the sorts of people that advertisers
wanted to attract.

From an advertiser’s point of view, it wasn’t a terribly efficient system. You never had a
sense of how effective any particular advertisement was at bringing in new customers.
But broadcast distribution to a mass audience—over the airwaves, via print--was the only
game in town and so advertisers played along and were handsomely rewarded.

[Next slide: Advertising inefficiency.] Here’s where it gets interesting—where we can
see that inefficiency isn’t always a bad thing. For you see, advertising inefficiency
allowed news organizations of the 20th century to invest in professional journalists who
spent years covering the same beats, building up an expertise. That inefficiency allowed
them to pursue months-long, even years-long investigations. When you think of the great
icons of investigative journalism – Watergate and the Pentagon Papers – or more recently
the neglect of Iraqi veterans at Walter Reed Army Medical Center or the massive foul ups
that occurred both prior to and after Hurricane Katrina – you also have to think about the
Ivory Soap and used car ads that made them possible.

Of course, when one person—or a small group of people—has the only megaphone, you

have to get that person’s attention unless, of course, you own a megaphone yourself.

It makes sense, you have to pay attention to the biggest voice in the room—even if there
are a lot of softer voices around. And if everyone with a message is trying to get the ear
of the person with the biggest voice, then that biggest voice grows even more powerful.

The Internet has changed all that and is still changing all that.

[Next slide: Internet map]
This is a map of the Internet and was put together by the folks at Lumeta Corporation and
ATT. They kindly gave me permission to use it in this talk. Actually, it’s a map of the
Internet as it was at a given point in time in August 2007. And it’s not even a map of the
whole Internet. It’s a map of the backbone—the basic skeleton as it were of the major
pipes that make up the Internet. It’s not even a complete map of the backbone. If it were,
it would be so thick you wouldn’t be able to make any sense of it.

As the creators note, quote “Each line depicts the shortest outgoing route from a test
computer to each of more than 320,000 network nodes around the world. The map does
not represent the physical or geographic location of servers, but rather is a topological
representation of the various networks that combine to form the Internet.” unquote

Now how on earth do you get a one-to-many conversation going in here? Where do you
find a Walter Cronkite or a Bob Woodward or an Oprah Winfrey in here? It’s much
harder to dominate the conversation. That doesn’t mean it’s impossible—and you could
introduce chokeholds and gateways into the Net that would make it easier to control the
pathways. But for now, this is more or less the shape of the Internet.

So besides being rather beautiful in a geeky kind of way, this map makes the point very
graphically that the Internet is a network. There is no central transmitter broadcasting to
everyone else. There may be some conversations that dominate large sections of the Net.
But the potential for many, many conversations among smaller groups of people that can
go as deep as the group wants to go is suddenly enormous.

This is the network that allowed Craig’s list and web-based ads to shorten the distance
between a willing seller and a willing buyer. This is network that cut out quite a lot of the
inefficiency out of advertising. This is the network that drove the production and
distribution costs of news and information to near zero.

Now a lot of energy and words have been devoted to what this means in terms of
maintaining a viable news industry both as an economic issue as well as a larger societal
issue.

A free press is every bit as important to democracy now as it was in Benjamin Franklin’s
day. And that’s something in which all citizens of the United States –whether they realize
it or not – are deeply invested. The economic reality, however, is that we just can’t pay
for a free press the same way we have since about the 1920s.

But while others are hard at work trying to figure out a viable business model for the
news industry, there is a different part of this story that I want to highlight today.

I believe that most people are still using and thinking about the Internet as a broadcast
medium. They are still mesmerized by the idea of being THE BIGGEST VOICE in the
room. They want the most page hits, the highest page rank, the most followers on Twitter
or friends on Facebook. They are still stuck in the broadcast mindset where the
predominant communication is a one-to-many conversation.

We still haven’t grasped what is possible when there are lots of conversations among
small groups happening in parallel. We assume it’s chaotic but I think that’s only because
we don’t have a lot of experience with it yet.

And because so many of us are still oriented towards using the Internet as a broadcast
medium—like the ones we grew up with—we miss the Internet’s extraordinary potential
for organizing people. The real Internet revolution is not its broadcast abilities, but the
various ways that, as Clay Shirky of NYU puts it, the Internet makes the formation of
groups ridiculously easy.

You don’t have to be in the same geographic area, belong to the same clubs or have gone
to the same schools. People with the same interests or passions find each other via text,
list-servs, blogs and virtual communities.

And with the ubiquity of easy messaging, they can create temporary groups that form and
melt away in order to do everything from the very silly to the very serious.

[Next slide: photo of Toronto pillowfight:
http://en.wikipedia.org/wiki/File:Wikipillow.jpg Wikimedia Commons]

This is a flash mob that got together in response to a group of text messages that were
forwarded and reforwarded to produce a seemingly spontaneous pillow fight in
downtown Toronto.

[Next slide Iran 2009 election protects; Milad Avazbeigi;
http://commons.wikimedia.org/wiki/File:Tehran_protests_(28).jpg].

Here we have demonstrators protesting apparent election fraud in Iran. The organizers’
were so adept at using social media to focus people’s anger that the government had to
shut down the cell phone networks across the country in addition to resorting to violence
to put down the protests. [pause]

There’s just something about our broadcast upbringing that makes us focus first on the
largest groups – the greatest number of connections – but I’d like to argue today that we
still have not seen the revolution that can come from the increased formation and
connection of small groups and small networks.

I have written a lot of stories over the past 20-plus years. I am particularly proud of the
articles I helped to shape at TIME Magazine during the early days of the AIDS epidemic
in the U.S. –

[Next slide: AIDS wordle]

The 1980s were a time when tremendous stigma still attached to the disease and to the
people who struggled with it. I believe those early stories – by myself and others –
eventually helped to change the national conversation.

Those stories could have just as easily NOT been published. I remember lots of fights in
the early days within TIME magazine about whether to cover the topic at all – and how to
frame the subject. One editor said he wanted to see only stories about “innocent victims”
in the opening paragraphs – by which he meant babies who had been infected in utero or
hemophiliacs who had been infected due to contaminated blood products. In his thinking
– and that of many people at the time – gay men, IV drug users and poverty-stricken
Haitians were all suspect, all guilty, all deserving of what befell them.

This was my first real-world education about the potential benefits as well as the
limitations of journalism. About how much time and energy are required to make sure
that certain stories get told and told well – the stories about people who do not travel the
corridors of power.

And it is a lesson that has stayed with me through the years. It certainly was not true all
the time but for so many stories, the size of the audience trumped the merit of a story.
Size or the power of the constituency. Since there was only a finite resource, a limited
amount of space in which to put the news, size and power mattered.

Just as important, however, was the lesson of how the gay community – a community
that was fragmented and did not even always think of itself as a community – could come
together to tell its own story and to get the public at large – including mainstream media
and the powers that be – to pay attention to that story.

The success of AIDS activists in getting more attention and funding to focus on a hitherto
obscure and highly stigmatized disease did not, of course, go unnoticed. Most notably,
those in the breast cancer advocacy community started adopting some of the strategies
and techniques they saw in the AIDS community to great success in order to raise money
and awareness.

Indeed, single-disease advocacy has become so successful that some folks are starting to
see it as the elephant in the room. The mammoth that is helping to keep us from looking
at larger health systems – another one of the siloes that keeps us from looking at bigger
but ultimately, perhaps greater payoffs in primary care, and chronic care and the social
determinants of health.

But those are all subjects for a different talk.

What I want to get back to is this idea of a community taking ownership of its own story
and its own destiny.

Communities have always been important. And under extraordinary circumstances they
can do extraordinary things.

But the Internet makes it easier for communities to come together under ordinary
circumstances to do both ordinary and extraordinary things.

I’m not talking about orchestrating mass movements – that is still, to my mind, a
broadcast way of thinking. I’m talking about bringing together smaller groups that may or
may not later grow in numerical size.

The truly revolutionary use of the Internet is not for broadcasting messages but for
organizing people.

This is the part that speaks most specifically to where nurses are today.

Over the past two decades and especially in the past two years, as I have spent more and
more time with nurses in the U.S. and overseas, I keep hearing some familiar laments.

[Next slide: familiar laments]

The nursing community is fragmented. Nurses are nearly 3 million strong in the US
and the largest health care workforce. Only 6% of nurses in the US belong to a
professional organization – any professional organization – compared to the United
Kingdom where nearly every RN is a member of the Royal College of Nursing.

Nurses have lots of responsibility but no power. They save and protect life and limb
but have relatively little power at either at their own institutions, clinics or society at
large.

Nurses are not utilized to their maximum potential. I actually found an article about
nursing I wrote 20 years ago that made this very point. Things still have not changed. As
we move forward with health care reform, will we finally start to address this issue?

Few people in the general public understand what nurses do. Despite the fact that the
general public trusts nurses a great deal – as seen in Gallup poll after Gallup poll.

Mostly I have heard these laments in my role as a member of the mainstream press. And
it’s absolutely true – nurses are not covered or quoted in the mainstream press to the
extent that their role in providing effective, high quality health care would merit.

But the landscape, as I have tried to demonstrate this afternoon, is changing.

And if you keep trying to get the broadcast media to pay attention to your message, your
mission and your values, you are going to find yourselves chasing an increasingly
diminishing target. Now more than ever, the message is in your hands to deliver.

So let’s start looking a little deeper at the ins and outs of making the network work for
you.

For such a supposedly free-wheeling place, you still hear a lot of shoulds on the Web:

[Next slide: various social media brands on the Internet]

You should be on Twitter, Facebook, Posterous or other social media sites. You should
contribute entries to Wikipedia, share photos on Flickr, share book marks on Delicious or
Digg. You should develop your own social network on the web through Ning or
LinkedIn. You should be in the Document Cloud, riding the Google Wave. You
absolutely must participate in your professional list-servs. You should share your reviews
on Amazon or Netflix. You should. Should. Should. Should. Should.

It’s enough to overwhelm anyone. Especially when you consider you can put a lot of time
and energy into something that could just as well disappear tomorrow – the way
MySpace is doing.

In fact, sometimes when I look at all these social media innovations, I can’t help but think
of Tom Sawyer and that white picket fence.

[Next slide: Tom Sawyer stamp] Here’s a Normal Rockwell illustration of the story. Aunt
Polly has told Tom to whitewash the picket fence—it’s his punishment for getting into
trouble yet again. But Tom cleverly tricks his friends into doing the work for him by
making it seem like something that not everyone can do. Soon they are competing for the
honor of whitewashing the fence. And there’s Tom supervising to make sure they do it
right.

What was true in 19th century Missouri is true for the 21st century Internet as well. If
you’re not careful, you will wind up doing someone else’s work for them – helping them
build a new platform – and all for free.

There are only so many hours in the day – only so much time you have available. So your
first priority when staking a claim on the web is to figure out what will be most beneficial
to you – whether on the job, or as part of your continuing education or advocacy work or
to help you in your personal life.

[Next slide: Basics]

Once you’ve decided that something is potentially beneficial, you need to answer a few
more basic questions.

Are my friends or people I admire here, too? What good is being on Facebook if all
your friends are on Orkut, which is apparently the most popular social platform in Brazil?

Is it easy? – The easier it is to do, the more that people you WANT to hear from will get
involved.

Is it fun? – Naturally it can’t JUST be fun if you want to get any work done. But a little
bit of fun keeps people going.

The next part is still something of a work-in-progress for me – but here are the guideposts
I am now using to help me to decide what is important and where to invest my time. I
have arranged them under three areas: organizing people, organizing information and the
benefits of sharing.

[Next slide: Organizing people]
Here are five points that I find myself coming back to over and over again when thinking
about organizing folks on the web.

Groups are easy to set up – It is also easy to join and leave groups

The collaboration itself still takes lots of time and energy

Who you know is just as important as it ever was – maybe more so

Diversity diminishes groupthink. You need rules and practices to keep a few loudmouths
and extroverts from dominating the conversation

Watch out for spammers, viruses, worms, porn pushers, hateniks. We’re not going to find
utopia on the Internet. You need to keep a step ahead of the destructive elements.

A lot of this will be familiar to you from your work on teams in the health care setting. So
translating this to the Web – what groups are you a part of – keeping in mind that they
don’t have to be permanent ones? To what extent are you breaking through silos?
Breaking outside your professional limits? What percentage of the folks you engage with
online are other nurses? Do you talk online about health care issues with health
professionals other than nurses as well as folks outside the health professions?

I would like to give you two examples from my own experience –

My first example has to do with patent issues and a product called Plumpy’Nut.

While I was doing a Nieman fellowship at Harvard, I discovered a weird cross-section of
patent law and hunger relief. I learned about a product called Plumpy’Nut – which is
basically ultra-fortified peanut butter that is shelf-stable for two years and so doesn’t
require a source of clean water. Plumpy’Nut has done wonders to save very young

children’s lives in famine settings. In essence, it does for severe acute malnutrition, what
oral rehydration therapy did for diarrhea. It doesn’t cure the larger public health problem
-- but it dramatically decreases the need for intravenous solutions and the skilled people
who provide them – thereby saving many more lives.

The recipe for Plumpy’Nut is also very simple. You can use locally grown peanuts and a
modest-sized industrial mixer. The fortified milk powder usually has to be imported but
it’s also ubiquitous. As with ORT, the recipe is simple – but somebody had to do the
research to figure out the right ingredients and prove it works.

Unlike ORT, however, Plumpy’Nut is protected by a patent – which was sought by its
manufacturer Nutriset at the urging of the French government. I learned that Nutriset had
issued a cease-and-desist order to a humanitarian group that used the very basic recipe to
make its own versions of Plumpy’Nut.

I thought, what a great topic for a group blog. We could get patent lawyers and public
health experts and peanut farmers and local communities around the world involved.
Naturally some of the big name foundations that have been fighting to bring essential
medicines to the poorest countries would want to comment – given similarities with
access to AIDS medicines.

And you know what? While I got the blog set up very easily, an interactive group of
contributors never materialized. Let me be clear, I discovered several lawyers and health
experts and activists who were very willing to talk to me about the issue. But they would
rather I wrote about what they said than to write it themselves. Or they didn’t want to be
quoted by name. Or – to be brutally honest – they really didn’t see what was in it for
them to participate. My original motivation – isn’t this a fascinating case study about how
intellectual property concerns are shaping development – wasn’t enough for them.

In other words, the technology was easy to set up but the collaboration proved much
more difficult.

On the other hand, I shared all my notes, the summaries of various conversations – in
person, online and via email. And once the search engines picked up the posts and others
referred to them, people started sending me more bits of pieces of information.

A year after the Peanut Butter and Patents blog first went online, I got an email from
Martin Enserink of Science magazine who decided to write up a sidebar on the patent
issue for a story he was writing on Plumpy’Nut. A US peanut manufacturers’ association
emailed me that they were hiring a lobbyist and using some of the material I had gathered
to see whether overturning the patent would lead to greater use of peanuts. More recently,
as the issues of whether or not to use Plumpy’Nut has heated up in India, I have heard
from a number of journalists there.

So the original idea of a more cohesive group didn’t take shape – but a series of ad-hoc
groups did form. Each of these temporary groups contributed a little more information –

and then disbanded.

I no longer maintain a separate blog on Plumpy’Nut. If I learn anything new I include it
in my regular sporadic blog on global health. And yet, even today, if someone puts the
words “Plumpy’Nut” and “patent” into the Google search engine, the first four items that
are returned are all written by me and will take you to a collection of material I have
pulled together – or curated, which is the term of art now favored by a lot of journalists.

By the way, if you want an example of a group blog for public health that I think works
particularly well, check out The Pump Handle. Just put the phrase “the pump handle” in
quotes into the Google or Bing or Yahoo search engines and you’ll find it. Good stuff.
[http://thepumphandle.wordpress.com/]

My second example has to do with “What to call swine flu?”

Just last spring we all learned about the new swine flu that was then wreaking havoc in
Mexico and parts of Texas and California. Several health journalists, myself included
were pressed into action to cover the story for various outlets. As it happens, one of the
top flu journalists in the world – Helen Branswell of the Canadian Press was just starting
to make her debut on Twitter. She and Maryn McKenna of Cidrap (which is the Center
for Infectious Disease Research and Policy) and Dick Knox of National Public Radio, Jon
Cohen of Science, Nancy Shute at USAToday and I quickly found each other on Twitter.
Mind you – we are all journalists with competing affiliations but we respect and admire
each other’s work.

In the midst of all this, a conversation developed amongst us over Twitter about what to
call this new flu. I wish I had the actual Tweetstream to show you but Twitter doesn’t
archive old posts and so I cannot now recreate what happened exactly.

The early press reports, of course, were about swine flu. Then the pork producers started
complaining that folks would get the wrong impression and worry they could catch the
flu virus from eating pork.

The public health authorities who were having their own internal debates about exactly
what to call the new flu strains themselves – settled on H1N1 flu for the general public.

The group of journalists I interact with on Twitter, thought that name – H1N1—was too
confusing because there was already a seasonal H1N1.

I remember proposing California flu since that’s where the new H1N1 strain was actually
first identified. But that seemed much too hard to explain to editors – why we would go
with a phrase no one had heard of before.

So each of us made our own decisions but the general consensus was to go with “swine
flu” or the “new swine flu” because we weren’t in the business of protecting the pork
industry from mistaken concerns.

It was quick, it was easy. No votes were involved. But it was a great chance to take the
temperature of what other journalists were doing – not all journalists, mind you – but the
journalists that I respect and admire on this topic. And anyone could listen in on and
participate in the conversation if they wanted to—if they acted quickly.

Because that conversation happened very quickly. It didn’t need to last long to fit our
purposes. As an extra benefit, it also didn’t allow enough time for spammers to break in.

So that’s a little bit about organizing people. And let me reiterate, I think this is the
easiest part to overlook about the Web. The true revolution and value of the Web isn’t so
much about organizing INFORMATION as it is about organizing PEOPLE.

Nevertheless, organizing information plays a big role and there are four areas that I see
coming up again and again here --

[Next slide: Organizing Information]

Out of this group, I want to focus on providing context, which I believe is one of the
greatest values that anyone can offer on the Web today. But before I do that let me just
say a little about the other three items on this slide:

Crowd-sourcing—is a great way to organize people AND information. In crowd-
sourcing, you recruit a lot of people to provide very specific pieces of information.
Crowd-sourcing has produced some incredible results, particularly when it comes to
monitoring elections. But we are starting to see its use in health care as well.

Some of the best and earliest examples of crowd-sourcing come from sub-Saharan
Africa. Citizens in Ghana in 2000 started texting the JoyFM radio station with reports
about voters being turned away from polling booths. The radio reports then forced
election officials to rectify the situation in real-time, before the voting booths closed.

Nine years later, the use of short but very specific messages has been adapted to help
health care personnel penetrate the very murky world of pharmaceutical stockouts in
Malawi and Zambia.

Here in the US, Josh Micah Marshall and the folks at Talking Points Memo blog used
crowd-sourcing to bring to light a pattern of firings for political purposes in the US
Justice Department, which is supposed to be a partisan-free zone. Talking Points Memo
won a Polk Award for investigative journalism as a result.

The next item is Structured data. Learning your way around a database is providing
more and more insights as large data sets becomes ever more transparent and accessible.
And it’s important we keep them open and compatible with each other. More folks are
paying attention to Nursing Home Compare, for example, as they make choices about

long-term care—despite some glitches in the software.

This massive amount of data is fueling the need for better ways to find and visualize
patterns in the numbers. The Dartmouth Atlas folks have been pioneers in showing us
these patterns in distributions of health care, staff and variations in costs. Hans Rosling of
Sweden has done some great work showing how public health measures change over
time—and he makes it fun, too.

But none of this –the crowd-sourcing, the structured data, the visualizing of complex
patterns—makes sense without context—without a story that gives greater meaning to all
the pieces.

In a world that is just exploding with information, being able to provide the context by
which alls those bits and pieces of data make sense has never been more important. It is
also, I think, the surest way to stake your claim on the web.

[Slide: implicit to explicit]
So how do you take what is implicit and make it explicit? How do you take what you
know implicitly from your professional education and experience and share that with the
rest of the world? How do you provide context?

First, talk about what you know. What you are already expert in – the ins and outs of
keeping people alive, preventing complications, limiting pain and maximizing quality of
life. Name the elephant in the room. Talk about how much time you spend on paperwork
versus caring for patients. Tel us about the move to restrict the use of Tylenol and what it
will mean to your practices. Just because it’s obvious to you doesn’t mean it’s obvious to
anyone else.

Clearly, you don’t want to break HIPAA rules on patient privacy and if you’re going to
take on your employer, you’d better make sure you’re part of a big group. [pause]

It’s also imperative to be a part of the important conversations of the day. And of course,
what bigger conversation can there be in the public realm these days besides health care
reform? Despite what President Obama said when he addressed Congress on Sept. 9, we
all know that health care reform is going to be with us for many years to come –even if
some kind of health care financing law passes later this year.

IF you want nurses to play more of a role in deciding what health care looks like, make
sure that health care – the way it is designed, the way it is delivered, how it could be
improved – is part of the ordinary conversations you are having on the Web.

Context does not have to be long and complicated. I am not asking you to write review
articles worthy of publication in your spare time. You’d be amazed the amount of context
you can pack into 140 characters on Twitter, for example. Listen to Ramsey Baghdadi of
the Regulation Policy Market Report, who was live-tweeting the markup of the Senate
Financing committee’s bill on health care reform on Sept. 23, 2009:

Baghdadi tweeted: “Two hours into Day 2 of Finance Committee Death March and still
not a single vote on 1 of close to 600 amendments. Bring it.”

Right away you get a sense of the complexity, the politics and the timing of it all.

Someone who is particularly good at providing this sort of context at a slightly longer
length is Ethan Zuckerman at Harvard’s Berkman Center for Internet and Society.

Back in February when the streets of Madagascar erupted into violence – I’m sure you all
remember that right? – there were a handful of reports in the New York Times. Each did
a good job of identifying the protagonists and the events of the day but Zuckerman
decided to do them one better. He tried to understand what major themes – besides
vainglorious politicians – might be underlying the unrest.

After a few phone calls to friends with ties in Madagascar, he quickly outlined the real
underlying tension. There was, Zuckerman writes, quote “an unprecedented agreement to
lease 3.2 million acres of arable land from Madagascar at $12 an acre.” unquote

This land was being leased to the Korean conglomerate Daewoo. And, as Zuckerman
made clear, the reason that is important is because quote: “That swath of land represents
half the arable land in the country – it’s an area half the size of the nation of Belgium.
Daewoo plans to put most of the land under corn for export to Korea and the remainder
under oil palms, hoping to export the oil on the bio-fuels market.” unquote

No wonder everyone was upset.

This little bit of context provided better understanding of what was going on half a world
away – it made my reading in the New York Times that much more informative. But as
Zuckerman says about his own experience, until he learned the context, quote “the news
[about Madagascar] largely floated over me, despite the fact that I have an interest in
Madagascar through my Malagasy friends.” unquote

In other words, the context made him more receptive to taking in and searching out even
more news on the topic.

Over and over again, we are seeing both in mainstream media and online, providing the
right context can drive the conversation. The better you are at providing the context, the
more likely people are to listen not only to what you have to say but what others are
saying that reinforces what you have to say.

Another person who does this so well is Jeb Sharp, a journalist with Public Radio
International whose series on “How We Got Here” provides a brilliant little history
lesson behind the headlines of the day.

Now stories about Plumpy’Nut and Madagascar may seem obscure and even a little

tangential. But doesn’t that also describe where nurses find themselves today—often
outside the conversation, clamoring for a seat at the table, a chance to influence the
decisions?

The point is to get from here to where you want to be by harnessing the tools of
communication and organizing people that the Web offers.

Remember, you want your circle of influence to include folks who aren’t nurses. That
means forgoing a lot of the nurse-speak that is second nature to so many RNs. For a
whole treatise on how to do this, I recommend a book you may already know about:
“From Silence to Voice” by Suzanne Gordon and Bernice Buresh.

Also, let me emphasize, this is a conversation – not a broadcast – there has to be give and
take. Ask questions, admit mistakes. By all means share what you know but also share
what you don’t know.

Which brings me to my last point – about the benefits of sharing in a networked world.

[Next slide: share what you learn}

When people talk about sharing and collaboration on the Web, they can start to sound
very utopian and even magical. I’ll just say that being more forthcoming with what I
share on the Web has helped me often enough that I keep doing it.

For example,

When I tweeted the other day about some outdated projections about the nursing
workforce from the Bureau of Labor Statistics, someone sent me a paper with more up-
to-date figures within five minutes.

When I traveled to Malawi last year, I spent three months interviewing nurses throughout
the country about their working conditions, the health care system, their challenges and
their successes. I posted most of my notes whenever I could get an Internet connection
and was in turn contacted by several young people who were looking for logistical
information for their own trips to Malawi. That is perhaps not so surprising.

But what did surprise me was that a nursing professor in England reached out to me for
advice on a graduate clinical program they wanted to create with a school in Malawi—
one of the very ones I had visited. I was able to reassure the professor of the school’s
good reputation locally. And I provided constructive criticism on aspects of the UK plan
that seemed destined to promote rather than deter the brain drain of nurses out of Malawi.

There is no doubt that sharing and collaboration provide tremendous benefits. But there
are still only 24 hours in a day. When thinking about social networks you are designing,
have been asked to join or are asking others to join, think about the different motives
people have for sharing. What cost – in terms of time and attention are you asking them

to bear? What level of commitment do you seriously think you can achieve?

These are extraordinary times. Everyone is out there staking a claim on the Web, trying
to get heard. You can improve your chances of success by remembering

ONE: that this is not a broadcast contest – small groups are more powerful than ever
before. Don’t get bullied into thinking you have to keep up with Oprah or CNN.

and TWO: your greatest value often lies in providing the context with which to make
sense of all the other information floating around out there.

[last slide]
Thank You.

Nurses And Web

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