Nurses and the Web: Text For My Talk

Here is the prepared text for the talk I gave yesterday at the American Journal of Nurses conference in Chicago. The slides to go with it are available here and here.

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]

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]

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.

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.

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. Her 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.

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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.

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Thank You.