SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCE UNIVERSITY OF GHANA EXPLORING SOCIAL MEDIA ADOPTION BY NURSES FOR NURSING PRACTICE IN CATHOLIC HOSPITAL BATTOR IN THE NORTH TONGU DISTRICT OF VOLTA REGION, GHANA. EXPLORING SOCIAL MEDIA ADOPTION BY NURSES FOR NURSING PRACTICE IN CATHOLIC HOSPITAL BATTOR IN THE NORTH TONGU DISTRICT OF VOLTA REGION, GHANA. BY NATHAN GAMOR (10262609) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF A MASTER OF PHILOSOPHY NURSING DEGREE SEPTEMBER, 2021 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Nathan Gamor, certify that this thesis is the result of the research I completed for the Master of Philosophy in Nursing Degree program at the University of Ghana, Legon, School of Nursing and Midwifery. Dr Gladys Dzansi of the University of School of Nursing and Midwifery, and Dr Kennedy Dodam Konlan, also of the School of Nursing and Midwifery, coordinated and supervised this study. This research has not been submitted to any other school for a degree. All writers and publishers whose works were referenced were properly credited. NATHAN GAMOR (STUDENT) (SIGNATURE) (DATE) DR. GLADYS DZANSI (SUPERVISOR) (SIGNATURE) (DATE) DR. KENNEDY DODAM KONLAN, ESQ (CO-SUPERVISOR) (SIGNATURE) (DATE) University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This study is a tribute to God Jehovah for his mercy, power, and wisdom. I dedicate this work to my wife Malwine Esi Kpeli and my three children, Worlanyo Gamor, Kafui Mamane Gamor, and Dzidedi Mamavi Gamor, for their unwavering support and encouragement throughout the process. I also dedicate this work to my Brothers and my Sisters, especially, Afenyo Derrick Gamor, and Fafa Comfort for their unmeasurable support. Finally, I dedicate this research to all my childhood friends in Mafi Adidome and Mafi Wute, as well as my colleagues at Catholic Hospital Battor in the Volta Region, Ghana. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT My greatest thanks go to God Jehovah for the strength, the wisdom, the direction, and more importantly for sustaining my life to complete this research. May your name be sanctified and may your kingdom come. I also want to express my heartfelt gratitude to my supervisors Dr Gladys Dzansi, and Dr Kennedy Dodam Konlan for your patience, guidance, assurance, direction and readiness to impact research knowledge into me and bring me back to track when am lost. I say “Akpe na mi, miawoe w4d4 nyuie nam”. I highly acknowledge and appreciate all the lecturers and the supporting staff of the School of Nursing and Midwifery, University of Ghana, for adequately equipping me with the necessary knowledge, skills, and confidence during my graduate study. I also want to thank my MPhil mates for the love and constant encouragement they give me. I highly appreciate it. I am also grateful to all the ward managers, unit heads, and nurses in Catholic Hospital Battor and the North Tongu District at large for their contribution in one way or the other toward the completion of this research. My deepest appreciation goes to the management members of Catholic Hospital Battor and the North Tongu District Health Directorate for permitting me to have the study conducted in their facility. My special thank goes to my siblings especially Gameli George Gamor, Blewusi Gladstone Gamor, Afenyo Derrick Gamor, Esinu Gamor, Celestine Adzoa Gamor, Forgive Tsoekewo Gamor, Fafa Comfort Gamor and Mawuyram Gamor for inculcating the “you can do it” attitude in me. I also want to acknowledge my wife Malwine Esi Kpeli Gamor, my son Worlanyo, and my daughters Kafui Mamane and Dzidedi Mamavi for the pressure they exert on me to finish this work. Finally, a special thank you to Miss Elizabeth Hamenu Ewoenam for proofreading this work. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENTS DECLARATION.............................................................................. Error! Bookmark not defined. DEDICATION............................................................................................................................... ii ACKNOWLEDGEMENT ........................................................................................................... iii TABLE OF CONTENTS ............................................................................................................ iv LIST OF TABLE(S) .................................................................................................................... ix LIST OF FIGURES ...................................................................................................................... x LIST OF ABBREVIATIONS ..................................................................................................... xi ABSTRACT ................................................................................................................................. xii CHAPTER ONE ........................................................................................................................... 1 1.1 Introduction ............................................................................................................................. 1 1.2 Background to the study ........................................................................................................ 1 1.3 Problem Statement.................................................................................................................. 7 1.4 Purpose of the study.............................................................................................................. 10 1.5 Objectives of the study.......................................................................................................... 10 1.6 Research questions ................................................................................................................ 10 1.7 Significance of the study ....................................................................................................... 10 1.8 Operational Definitions ........................................................................................................ 11 1.9 Organisation of the Research ............................................................................................... 12 CHAPTER TWO ........................................................................................................................ 13 LITERATURE REVIEW .......................................................................................................... 13 2.1 Introduction ........................................................................................................................... 13 2.2 Justification of Models / Theoretical Frameworks of the Study....................................... 13 2.2.1 Theory of Reasoned Action (TRA) .................................................................................. 14 University of Ghana http://ugspace.ug.edu.gh v 2.2.2 Innovation Diffusion Theory (IDT) ................................................................................. 14 2.2.3 Model of Personal Computer Utilization (MPCU) .......................................................... 16 2.2.4 Technology Acceptance Model (TAM) ........................................................................... 17 2.3 Social Media .......................................................................................................................... 18 2.4 Perceived usefulness of social media ................................................................................... 19 2.5 Perceived Ease of Use of Social Media ................................................................................ 21 2.6 Attitude towards using social media ................................................................................... 23 2.7 Behavioral intention to use social media ............................................................................. 24 2.8 Actual use of social media .................................................................................................... 26 2.9 The Benefits of social media in Nursing .............................................................................. 27 2. 10 Risks of using social media in nursing ............................................................................. 32 CHAPTER THREE .................................................................................................................... 35 METHODOLOGY ..................................................................................................................... 35 3. 2 Philosophical paradigms ..................................................................................................... 35 3. 3 Research Design ................................................................................................................... 36 3.4 The setting of the study......................................................................................................... 37 3.5 Target population.................................................................................................................. 38 3.6 Inclusion and Exclusion Criteria ......................................................................................... 39 3.6.1 Inclusion Criteria .............................................................................................................. 39 3.6.2 Exclusion Criteria ............................................................................................................. 39 3.7 Sampling Technique and Sample Size ................................................................................ 39 3.8 Data Generation Tool ........................................................................................................... 40 3.9 Data Collection Procedure ................................................................................................... 41 3.10 Data Management and Analysis ........................................................................................ 41 3.11 Methodological Rigor ......................................................................................................... 42 University of Ghana http://ugspace.ug.edu.gh vi 3.12 Ethical Considerations........................................................................................................ 44 CHAPTER FOUR ....................................................................................................................... 46 FINDINGS OF THE STUDY .................................................................................................... 46 4.1 Findings .................................................................................................................................. 46 4.2 Socio-Demographic Characteristics of Participants .......................................................... 46 4.3 Organisation of Themes and Sub-themes ........................................................................... 47 4.4 Nurses’ perceived usefulness of social media ..................................................................... 48 4.4.1 Quick Accomplishment of Nursing Tasks ....................................................................... 48 4.5.2 Dissemination and reception of information .................................................................... 50 4.4.3 Professional Development................................................................................................ 51 4.4.4 Enhance Referral Network ............................................................................................... 53 4.5 Nurses’ perceived ease of use of social media ..................................................................... 54 4.5.1 Clear and understandable ................................................................................................. 55 4.5.2 Low mental effort (Stress-free) ........................................................................................ 56 4.5.3 Easy to navigate ............................................................................................................... 57 4.6 Perceived Potential Risks of Use .......................................................................................... 59 4.6.1 Inaccurate information ..................................................................................................... 59 4.6.2 Privacy and Confidentiality Concerns.............................................................................. 60 4.6.3 Distraction ........................................................................................................................ 62 4.6.4 Addiction .......................................................................................................................... 62 4.7 Attitude toward using social media ..................................................................................... 63 4.7.1 Favorable approach .......................................................................................................... 64 4.7.2 Unfavourable Attitude ...................................................................................................... 65 4.7.3 Pleasant Experience.......................................................................................................... 66 4.7.4 Unpleasant Experience ..................................................................................................... 67 University of Ghana http://ugspace.ug.edu.gh vii 4.8 Behavioural intention to use social media .......................................................................... 68 4.8.1 Facilitating Conditions ..................................................................................................... 68 4.8.2 Social Influence ................................................................................................................ 69 4.8.3 Knowledge Seeking Behavior .......................................................................................... 70 4.9 Actual use of social media .................................................................................................... 71 4.9.1 Frequency of Use ............................................................................................................. 71 4.9.2 Cumulated Time Spent ..................................................................................................... 72 4.9.3 Types of Social Media...................................................................................................... 73 4.10 Finding Summary ............................................................................................................... 74 CHAPTER FIVE ........................................................................................................................ 76 DISCUSSION OF THE FINDINGS.......................................................................................... 76 5.1 Introduction ........................................................................................................................... 76 5.2 Demographic Characteristics of Participants .................................................................... 76 5.3 Nurses’ Perceived usefulness of social media ..................................................................... 77 5.4 Nurses perceived ease of use of social media ...................................................................... 82 5.5. Perceived potential risks of use of social media in nursing .............................................. 83 5.6. Attitude toward the use of social media by nurses............................................................ 88 5.7 Nurses’ behavioral intention to use social media ............................................................... 91 5.7 Nurses’ actual use of social media in nursing practice ...................................................... 94 5.8 Application of Model to Study ............................................................................................. 95 CHAPTER SIX ........................................................................................................................... 98 6.1 SUMMARY, IMPLICATIONS, LIMITATIONS, CONCLUSION, AND RECOMMENDATIONS ............................................................................................................ 98 6.2 Summary of the Study .......................................................................................................... 99 6.3 Limitations of the study ...................................................................................................... 101 University of Ghana http://ugspace.ug.edu.gh viii 6.4 Implications of findings ...................................................................................................... 102 6.4.1 Implication for nursing practice ..................................................................................... 102 6.4.2 Nursing education .......................................................................................................... 102 6.4.3 Nursing research ............................................................................................................. 103 6.4.4 Policy formulation .......................................................................................................... 104 6.5 Limitations of the study ...................................................................................................... 105 6.6 Conclusion ........................................................................................................................... 105 6.7 Recommendations ............................................................................................................... 106 6.7.1 Recommendations for Ministry of Health ...................................................................... 107 6.7.2 Recommendations for Ghana health service / Christian Health Association of Ghana . 107 6.7.4 Recommendation for Social Media Apps developers and social networking site operators ................................................................................................................................................. 108 6.7.5 Recommendation for Internet network providers .......................................................... 108 6.7.6 Recommendation for Catholic Hospital Battor .............................................................. 108 6.7.7 Recommendation for National Catholic Health Service ................................................ 109 REFERENCES .......................................................................................................................... 110 APPENDICES ........................................................................................................................... 127 Appendix A: Ethical Approval Letter ..................................................................................... 127 Appendix B: Introduction letter .............................................................................................. 128 Appendix C: Participants’ information sheet .......................................................................... 129 Appendix D: Consent form ..................................................................................................... 133 Appendix E: Interview Guide ................................................................................................. 135 Appendix F: Themes and Sub-themes .................................................................................... 138 Appendix G Table 4.1: Participants’ Characteristics Profile .................................................. 139 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLE(S) Table 1: Themes and Sub-themes .............................................................................................. 47 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure 1: Technology Acceptance Model (TAM) ..................................................................... 18 Figure 2: Map of Ghana showing North Tongu District ......................................................... 38 University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABBREVIATIONS CHAG Christian Health Association of Ghana GES Ghana Education Service GHS Ghana Health Service IDT Innovation Diffusion Theory MOH Ministry of Health MPCU Model of Personnel Computer Utilisation SM Social Media TAM Technology Acceptance Model TRA Theory of Reasoned Action USA United of States America WHO World Health Organisation University of Ghana http://ugspace.ug.edu.gh xii ABSTRACT There is an ongoing social media technological revolution globally and this is impacting people’s approach to work and organizational outputs. The health care industry is not left out of this intriguing, drastic, and far-reaching change that social media has brought forth. Healthcare organizations and individuals are said to be adopting social media for nursing care in Ghana. It remains largely undetermined the factors influencing nurses in the Catholic Hospital Battor to adopt social media to enhance nursing care. The study, therefore, seeks to explore social media adoption by nurses for nursing care in Catholic Hospital Battor using the technology acceptance model as the guiding framework. An exploratory descriptive qualitative study design with a purposive sampling technique was employed to recruit twelve (12) participants for the study. A semi-structured interview guide was used to conduct in-depth interviews which were audiotaped, transcribed verbatim, coded, and analyzed. Thematic analysis was used to analyze the data with NVivo. The findings revealed that nurses found social media to be useful for the accomplishment of nursing tasks, dissemination, and reception of information, professional development and enhanced referral networks. Apart from its usefulness, participants believe it is easy to navigate its apps, clear and understandable to use and its usage in nursing does not involve much mental effort hence their favourable attitude toward use. Notwithstanding, some participants also believe that inaccurate information, privacy and confidentiality concerns, distraction, and addiction were some potential risks that are associated with its usage in nursing practice. Due to this, some participants developed a negative attitude toward its usage as a result of the unpleasant experience they have with its usage. This study, therefore, recommends prudential use of social media in health institutions. It also advocates for the development of policies to govern its use in healthcare facilities. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Introduction This chapter presents the background of the study, the statement of the problem, the purpose of the study, and the objectives of the study. It also contains research questions, the significance of the study, and ends with an operational definition of terms. 1.2 Background to the study Globally, the internet is the backbone of our society with about 4.66 billion people globally using the internet today representing roughly 59.9% of the world's population (Kemp, 2021). Chaffey, (2021) and Kemp, (2021), also noted that more than half of the world's population is using social media, with the average user having almost nine accounts on different networking sites. These social media sites and platforms are accessed through connected devices like personal computers, digital video, and audio recorders, smartphones, webcams, and wearables like smartwatches to ensure that users who live virtually in any part of the world can create and share content (Heinrichs et al., 2012). The social media user base has also become more reflective of the general population, as more people have embraced social media internationally (Berthon et al., 2012). Young adults were among the first adopters of social media and continue to use these platforms at high levels, although in recent years, the use by older adults has increased (Koiranen et al., 2020). A social media demographic survey study in the United States of America (USA) has shown that social media users appear to be younger and more qualified than the general population, with a more skewed distribution for Facebook, WhatsApp, and Twitter (Greenwood et al., 2016; Pew Research Center, 2021). Studies using geotagged USA Twitter data have shown that users of Facebook and University of Ghana http://ugspace.ug.edu.gh 2 Twitter are more frequently found in urban areas (Pew Research Center, 2021) and younger communities in especially wealthier areas (Malik et al., 2015). Social networking platforms provide the individual user with several characteristics that serve various purposes (Kircaburun et al., 2020). There are hundreds of social media sites and platforms in the world. Facebook, WhatsApp, Twitter, Instagram, Snapchat, Youtube, and Google are the most popular and widely recognized social media sites in the world (Alexa, 2017). Kung and Oh (2014) listed social media as mainly used by nurses. In their study, nurses showed high preferences for social networking sites (90.33 percent) and podcasts (76.24 percent), but the least used was SlideShare (9.92 percent). Lefebvre et al. (2020), also observed that Facebook, WhatsApp, Twitter, Instagram, Snapchat, YouTube, Tinder, LinkedIn, WikiAnswers, Google+, Yahoo! Answers, and Pinterest, as the most frequently used social media sites by nurses. Social networking site is a category of social media, also used by nurses. NurseBuff (2015), listed 30 social networking sites that are used by nurses. They included AllNurses, Mighty Nurse, EverydayNurses, Nurse.com, NurseZone, NursingLink, Nurse Practice Doctors, RNRounds, and NurseTogether among others. While the purpose of an online social network remains the same as an offline social network that connects people and shares network resources, online networking also benefits users with its specific computer-mediated communication features that improve user interaction (Pang et al., 2018) They use them to interact with family members and friends, colleagues, meet new people, shared interests, and, most importantly, to deepen their understanding and awareness of different subjects and thus enhance their learning experience (Faizi et al., 2014; Faizi & El Fkihi, 2016). Hospitals and health care professionals' use of social media have expanded dramatically. This is shifting the nature and pace of the health care partnership between individuals and health University of Ghana http://ugspace.ug.edu.gh 3 organizations. The general public, patients, and health professionals use social media to interact about health problems (Panahi et al., 2016). Works of literature (Casella et al., 2014; Lee Ventola, 2014; Peck, 2014) show that social media has significant potential value for this wide area of emerging healthcare technology as they provide a new way of accessing and exchanging information (Barrett et al., 2012), encouraging social collaboration and stakeholder participation, as well as improving contact between people and allowing users to directly engage in health-related issues of concern (Heidelberger, 2011). Nursing practice has been explained as a caring-based practice in which processes of assessment, diagnosis, planning intervention and evaluation are applied in the treatment of human experiences of health and illness. It includes direct and/or indirect care in clinical practice, nursing administration, education, research, or consultation in the speciality represented by the credential (ONCC, 2021). Its application necessitates not just scientific knowledge but also interpersonal, cognitive, and technical competencies and capabilities (Wilson, 2017). The impact of technology on nursing practice is one of the most significant developments that nurses encounter. Professional nursing must be included in the process of developing and implementing technology equipment that has a significant impact on health and well-being. Social media provided such technologies to advance nursing practice in many aspects. Social media can promote the profession of Nursing in different ways. To further their personal and professional interests, nurses can use several social media programs. Ferguson (2013) gives nurses a call to action to move up and be pioneers in the use of social media. Nurses can access data for their workplace or personal lives, collaborate with peers, exchange best practice knowledge, and promote health by personal and professional means. Social networking is closely University of Ghana http://ugspace.ug.edu.gh 4 related to the professional advancement of a nurse across four nursing fields: clinical practice, management, academia, and research. In clinical practice, nurses can access information in real-time, allowing cutting-edge information to be unprecedentedly available (Jackson et al., 2014). Some research supports social media as an efficient method in a clinical setting for nursing students to improve their skills (Jackson et al., 2014). Social media can be used by nurses to access opportunities for continued education and tools to promote professional growth (Murray & Ward, 2019). The advantages of this can include reducing anxiety through offering expert access; building personal and professional self-image by sharing achievements and skills; and creating local support networks and practice groups. The advantages of social media users are also experienced by nurses serving in the administration. For example, #hcsm (Symplur, 2021b) and also #hcldr (Symplur, 2021a) connect Twitter® users in health policy conversations, and the online communities of nurse administrators are linked to many social media networks and sites where they interact with other nurse administrators and team. Social networking helps nurses to interact with others through organizations and boundaries, to share knowledge and opinions in ways that only a few years ago would not have been possible. Social networks have been effective tools in the field of academic education to help improve the teaching-learning process, especially for undergraduate students (Tower et al., 2014), data evidence to corroborate the results of studies on the use of social networks in the teaching method of nursing education using social networking technologies as a learning tool is of growing interest to students (Tower et al., 2014). Studies indicate that social networks promote student engagement, communication, knowledge, resource sharing, and the development of critical thinking skills. It is vital to remember that social networking sites such as Facebook can allow students the ability to University of Ghana http://ugspace.ug.edu.gh 5 engage in peer learning where they can direct and monitor their learning autonomously (Tower et al., 2014). (Tower et al., 2014). Social media has been used in rural areas to enhance and enrich the education of PhD students in nursing practice and to lessen the accompanying geographical isolation and pressure (Daly et al., 2013). Educators are discovering how social media can be utilized to support nurses during transition phases (e.g. entry to work, change in fields of practice) and improve nursing skills and patient outcomes. Social media may be of benefit to nurses working in research environments. The willingness to communicate results from research is a crucial factor. The simplicity of using Twitter® to help disseminate study results is demonstrated by Archibald and Clark (2014). Social networking also provides opportunities to track health and promote the collection of data. More data is accessible to nurse researchers as more social media platforms enable health metrics to be monitored. Interventions can be studied at lower costs and with wider audiences, using social media. Advances in this online technology can also assist nurses in the selection, management, and engagement of higher-quality services. In nursing fields, the use of social media platforms can also inform health patterns in real-time and promote information exchange for enhanced clinical outcomes (Rolls et al., 2016). They also facilitate programs for wellness campaigns and patient education and provide an impetus for knowledge exchange and the development of nursing networks. Bad information quality, patient confidentiality, and legal issues, however, are risks and barriers to the effective and efficient adoption of online platforms such as social media (Lee Ventola, 2014) The creation of virtual practice groups is the main factor affecting the intention of nurses to participate in social media. Knowledge sharing between colleagues is enhanced, but because these University of Ghana http://ugspace.ug.edu.gh 6 online communities are private, it restricts knowledge to specific users and prevents the information from being transmitted in a multidisciplinary setting to help boost productivity and results (Rolls et al., 2016b). In the nursing context, the use of social media is affected by ethical dilemmas and privacy problems that could prevent users from benefiting from this highly interactive communication process. The process of information transfer and interaction between different users is intended to be understood through study and trials (Dumas et al., 2018). The significant data provided by the participation of patients within social media groups would support nurses in different health care fields. Furthermore, it is possible to improve interpersonal contact and disseminate evidence-based information more effectively than through traditional networks. The adoption of social media by nurses in their nursing practice has been well established. What remains widely unclear is what affects the decision of nurses to participate in their activities on social media. Cautionary aspects of the use of social media especially among Ghanaian nurses remain unknown. There are precautionary aspects of social media that need to be raised, especially because professionals employed in the country's health organizations now have daily access to social media most of the time. E-professionalism in healthcare highlights patient confidentiality concerns, low-quality data, lack of evidence-based advice, and blurring of personal-professional limits (Levati, 2014). Many issues persist regarding policy, ethics, professionalism, privacy, and confidentiality, according to Grajales III et al. (2014)'s narrative study on the role of social media in the medical and health care industry. Social media conversation is usually led by beginners in the sector, as opposed to more senior healthcare authorities (Carroll et al., 2016). According to Ferguson (2013), the nursing profession must actively participate in social media if it wants to gain a full understanding of it. A current online solution, the usage of social media for nurses to continue their University of Ghana http://ugspace.ug.edu.gh 7 professional development, and revalidation requirements now require particular rules from nursing regulatory authorities (Moorley & Chinn, 2014). Social media should be used in nursing school to help students better define their professional identities and meet their professional goals (Barnable et al., 2018). There is a knowledge gap and a need for greater research in identifying the characteristics that promote the practical use of social media in nursing and the successful types of platforms (Moorhead et al., 2013). It is yet too early to tell whether or not social media will have a positive or negative impact on the health care industry, but early research suggests that it will have a positive impact on patient care. It is possible to enhance information about the appropriate integration of social media in health care by studying the traits, attitudes, and external factors of users who contribute to the usage purpose and frequency of use of social media. It is a challenge for this study to focus on what motivates nurses to use social media in their daily work. 1.3 Problem Statement Globally, half of the world's population are social media users (Kemp, 2021) and this includes nurses who are using it both to enhance work performance and for personal related work. A study conducted in the United State of America revealed that the majority (93.41%) of nurses are active users of social media (Kung & Oh, 2014) for nursing practice. Barry and Hardiker (2012) disclosed that social media is gradually gaining root among nurses to enhance performance with more than 540,000 registered nurses and midwives on social media in the UK. These findings indicated that social media usage is considered a necessity and is being used routinely (Mukhtar et al., 2018) by nurses in their daily work activities. This clearly shows that nurses globally are adopting social media to enhance their work performance, but most works of literature on social media studies University of Ghana http://ugspace.ug.edu.gh 8 globally are focused on the end-user of social media, with little or no attention to factors that influence the adoption process (Ainin et al., 2015). In Africa, doubts have been raised about the general benefits of internet access and social media use. But in recent years, Africans actively using social media stood at 216 million (representing 17% penetration), and out of this number 202 million access social media on their mobile phone (Kemp 2021). The healthcare industries in Africa are also gradually adopting social media in their service delivery as a result of escalating competition and patient demand for the highest quality care (Britnell, 2012). While social media technology has the potential to improve nursing care, it is not without risks. Social media technology has been described as both part of the problem and part of the solution for safer health care, and some observers warned of the introduction of yet-to- be errors after the adoption of new technologies (Indra & Urmela, 2018). Privacy and confidentiality, unprofessional behaviour, and organizational risk are risks related issues that African face with the use of social media technology while at work (Barry & Hardiker, 2012). Understanding what influences nurses to adopt social media technology in nursing care will help to ensure that the nurses' focus on patient care is never lost as risks involved in using social media are being avoided. (Allen, 2012). As of January 2020, there are 6 million social media users in Ghana representing 20% penetration (Kemp, 2020). Quite apart from this, there are more than 22 e-health projects in Ghana (Afarikumah, 2014) which are being used by nurses and midwives to facilitate their work and most of these e-health projects are supported by social media. Dwamena et al. (2016), also observed that the majority of nurses in Ghana are using social media for job-related work and professional development. There is enough evidence to suggest that majority of nurses in Ghana are adopting social media to engage in the promotion of health, patient education, outreach, professional University of Ghana http://ugspace.ug.edu.gh 9 development, and other nursing-related activities. But little has been done in terms of evaluating the factors that impact the adoption of social media by Ghanaian nurses. Nursing stakeholders have not all embraced social media despite its advantages. Inadequate technical expertise, ethical and privacy issues, a lack of policies and norms, as well as other negative moral and societal consequences associated with traditional social media use, are also probable explanations (Mariano et al., 2018; Ryan, 2016; Schroeder, 2017; Yunus et al., 2013). Regardless of the negative perspective on the adoption of social media, this study acknowledges its power in enhancing the practice of nurses. Though there have been several cautions to nurses by stakeholders in the nursing field about the pervasive of social media for non-worked related issues during working hours, its adoption is still on the increase without much evidence on factors mitigating its escalation among nurses in Ghana. In Catholic Hospital Battor and other health care facilities in the North Tongu District, it has been anecdotally observed that nurses and midwives adopt social media in nursing activities and other personal issues. For instance, nurses, midwives, and doctors in the obstetric department in Catholic Hospital Battor adopt social media to enhance referral communication among themselves and their catchment areas. Likewise, nurses and other departments in the hospital adopt social media for the nursing process, client education, and professional communication among themselves. There are clear indications that nurses in Catholic Hospital Battor and other health care facilities in the North Tongu District are embracing this new internet-based technology to speed up and enhance their nursing care. The driving forces behind this technology acceptance remain unknown. Therefore, there is a need to understand the factors that flare the adoption of social media by nurses in Catholic Hospital Battor and other health facilities in the North Tongu District of the Volta Region. University of Ghana http://ugspace.ug.edu.gh 10 1.4 Purpose of the study The purpose of the study was to inquire into social media adoption by nurses for nursing practice in the North Tongu District in the Volta Region. 1.5 Objectives of the study The research is intended to focus on the following objectives: 1. To explore nurses' perceived usefulness of social media in nursing practice. 2. To examine nurses' perceived ease of use of social media in nursing practice. 3. To assess nurses' attitudes toward the use of social media in nursing practice. 4. To explore nurses' behavioural intention to use social media in nursing practice. 1.6 Research questions To address these issues, the study is intended to focus on the following questions: 1. How do nurses perceive social media to be useful in nursing practice? 2. How do nurses perceive ease of use of social media to enhance nursing practice? 3. What is the attitude of nurses toward the use of social media in nursing practice? 4. What is the behavioural intention of nurses to use social media in nursing practice? 1.7 Significance of the study The study is important because of the benefits that the many healthcare industry stakeholders will get from the study's conclusions. Nurses in the North Tongu District are using social media more than ever before, according to the study's findings. The results of the study will show the difficulties that come with nursing's usage of social media. The study's findings will help nurses better utilize social media in their nursing care delivery, while also adding value to their personal University of Ghana http://ugspace.ug.edu.gh 11 lives and boosting their sense of self-worth. As a result of the findings, health educators and promoters will be more equipped to use social media platforms for teaching and learning. Other healthcare professionals will benefit from the study's findings as well since it could help guide their usage of social media when interacting with patients. Additionally, the findings of this study will have implications for policy development on the use of personal communication devices in healthcare settings for social media, theoretical advancement/refinement, and scientific publication. Finally, the research will serve as a springboard for further investigation into the challenges surrounding the use of social media in Ghana's health care sector. 1.8 Operational Definitions Social media: networking with other people to share information via an electronic communication medium such as Facebook, WhatsApp, Snapchat, telegram, etc. Perceived Usefulness: Relevance associated with the use of social media usage Perceived Ease of use: When a person believes that the use of social media is not difficult or requires little effort. Attitude Toward use: An individual's positive or negative feelings using social media. Behavioural Intention to use Social Media: An intention of an individual to perform in a specific way toward someone or something. Nurse: a person who cares for the sick or infirm specifically a licensed healthcare professional who practices independently in a health institution to promote and maintain health. University of Ghana http://ugspace.ug.edu.gh 12 Nursing Practice / Nursing care: This encompasses services offered by nurses such as health promotion and prevention; care of the sick and disabled; end-of-life care; education; advocacy; research; engagement in defining health policy and in-patient treatment; and research. 1.9 Organisation of the Research The following are the chapters that make up this research. The study background, problem statement, purpose of the study, study objectives, research questions, and significance of the study, as well as definitions of key terms, are all presented in Chapter One. Chapter Two dealt with the theoretical framework, a review of related literature based on the constructs of the theory used, and the research objectives. The research approach was provided in the third chapter. The study's findings were given in Chapter four. The important findings were discussed in Chapter five. The study's summary, implications, limits, conclusions, and recommendations were discussed in Chapter six. University of Ghana http://ugspace.ug.edu.gh 13 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction The literature review for the study focuses on the theoretical framework of the Technology Acceptance Model (TAM) and literature on social media. The searches were made from Google Scholar, PubMed, Science Direct, African Journals Online (AJOL), EBSCOhost, CINAHL, and MEDLINE. Key terms such as “social media”, “social media and nurses”, “social media and nursing practice”, “social media adoption by nurses”, “social media adoption by health professionals”, “perceived usefulness”, “perceived ease of social media”, “attitude toward the use of social media” and “behavioural intention to use social media” were used for the search. Relevant pieces of literature written in the English language from 2012 to 2021 were retrieved and used. 2.2 Justification of Models / Theoretical Frameworks of the Study The use of psychological, social, and behavioural science theory/models provided the foundation for comprehending human behaviour as it relates to technology acceptance. Several behavioural models or theories guide to explain and predict the adoption of technology by people. Four frameworks could be related to this research. They are: 1. Theory of Reasoned Action (TRA) by Ajzen and Fishbein (1980), 2. Innovation Diffusion Theory (IDT) by Rogers (1995) 3. Model of Personnel Computer (PC) Utilization by Thompson et al. (1991) and 4. Technology Acceptance Model (TAM) by Davis (1989) Only, one of these frameworks was selected for this current study due to its applicability to the study objectives. University of Ghana http://ugspace.ug.edu.gh 14 2.2.1 Theory of Reasoned Action (TRA) Research on the Theory of Reasoned Action (TRA) has been done by Fishbein (1967), however, it is unrelated to the study because it was revised and tested by Fishbein and Ajzen (1975). According to TRA, three general components exist, namely: (1) behavioural intention; (2) attitude; and (3) subjective norm (Otieno et al., 2016). According to the notion, a person's behavioural intentions are influenced by their views and subjective norms (Yzer, 2017). There is no way to tell whether individual behaviour like using innovation is driven by behavioural intentions unless you use the TRA to find out. This is because behavioural intentions are determined by an individual's attitude toward behaviour, by subjective norms surrounding behaviour, and by their perceptions of how easy it is to carry out a particular behaviour (Otieno et al., 2016). However, Otieno et al., (2016), disclosed that the TRA does not fit for evaluating studies such as technology adoption and diffusion. TRA also lacks the credibility of addressing the role of habit in addiction and cognitive deliberation (Taherdoost, 2018). 2.2.2 Innovation Diffusion Theory (IDT) Innovation Diffusion Theory was proposed by Rogers (1995). He proposed that innovation is an individual, a group, or an organization's perception of a new idea, practice, or objective. Diffusion is a social change process in which an innovation is conveyed to members of a social system over time through certain channels (mass media or interpersonal). The choice to adopt or reject a new technology is conceptualized in numerous stages. He or she begins by being aware of an innovation and then forming an opinion about it based on that perception (its characteristics). The individual next decides whether to adopt or reject the innovation, puts it into practice, and then verifies his or her decision. The relative advantage, compatibility, complexity, trialability, and observability of innovation are all perceived features (Rogers, 1995). Perceived attributes, according to Rogers University of Ghana http://ugspace.ug.edu.gh 15 (1995), are the characteristics of an innovation that make it more or less appealing to the individual. The perceived relative advantage of an invention is the degree to which it is regarded to be superior to the current idea or practice; the larger the perceived relative advantage of an innovation, the faster it will be adopted. The degree to which an innovation is seen to be compatible with an individual's current values, beliefs, past experiences, and requirements is referred to as compatibility. The degree to which an innovation is seen as difficult to comprehend or use is called complexity. The degree to which users can alter or apply an innovation on a small scale is referred to as trialability. The degree to which the outcomes of an innovation are visible to others is known as observability. Innovations with obvious results are more likely to be adopted than those with less obvious outcomes (Rogers, 1995). The current version of the theory does not effectively describe what we see in the behaviours of individuals and organizations when making decisions about innovation adoption, hence it is unsuitable for the current study. Diffusion theory's relevant drawbacks include the following; 1. Much of the evidence for this theory, including the adopter types, did not come from the health field, and it was not created to specifically apply to the adoption of new behaviours or health innovations. 2. It does not consider an individual's resources or social support when deciding to adopt a new behaviour (or innovation). 3. Failure to provide precise conceptual and operational definitions of adoption. 4. It is more effective with behaviour adoption than with behaviour cessation or prevention. University of Ghana http://ugspace.ug.edu.gh 16 2.2.3 Model of Personal Computer Utilization (MPCU) Thompson et al. (1991) established the Model of PC Utilization based on Triandis' (1979) theory of interpersonal behaviour (MPCU). Triandis' research yielded a theoretical framework for describing how human behaviour occurs and the factors that influence it (Triandis, 1979). "Action is determined by what people would like to do (attitudes), what they think they should do (social norms), what they have usually done (habits), and the expected consequences of their behaviour," according to Triandis' paradigm. As time went on, Thompson et al. (1991) developed and adapted Triandis' theoretical model for the information systems setting to forecast PC use (Venkatesh et al., 2003). Although it is difficult to forecast human acceptance and usage of new information technologies, the nature of this theoretical model allows it to be particularly useful. Six core constructs are mentioned in the MPCU as having the potential to influence PC usage behaviour. These include people's feelings (affect) toward the use of PCs, social norms surrounding the use of PCs at work, general computer usage habits, expected consequences of PC usage by individuals, and the degree to which facilitating conditions are available at the workplace (Thompson et al., 1991). The Personal Computer Use Model is likewise inappropriate for this research. The model was criticized for having a successful theoretical foundation for explaining and analysing computer usage behaviour in a voluntary situation. Furthermore, this model's ability to adequately convey the subject matter to which it belongs is quite limited. University of Ghana http://ugspace.ug.edu.gh 17 2.2.4 Technology Acceptance Model (TAM) Lastly, Fred Davis' Technology Acceptance Model (TAM) was considered for inclusion in the analysis. Taking into account the study's goals, this framework is ideal. This method was better suited to qualitative research due to its five simple constructs. Because of its structure, TAM is ideal for simulating how users will accept new information systems or technologies. To motivate a user to accept new technology, TAM uses core variables such as perceived utility, perceived ease of use, and attitudes toward new technology. Outcome variables are then used to measure whether or not a user has accepted the technology. One way or another, perceived usefulness (PU) and perceived ease of use (PEU) explain the results. Directionally, perceived usefulness and perceived ease of use of technology determined an individual’s attitude toward the use of that technology. Whiles both perceived usefulness and perceived ease of use influence one attitude, perceived usefulness can directly influence individual behavioural intention to use a technology (Rafique et al., 2020). Attitude toward use also determines behavioural intention to use. In short, these two behavioural beliefs, perceived usefulness and perceived ease of use, directly determine individual attitude toward use which intend also influence one behaviour intention and actual use of that technology. The direction of the flow of constructs in the TAM is illustrated in Figure 2. 1. Perceived usefulness is the strongest predictor of an individual’s intention to use information technology (F. D. A. Davis, 1986). Literature on the model's constructs was primarily reviewed, but literature on social media and social media in nursing had previously been examined. University of Ghana http://ugspace.ug.edu.gh 18 Figure 1: Technology Acceptance Model (TAM) Technology Acceptance Model (TAM) Adapted from Davis (1989). 2.3 Social Media The phrase "social media" has a wide range of definitions that are always changing. Individuals and communities can use the phrase to refer to Internet-based tools that allow them to gather and communicate, exchange information, ideas, personal messages, photographs, and other content, and, in some cases, collaborate with other users in real-time (Peck, 2011). Kaplan and Haenlein (2012) also defined social media as “a group of Internet-based applications that allows users to create and exchange user-generated content”. The establishment of profiles for social connectivity and information sharing, as well as search algorithms and privacy features, are enabled by social media (Chang & Hsiao, 2013). Users can then articulate a list of other users with whom they share and interact (Kane, 2014). Carr and Hayes (2015), observed that social media is composed of three parts. They defined them as devices that create and distribute content, devices that retrieve content, and individuals who use the information for official and personal purposes. These three parts tie its users to one platform (Varotto et al., 2016). According to Gao et al. (2019), these platforms facilitate users to send and share information without any time and space constraints. van Zoonen et al. (2017), observed Perceived Usefulness (PU) Perceived Ease of Use (PEOU) Attitude towards using (AT) Behavioural Intention to use (I) Social media use (U) University of Ghana http://ugspace.ug.edu.gh 19 social media from an organizational behaviour perspective is divided into two categories: enterprise social media and public social media. Web-based platforms for enterprise social media allow employees to: (1) communicate private messages with co-workers or broadcast messages to the entire organization; (2) explicitly indicate or implicitly instruct specific co-workers as communication partners; (3) post, edit, and sort texts and files linked to themselves or others; and (4) view the messages, connections, texts, and files linked to themselves or others. (Leonardi et al., 2013). Commercial providers (e.g., Facebook, Linked In, WhatsApp, and Twitter) create and administer public social media, which is frequently supplied for free. (Moqbel et al., 2013). There are numerous social media apps and social networking sites that are always open for social interaction. (Gao & Feng, 2016). SNSs are web-based platforms that incorporate a variety of computer-based communication tools. As a result, different social networking (SN) applications provide users with diverse functions. Kaplan and Haenlein (2012), divide social media into six categories: collaborative projects (e.g., Wikipedia); blogs and microblogs (e.g., Twitter); content communities (e.g., YouTube); social networking sites (e.g., Facebook); virtual gaming worlds (e.g., World of Warcraft); and virtual social worlds (e.g., Second Life). Social media has become an integral part of our information gathering and sharing tactics, and it is changing the way we interact. 2.4 Perceived usefulness of social media According to the TAM, perceived usefulness and ease of use of technology determine attitude and usage intention, which leads to acceptance and usage of the given technology. Perceived usefulness is defined as an individual's belief that utilizing new technology will improve or enhance his or her performance. (F. D. Davis, 1989). In another word, it is the benefits or the advantages the user derives from the use of the technology. University of Ghana http://ugspace.ug.edu.gh 20 In the context of nurses' social media adoption for nursing practice enhancement, usefulness refers to the extent to which nurses feel that utilizing social media would improve their nursing care or productivity, hence improving the health institution's outcome. A technology system is highly perceived as useful if the user believes that its existence will positively enhance the user practices hence the user perceives the system to be an effective way of practising the tasks (Henderson et al., 2017). An individual's assessment of the outcome of their conduct in terms of the anticipated advantages is based on the desirability of usefulness. (Al-Daihani, 2010; Verhoef et al., 2014). Most users reject technology if they perceived it not to be useful even if the technology was easy to use (Dzandu et al., 2016). It has also been established that the reason cited for the rejection of social media by young non-users is related to perceived usefulness, specific social practices, and self-presentation and identity of the social media (Laranjo et al., 2015; Muslichah, 2018). Findings from the literature have shown that perceived usefulness has a significant effect on user adoption and satisfaction across a range of technologies including social media (Plewa et al., 2012). A study conducted by Muslichah (2018), on students, revealed an indirect effect of self-efficacy on behavioural intention to use academic information systems though perceived usefulness is not significant. Perceived usefulness does not always influence the intention to use social media (Boon-itt, 2019; Kim, 2014). Ismail (2016), cited the reason that owning a social media tool and accessing social media sites or platforms can be for prestigious reasons rather than for job practices and, mostly the user does not comprehend the enormous benefit for its usage for nursing practices. The degree of technology's perceived usefulness and asymmetric information flow also can be affirmative factors (Ismail, 2016). University of Ghana http://ugspace.ug.edu.gh 21 2.5 Perceived Ease of Use of Social Media The degree to which a person believes that utilizing a system will be simple is characterized as perceived ease of use. (F. D. Davis, 1989). Perceived ease of use of social media in the context of this study refers to the extent to which users believe that using social media to improve performance is effortless. Furthermore, because human effort is a finite resource, users are more likely to adopt an application that is seen to be easier to use than another. (F. D. Davis, 1989). The point of view of the user on the ease of understanding greatly aids to determine the potency and the degree of the user’s adaption to new technology (F. D. Davis, 1989). Dzandu et al. (2016), discovered that if a system is very simple to use, people will go to great lengths to learn about its capabilities and eventually desire to keep using it. Numerous studies have revealed that perceived ease of use is a major causal factor of attitude towards a technology (Acarli & Sağlam, 2015; Al- Rahmi & Zeki, 2017; Setterstrom et al., 2013). In support of this, (Sago, 2013), proposed that the perceived ease of use of social networking services is the driving factor behind their popularity. Furthermore, numerous research has found that perceived ease of use has a favourable association with behavioural intention to use social media, both directly and indirectly. (Al-Rahmi et al., 2015; Chang & Yang, 2013; Dumpit & Fernandez, 2017). Initial drivers of system-specific (social media) perceived ease of use are individual differences and situational circumstances, with the effect becoming greater with experience. Characteristics of the user-system interaction play a role in driving the perceived ease of use of the target system as the user experience with the target system (social media) grows. The perceived ease of use of social media is also influenced by internet reliability and speed. Dumpit and Fernandez (2017), observed that social media can be adopted to enhance performance if the internet and the speed are reliable. University of Ghana http://ugspace.ug.edu.gh 22 Chow et al. (2012) discovered that computer self-efficacy only explained 7% of the variance in perceived ease of use in a study to investigate the intention to utilize Second Life (virtual environment) for boosting healthcare education. Even though students were generally confident in their computer skills, the data demonstrated that they did not find the virtual ward easy to use, with just 7% of the variance explained by the perceived ease of use construct. (Chow et al., 2012). Similarly, Djamasbi et al. (2016) discovered in their study that there is no significant relationship between the system’s ease of use and the users’ attitude. In another study, Wiid and Cant (2013) revealed that perceived ease of use of a technological system (social media) is strongly linked to clarity and understandability of the system. If a system's applications are very clear and users can understand how it works, it will be perceived as easy to use hence its adoption by workers but if its usage is complex, workers will feel reluctant to use it (Wiid & Cant, 2013). Similarly, Moslehpour et al. (2018), opined that a social media application will be more favourable to use than another if it is most likely to be clear and understandable. In a study conducted in Germany, it has been revealed that the understandability and clarity of social media are dependent on digital literacy (Festl, 2021). Some technology demands deep thinking before it can be applied to work. Mitzner et al. (2016) observed that technology is perceived to be easy to use if it does not demand much thinking in the working setting. Deng et al. (2018), also stated that employees' perceptions of using a specific technology that will be free of physical or mental effort will lead to its perceived ease of use, and thus technology adoption. Shaw et al. (2018) and Setterstrom et al. (2013), also linked perceived ease of use of technology to its ability to be navigated. They discovered that people accept certain technologies because they are easier to use. People, on the other hand, will not use or adopt technology if it is difficult to use or requires a specific skill to operate (F. D. Davis et al., 1989). University of Ghana http://ugspace.ug.edu.gh 23 2.6 Attitude towards using social media Attitude toward the usage of technology refers to a physical propensity that is shown by appraising a specific entity favourably or unfavourably. (Davis, 1989). According to TAM, personal attitudes regarding technology influence the adoption and use of that technology (Bogea & Brito, 2018). Similarly, attitude toward social media use has a direct effect on user intention (Rolls et al., 2016). Al-Shdayfat (2018), revealed in a study on undergraduate student nurses' attitudes toward utilizing social media websites that the majority of nurses students have good attitudes regarding social media use for educational and professional objectives, even though just a minority use it for professional purposes. Oducado et al. (2019), also stated that nurses had a favourable attitude and impression of using social media properly for professional purposes. The leadership of nurses influences their attitudes on social media usage. In encouraging and supporting a positive attitude toward social media usage by nurses, the hospital plays a leadership role; thus, leadership and support in developing a Web 2.0 environment are important to the decision-making process, including the exchange of information, education, social engagement, and mutual intelligence development (Lau, 2011). The attitude of the hospital is therefore a major concern of nurses connected with the implementation of Web 2.0software (Lau, 2011). Evidence-based medical-surgical knowledge is a valuable resource for nurses in healthcare systems. Nurses generally use social media for this purpose. The general attitude of nurses toward the use of social media as their primary source of medical and surgical knowledge was much more hopeful when compared to those who do not utilize social media as a source of medical and surgical information. (Zigdon et al., 2020). Nurses who used mobile phones to acquire health information had considerably higher attitudes toward the ease of using social media platforms for University of Ghana http://ugspace.ug.edu.gh 24 health requirements than those who did not use mobile phones to access information. (Zigdon et al., 2020). Wai-Yu Lee and Mei-Kwan Cheung (2014), said the attitude toward the use of technology depends on individual experience with the technology. Individuals who have a pleasant experience with social media are more likely to use it again. Lee et al. (2012), also disclosed that people demonstrate a pleasant or feeling-good state when they require minimal effort but can achieve a satisfying goal through the use of technology hence developing a positive attitude toward technology. Notwithstanding these observations, people have an unpleasant experience with technology use hence their negative attitude toward technology use is unfavourable. Terzi̇ et al. (2019), observed that socially isolated students have a negative attitude toward social media. In Leist (2013)’s study, data privacy protection, a lack of a social media code of conduct, different forms of self-unveiling and self-reporting on social media, a lack of personal germane on social networks, and disorder of managing registration were identified as troubling reasons for negative attitudes toward social media use among adult novices. 2.7 Behavioral intention to use social media The motivational elements that drive a specific behaviour to utilize technology or the desire to use technology that is propelled by certain underlying variables are referred to as behavioural intentions. (Chao, 2019). The stronger the motivation to use the technology, the more likely the technology will be used (Chao, 2019). In the technology acceptance model, behavioural intention to use technology leads to the actual use of the technology (F. D. Davis, 1989) University of Ghana http://ugspace.ug.edu.gh 25 Bogea & Brito (2018), proposed that personal attitudes regarding technology influence the adoption and use of technology. As a result, the perceived utility, perceived ease of use, attitude toward usage, and behavioural intention to use the technology acceptance model predict nurses' adoption of new technologies. (Lederer et al., 2012). Results from the multivariate regression analyses revealed that social influence, performance expectancy, facilitating conditions and voluntariness of use social media were positively associated with behavioural intentions to use the technology (Bogea & Brito, 2018). Social influence is the mechanisms by which people affect the beliefs, feelings, and actions of others, either directly or indirectly (Turner, 1991). Abbas Naqvi et al. (2020)'s work identified social influence processes as having a significant impact on long-term social media intention. Likewise, Pahnila et al. (2011) showed that enabling conditions, such as the availability of strong networks and fast internet, had a direct impact on behavioural intention to use social media. Another factor that influences behavioural intention to use technology is knowledge or information-seeking behaviour (Ghazavi-Khorasgani et al., 2018). Knowledge or information- seeking behaviour is a deliberate effort to find information and use that information to meet needs that arise out of necessity to achieve a goal. (Ghazavi-Khorasgani et al., 2018). Nurses and other health professionals are said to prefer social media and other online resources when looking for information about their jobs (Sarbaz et al., 2016). Similarly, a study undertaken in the United States, Canada, Taiwan, and Nigeria discovered that social media, internet resources, and peers are the top sources of evidence-based knowledge for hospital nurses. (Alving et al., 2018). Many previous types of research on technology adoption have suggested a significant indicator in the use of social media (Al-Rahmi et al., 2015). Lulin et al. (2020) show that the optimistic mindset of users contributes to a greater intention to use the technologies of social media. To better University of Ghana http://ugspace.ug.edu.gh 26 understand the usage of these social media, Altawallbeh et al. (2015) postulated in their study that there is a likelihood of contradictory intent and actions because unexpected events will affect the intention to embrace social media. Another research by Dlalisa and van Niekerk (2015),) investigated the user's purpose and found no significant association between their actual use of social media for learning. Hazzam and Lahrech (2018) revealed that perceptions, perceived utility, habits, and behavioural goals are key factors that affect the frequency of social media usage by health professionals to improve efficiency. Furthermore, the ease of use of social media has a positive impact on behavioural intent, as evidenced by easy access and navigation among social media networks. Again, Hazzam and Lahrech (2018) suggested that the image of health professionals was negatively affected by the intention to use it. Confidentiality, personal information, and the transparency of social networking platforms could all help to explain such a bad association. (Hazzam & Lahrech, 2018). 2.8 Actual use of social media The actual technology use is the end-point where people put into use the new technology and this is manifested through the frequency of use and accumulated time spent using the new technology (Mariano et al., 2018). In the context of this study, actual social media use is manifested through the cumulated number of hours spent on social media, frequency of use, and types of social media application use. Turner et al. (2012), observed that due to the need to use computer-recorded forms of new technology usage, it is likely that qualitative measures of actual usage are used because it is much more difficult to measure actual usage quantitively than qualitatively. University of Ghana http://ugspace.ug.edu.gh 27 In a study to show the actual use of social media, Kung and Oh (2014) observed that on a daily or weekly basis, nurses spent over five hours per day on social media, looking for health information, and they felt comfortable doing so. In a similar study conducted by Surani et al. (2017) and Wang et al. (2019), they revealed that nurses spent five hours or less on daily basis connecting with colleagues, clients, family, and friends discussing professional or social issues. In a related study, Marin-Gomez et al. (2018), Nikolic et al. (2018), and Torrejon et al. (2020) indicated that nurses and other health professionals prefer WhatsApp as their first-choice social media application followed by Facebook, Youtube before Instagram and Twitter. 2.9 The Benefits of social media in Nursing The growth of online communities in nursing via social networks has emerged as a driving factor in health care (Moorley & Chinn 2014). The advantages of such technology are well-known, including real-time exchange of health-related information, access to research data, the ability to maintain contact with patients and their families, reaching new audiences for education and health services, and disseminating organizational achievements, among others. (Reinbeck & Antonacci, 2019a) also, some of these benefits range from enhanced professional networking, professional education and continuous professional education, patients care, and patient education (Lee Ventola, 2014). Some of the most popular social media sites for nurses include those that allow them to join online groups, listen to experts, network, and interact with colleagues about patient issues. (Courtney, 2013). Nurses' social-networking platforms for professional networking are generally restricted to specific nursing specializations and cadres (MacMillan C., 2013). These sites cover a wide range University of Ghana http://ugspace.ug.edu.gh 28 of themes, including ethics, politics, biostatistics, practice administration, career planning, and even medical dating, in addition to clinical problems (Grajales III et al., 2014). Another type of professional networking among nurses is using crowdsourcing to solve problems or gather information and opinions. (Chretien & Kind, 2013; Dizon et al., 2012). Sociable networks can also be used to connect nurses in developing nations to medical experts who are based in more developed ones (MacMillan C., 2013). A surgical procedure can be streamed via Youtube, and Twitter can be used to ask real-time questions about it (MacMillan C., 2013). A new communication channel has opened up for nursing professionals to network and share medical information in ways that were previously impossible (Dizon et al., 2012) Professional education is one area in which social media is very useful to connect with students in a real life. These social media's communication capabilities are also being used to improve clinical education (von Muhlen & Ohno-Machado, 2012) Clinical curricula are being updated to meet the changing habits and culture of new students as a result of the high percentage of social media use among 18- to 30-year-olds. (Grindrod et al., 2014; von Muhlen & Ohno-Machado, 2012) Numerous studies have demonstrated the use of social media platforms to improve clinical students' understanding of communication, professionalism, and ethics. (Peck, 2014). Universities are also utilizing social media to attract students, offer access to academic resources, and establish virtual classes and office hours, among other unique educational opportunities. (Peck, 2014). Online social networking platforms have also altered nurses' educational experiences, with one survey suggesting that fifty-three percent of nursing schools now employ these techniques. (Peck, 2014). Nursing students, for example, have used Twitter to improve their clinical decision-making skills in critical care settings (Peck, 2014). Again, Peck (2014) stated that clinical professors University of Ghana http://ugspace.ug.edu.gh 29 instructed students to examine films of clinical scenarios and tweet their thoughts on the condition of the patient to receive feedback from their peers. Using a class hashtag to share resources such as podcasts, websites, articles, and photographs, or offering a live stream of student insights throughout the class, are two other ways Twitter is used in nursing education. (Peck, 2014). YouTube and other video-sharing websites can be used in the classroom to stimulate discussion, explain a point, or reinforce a concept. Students can see a video before answering clinical reasoning problems (Peck, 2014). The use of social media in clinical education, on the other hand, has gotten mixed reviews. Courses that use such tools have typically received an excellent response, although some students are concerned that using Facebook for instructional purposes is invading their personal lives (von Muhlen & Ohno-Machado, 2012). Balancing the benefits of increased communication provided by social media with the negatives of increasing distraction is also an issue in an educational context. Regrettably, standards for the appropriate use of social media platforms in education are still in their early stages. (Peck, 2014). In nursing, Continuous professional development is key to new skills acquisition and knowledge update. Social media sites have helped to connect nurses through online social media applications like Facebook and Twitter, as well as more professional-oriented networks like LinkedIn and ResearchGate for teaching nurses in their particular specializations. (George et al., 2013). In recent years, several nurse-specific networks have emerged, such as WeNurses, Evidence-Based Nursing Journal Chat, and WeMidwives, to serve as an online meeting point for nurses to learn from peers, communicate clinical issues, and manage problems, consult about specific patients, and even coordinate care team interactions. (Moorley & Chinn, 2015). Maloney et al. (2017) observed that health professionals are increasingly using social media platforms to maintain their professional University of Ghana http://ugspace.ug.edu.gh 30 progress, which is becoming acknowledged and financially viable hence social media have been established as useful for training nurses and midwives irrespective of their geographical location (Mather et al., 2017; Mather & Cummings, 2015; Murray & Ward, 2019) Although there has been a hesitation among healthcare practitioners to use social media for direct patient care, physicians and healthcare facilities are steadily accepting this practice. (Dizon et al., 2012). Nurses are becoming more interested in connecting with patients online, according to recent studies (Larson, 2020). Twitter, YouTube, and Facebook are just a few of the social media tools nurses are using to communicate with patients (Paton, 2020). The majority of nurses believe that social media may be used to educate and monitor patients, as well as urge changes in behaviour and medication compliance, with the goal of "improved outcomes."(Larson, 2020) according to a recent survey. According to Santoro and Quintaliani, (2013), smart gadgets and social media apps have made it easier to retrieve educational resources, allowing for point-of-care education to take place. In a similar study, Rolls et al. (2016) noted that virtual communities on YouTube are viewed as important knowledge gateways by health care practitioners for accessing clinically meaningful and high-quality information that helps them make better practice decisions. It was concluded by Piscotty et al. (2016) that immediate access to important health information can contribute to better patient outcomes. Other research, however, has revealed that there is still considerable opposition to using social media to communicate with patients. (Dizon et al., 2012). According to Org et al. (2017), technical challenges associated with social media use can slow down its utilization for nursing activities. Another benefit of social media in nursing is its ability to generate, disseminate and share health and other relevant information promptly among nurses and patients. This has given nurses a new University of Ghana http://ugspace.ug.edu.gh 31 communication channel through which they may share and discuss health information in previously impossible ways (Farsi, 2021; Org et al., 2017b; Piscotty et al., 2015). Ng et al. (2019), discovered that the usefulness and efficiency of using social media to actively communicate a clinical and educational patient safety message to a specific target audience are increasing as web 2. technology improves. This has made it more effective for nurses to use a coordinated social media strategy to share health evidence with a geographically diversified audience of healthcare practitioners, researchers, and healthcare organizations. can be effective. (Burke-Garcia et al., 2018; Dyson et al., 2017; Sibley et al., 2020). Again, Loeb et al. (2017) revealed that the European Association of Urology used Twitter to distribute clinical procedures to its members. In comparison to traditional techniques, the study found that social media is an effective instrument for clinical practice guideline dissemination and adherence. This contradicts a study by Narayanaswami et al. (2015) who discovered no difference in the importance of social media-based interventions for disseminating clinical guidelines when compared to traditional techniques, even though social media was effective in reaching a huge number of participants. Social media can also be used to expand the health referral network. According to Joshi et al. (2018), the WhatsApp application is a powerful tool for neurosurgical referrals. It is a low-cost, dependable, and user-friendly program that enables the smooth transfer of clinical videos and scan pictures to the on-call neurosurgical team. Solely on medical data and imaging tests, Othman and Menon (2019) concluded that the WhatsApp chat interface looks to be an excellent tool for inter-hospital referral and gaining rapid responses from hospitals' referee centres. University of Ghana http://ugspace.ug.edu.gh 32 2. 10 Risks of using social media in nursing Social media adoption by nurses has many perceived benefits, but the literature study found that several obstacles made it difficult for nurses to use social media in their nursing practice. Maintaining professional integrity when using social media is exceptional for working nurses. Panahi et al., (2016) indicated that inaccurate information is one of the primary issues social media users are faced with. They opined that information anarchy and inaccurate information are characterized by a situation in which locating relevant information is difficult due to the less ordered, unauthenticated, and uncontrolled nature of information created and share(Panahi et al., 2016a). Mostly, if there is no information anarchy and the information is accurate, most professional discussions are intermingled with both social and professional conversations (Panahi et al., 2016a). Moorhead et al. (2013) also observed that the biggest issue with health information found on social media or other internet sources is a lack of quality and reliability. Authors of medical material published on social media sites are frequently unknown or just have insufficient information to identify them. Furthermore, medical information could be unreferenced, incomplete, or informal (Pirraglia & Kravitz, 2013). Meanwhiles, Learmonth et al. (2017), indicated that because of the professional expertise and qualifications of health professionals, health information transmitted by them through any health-related websites are preferable sources of health information for patients and the general public. With the advent of information technology, laws for the protection of privacy were developed, and they have since been accepted all over the world (Green, 2017). The concept that individuals should have control over their personal information is at the heart of data protection legislation (Green, 2017). Nurses' concerns about using social media typically revolve around the possibility of negative consequences coming from a breach of patient confidentiality (von Muhlen & Ohno- University of Ghana http://ugspace.ug.edu.gh 33 Machado, 2012). Under state privacy laws, such transgressions might expose nurses and healthcare organizations to liability (Chretien & Kind, 2013). This patient's charter, according to Petrie and Bennington (2014), describes the privacy, rights, and expectations that patients have as part of their human basic rights. Patients may feel they have lost their dignity when their privacy is violated, even if it is done inadvertently, according to Spector and Kappel (2012), damaging the therapeutic relationship that occurs between nurses and patients. These unethical practices may jeopardize the professional reputations of nurses as well as the reputations of healthcare facilities (Lee Ventola, 2014). According to Ghana Health Service (2018), health practitioners, such as registered nurses, must conform to the professional standards of the code of professional conduct when using social media. Patient information must always remain confidential and only be used for professional purposes (Ghana Health Service, 2018). Distraction and task interruption are other potential risks associated with social media in nursing. According to Kushlev et al. (2016), Phone alerts draw users' attention away from other tasks; phones may raise cognitive burden by rendering people more susceptible to distractions, and increased mental load can lead to inattention and hyperactivity. People were more upset and frustrated, felt more time pressure, and expended more mental effort when they were interrupted by social media notifications than when they were not. (Kushlev et al., 2016). Thus, not all digital interruptions are created equal: People are more likely to incur attentional and emotional costs when they are interrupted by the unexpected arrival of a new notification. Distractions from the social media alert have been shown to have an impact on nurses' and other health professionals' decision-making processes (Reed et al., 2018). Nurses who are constantly distracted by social media can make mistakes in medication calculations and administration, resulting in significant harm to patients, or even death (Thomas et al., 2017). According to University of Ghana http://ugspace.ug.edu.gh 34 research, the social media application on smartphones is a stimulator that can divert nurses' attention away from their nursing procedures and absorb cognitive resources that are useful for these activities (Fiorinelli et al., 2021). Another setback with social media usage in nursing is its addictive nature. Social media addiction is characterized by a compulsive need to use social media at the expense of other activities and is characterized by clinical features such as loss of attention, tolerance, and control; mood disorders; and withdrawal symptoms (Lee et al., 2014; Zivnuska et al., 2019). The prevalence of social media use among younger people and its association with addictive behaviour is a common theme in studies on social media (Davey & Davey, 2014; Kim et al., 2014). Because young people use social media more frequently, they are more vulnerable to the negative consequences of excessive use, and social media addiction is seen as a particularly high-risk factor for young people (Kim et al., 2014). There is evidence that nurses who use social media too much both at home and work, delay nursing tasks and struggle to meet their standard of care (Duke & Montag, 2017; Priyadarshini et al., 2020; Zivnuska et al., 2019). According to Hoşgör et al. (2021), excessive use of social media by health professionals during working hours had negative consequences such as the inadequate provision of health care to patients, not using their time in a patient-centred manner, (McBride et al., 2015) using their energy for socializing and recreational purposes, and thus lowering their working performance. Hoşgör et al. (2021) concluded that health professionals, particularly nurses, play an important role in providing and maintaining the healthcare that patients require. At work, nurses think, plan their actions, and contribute to the healing process on behalf of and with the patient, hence, addictiveness to social media could impede the healing process. University of Ghana http://ugspace.ug.edu.gh 35 CHAPTER THREE METHODOLOGY This chapter addresses the study designs used, the research setting, the target population, and the sampling strategy used to achieve the specified objectives. It also looked at the tools that were used, as well as the data collection, analysis, and management methods. It also includes details on how ethical requirements were met and the study's trustworthiness. 3. 2 Philosophical paradigms The constructivism philosophical paradigm underpinned the methodological approach of this study. According to this philosophical paradigm, people develop their understanding and knowledge of the universe by experiencing the world and reflecting on those experiences. (Kivunja & Kuyini, 2017). It is based on the analogy or basis that people form or construct much of what they learn through experience (Mittwede, 2012). The researcher believes nurses’ experience with social media usage in their nursing practices is a phenomenon with several meanings and interpretations. As a result, the constructivist paradigm, which underpins qualitative inquiry, was employed. As a result, an exploratory qualitative approach was suited for the study because it allowed participants to express themselves freely and honestly. Reality can be viewed from a variety of philosophical perspectives. Qualitative and quantitative paradigms both seek to discover the truth. Because of the positivist orientation, social observations are treated as physical phenomena in the quantitative research paradigm. The qualitative research paradigm argues that genuineness is subjective, multifaceted, and socially constructed by University of Ghana http://ugspace.ug.edu.gh 36 participants. Mixed methods are a synthesis of both paradigms, even though the level of mixing is still a source of contention in the literature (Creswell, 2014). 3. 3 Research Design An exploratory descriptive qualitative design was employed in understanding social media adoption for nursing care among nurses in North Tongu District. Situating the in-depth exploration of this phenomenon within the technology adoption model; the usefulness, ease of use, attitude, and behaviour towards social media use was explored. Interviews were conducted within the natural environment of participants and their narratives were recorded, transcribed, and analyzed for patterns. Bradshaw et al. (2017), noticed that qualitative research is founded on a global, holistic perspective; it believes that there are various built realities in life where the known and the unknown cannot be separated; the inquiry is also value bound, and all of its application is time- bound and time context. The naturalistic approach is used in qualitative research to gain an understanding of a phenomenon by accessing the meanings that participants attach to it (Bradshaw et al., 2017). When little is known about a phenomenon, scenario, or problem, an exploratory qualitative design is utilized. (Polit & Beck, 2013). An exploratory qualitative approach was then suited for the study since it allowed participants to express themselves more freely than closed-ended questions utilized in quantitative methodologies. This method was used to explore factors that influence social media adoption by nurses in the Catholic Hospital Battor in the North Tongu District because little is known about the factors influencing its adoption by nurses for practice enhancement in the Catholic Hospital Battor in North Tongu District. University of Ghana http://ugspace.ug.edu.gh 37 3.4 The setting of the study The research was carried out at the Catholic Hospital Battor in the Volta Region's North Tongu District. The district is one of the Volta Region's twenty-five districts. The North Tongu District, which was founded in 2012, is one of the newest District Assemblies, with its capital in Battor. The North Tongu District Assembly was established in July 2012, carved out of the former North Tongu District, which is now Central Tongu, by Legislative Instrument (L.I 2081). The district shares borders with the Central and South Tongu districts to the east, to the west with the Asuogyman district and Dangme West district, Adaklu district and Ho municipality to the north, and to the south with the Dangme East District. The population of The District is 89,777 of which 42,492 are male (representing 47.3 percent) with 47 females, 285 representing 52.7 percent. The district contributes 4.2% of the total population of the Volta Region and 0.4% of the total population of Ghana (Ghana Statistical Service, 2013). There are twenty-eight health facilities in the North Tongu District Assembly, including one hospital (Catholic Hospital Battor), six health centers, twenty CHPS zones, and one private clinic. These establishments, which provide health services to citizens, are Ghana Health Service and the Christian Health Association of Ghana. Because it is the largest and only hospital in the district, Catholic Hospital Battor was purposefully chosen for the participants' recruitment. Furthermore, Battor has two internet network providers (MTN and Tigo) with good coverage. According to Ghana Statistical Service, (2013), 37.3 percent of the district's population aged 12 and up owns a mobile phone. Males account for 43.4 percent of mobile phone owners, while females account for 32.1 percent. This suggests that males are more likely than females to own a mobile phone. In the District, 2.2 percent of the population aged 12 and up uses the Internet. According to the report, males account for 3.3 percent of internet users, while females account for University of Ghana http://ugspace.ug.edu.gh 38 1.2 percent. Furthermore, the survey shows that 444 houses have desktop/laptop computers, accounting for 2.4 percent of the district's total households. Male-headed households account for 3.1 percent of those with desktop/laptop computers, while female-headed households account for 1.3 percent. Figure 2: Map of Ghana showing North Tongu District 3.5 Target population The study's target group was all nurses working at Catholic Hospital Battor in the Volta Region's North Tongu District. University of Ghana http://ugspace.ug.edu.gh 39 3.6 Inclusion and Exclusion Criteria 3.6.1 Inclusion Criteria The criteria for inclusion in this study were nurses (RGN, EN, RM) working in the North Tongu District at the time of data collection who: 1. Voluntarily consented to participate in the study. 2. Have been working as a permanent staff for more than six months (this is to enable new staff to be well integrated into the working environment) in Catholic Hospital Battor in the North Tongu District uninterrupted. 3. Have ever used a smartphone or any other personal communication device to access social media before. 3.6.2 Exclusion Criteria 1. Student nurses were not part of the study 2. Nurses on any form of leave were not part of the study. 3.7 Sampling Technique and Sample Size Sampling is a strategy for selecting a subset of a population of interest to collect information that will be used to analyze the features of the population under study. (Hossain, 2014). A purposive sample technique, also known as a judgmental sampling technique, was used to elicit a wide range of opinions from participants. Purposive sampling was chosen to attract informants who possessed the information required by the researcher. (Etikan, 2016; Palinkas et al., 2015). A good informant is well-versed in the phe