#Boundaries: When patients become friends

Abstract

The personal use of social media by healthcare professionals is a hot topic within oncology practice settings. The widespread availability of both patient and provider personal information online threatens professional boundaries. This commentary article will provide an overview of the oncology nurses’ responsibility to maintain boundaries and the potential risk to professional image if clients and families are able to access providers’ personal information online. Work undertaken by the Advanced Practice Nursing Social Media Taskforce in the Hematology Oncology Transplant Program at the Alberta Children’s Hospital will be presented including a literature review and development of a staff survey to explore perceptions and practices related to personal social media use by health professionals. Case scenarios of common social media challenges are explored and knowledge translation activities presented.

A nurse arrives to work on the final day of a block of shifts. She expects to have the same patient assignment as she had all week. Upon arrival, the charge nurse pulls her aside to disclose that her assignment has been changed. The previous day the nurse had accepted a social media ‘friend’ request from a patient’s wife. It seemed natural, as they had discovered through many, many hours side by side that they had a great deal in common outside of the hospital. Both enjoyed cooking, rock climbing and had even both recently returned from similar trips abroad. Overnight the patient’s wife had looked through the nurse’s social media account and discovered that the nurse herself had a very ill family member. The wife felt that the nurse had too much stress in her personal life and was worried the nurse might be too distracted to provide optimal care; the wife requested the nurse no longer care for the patient. The nurse felt shocked at this request, as she never let her personal life impact her work and did not believe it was fair for her clients to make judgments on her ability to provide care based on something they saw online.

Professional boundaries are the cornerstone for nursing professionals to build and maintain therapeutic relationships with clients and their families (Peluchette, Karl, Coustasse, Rutsohn & Emmett, 2012). However, the ever-increasing use of social media has posed significant threats to these relationships. As personal information about both health professionals and the clients they serve can be easily accessed online the risk of boundary crossings is high (Ginory & Sebatier 2012). In oncology practice settings, navigating this risk can be a daily challenge. The acutely chronic nature of many cancer trajectories means that oncology nurses often develop close relationships with clients. Oncology nurses become educators, caregivers, hand holders, and trusted confidants through the most traumatic and triumphant experiences. Patients often feel that their nurses are like family. In an age when technology is literally always in hand it is easy to imagine that the oncology nurse-patient relationship might naturally drift online.

In response to concerns regarding boundary crossings, the Advanced Practice Nursing group in the Hematology Oncology Transplant (HOT) Program at the Alberta Children’s Hospital developed a social media taskforce. The goal of the taskforce was to identify knowledge gaps that existed for staff with regards to boundaries and personal social media use by health professionals. First, the taskforce sought to identify existing resources that addressed the impact on professional boundaries of personal social media use. Next, a review of the literature was conducted. The existing literature on this topic is largely editorial in nature and there is a lack of peer-reviewed publications. Review of the literature that does exist provides insight into nursing practice challenges and revealed three key themes: 1) the onus of boundary maintenance is on health professionals; 2) the most frequent boundary violations are related to breaches of confidentiality; and 3) there is an obvious gap in organizational policy to assist providers in navigating these issues.

BOUNDARY MAINTENANCE

The imbalance of power between a health professional and client means that the responsibility of maintaining professional boundaries lies with the professional (Baker, 2013). Much as we would do during ‘in person’ interactions with clients, oncology nurses must take responsibility for directing boundary management. The development of dual relationships with patients (professional and personal) can lead to serious ethical issues and can potentially impair judgement (Peluchette et al., 2012). Ultimately, the onus lies with the health professional to establish practices that safeguard these relationships. It is unrealistic for today’s oncology nurse to imagine that their personal engagement in social media cannot or will not in any way be linked to their professional nursing roles. Comments made on one’s ‘own time’ may be subject to the same level of scrutiny as those made professionally (Stott, 2015). In advance of engaging in the use of social media (personal or professional) nurses have a responsibility to consider their approach to boundary management in an effort to more easily identify scenarios that are of concern and consider how they might be managed (Foster, 2016).

PRIVACY AND SECURITY

The most commonly reported adverse outcomes related to professional nursing practice and social media use are breaches of confidentiality and privacy (Johnstone, 2016). Case reports of disciplinary actions detailing stories of nurses who have intentionally or unintentionally disclosed information that can be linked to a patient are common. For example, a group of nurses post a photo of themselves celebrating a holiday or birthday while on shift. However, the patient board is visible in the background. When this photo is posted to social media confidential information such as patient names and location can be viewed by the public. Alternately, a nurse makes a post lamenting the death of a patient that occurred while she was on shift that day. The nurse does not directly disclose any patient identifiers. However, she provides enough generic details that some of her own family and friends inquire if this is the same individual they recently saw on the news. Again, client privacy is unintentionally breached through the posting of a personal experience. Ultimately, the concern to protect patient information should be at the forefront of any social media activity undertaken by health professionals.

The other side of privacy protection must consider the privacy of nurses themselves. Privacy is not simply protecting client information, but also about maintaining one’s own professional integrity (Aylott, 2011). Social media not only puts client confidentiality at risk, but also exposes health professionals to increased public scrutiny (Kimball & Kim, 2013). A nurse’s professional image can quickly be besmirched with a single status update or shared photograph. When engaging in personal social media use nurses must consider not only the privacy of patients, but also the implications for the professional image of themselves and anyone potentially linked to their posts.

NEED FOR ORGANIZATIONAL GUIDANCE

The third theme apparent in the literature was a need for more directive guidance from employers and professional bodies. Nurses need to know what acceptable professional social media activity is and require assistance in navigating this. Professional oncology nurses look to their employers and regulatory bodies to develop an understanding of professional responsibility (Peluchette et al., 2012). While many employers do have social media policies these policies are general and offer little specificity in terms of how nurses might navigate the complexities of online relationships with clients or coworkers. Broad statements around maintaining professionalism and safeguarding client privacy are often not concrete enough to be applied in practice. Are certain online activities acceptable for the nurse but not others? Does the nurse’s specific role matter? What if the patient is no longer receiving treatment in the nurse’s area? The legal implications of online interaction may be more obvious, but beyond that there is a lack of clarity leaving nurses to wade through these murky waters on their own (Koh, Cattell, Cochran, Krasner, Langheim, & Sasso, 2013). While many healthcare organizations employ some type of online monitoring to protect the reputation of the institution they generally do not provide clear direction to assist staff in navigating daily personal decisions and appropriate behaviours on social media.

IN PRACTICE

In examining our own organization and regulatory bodies the APN Social Media Taskforce was able to find information on posting about work, expectations around privacy of patients and the organization itself, as well as guidelines on how to manage a social media account that represents the organization. However, resources that offer direction or considerations for how employees might navigate personal social media use, as health professionals, have yet to be developed.

Regulatory bodies and professional interest groups were similar in their guidance: the (oncology) nurse has a duty to protect the patient by avoiding any breaches in confidentiality and privacy. Again, explicit direction regarding what was acceptable or unacceptable was hard to come by. Interestingly, the Association for Pediatric Hematology Oncology Nurses (Boyce, Davis, Gerdy, & Pool, 2011) had the only position statement we could find that included a clear list of ‘dos and don’ts’, as well as some scripting that nurses could offer when they received friend/follow requests from patients or patients’ family members.

SURVEY

In an effort to further understand how this was impacting frontline oncology nurses, the APN Social Media Taskforce created a social media use survey for staff within the HOT Program. Survey results echoed much of what could be found in the literature. There were a few findings that stood out from these results. First, it was not surprising that the majority of staff did engage in some type of personal social media activity. Of those staff, more than 60% had received a friend/follow request from a patient or family member. Eighty-five percent of staff were ‘friends’ or ‘followers’ to coworkers. Additionally, 50% of respondents indicated they had been uncomfortable with something a coworker had posted on social media, which reiterates the concern for how one’s professional image might be impacted through social media.

When staff were asked if they employed security settings on their accounts, 100% said ‘yes’. However, 40% acknowledged these were not employed on all social media accounts leaving their personal information easily accessible. Greater than 30% of respondents were not aware that their employer had guidelines on personal social media use and another 20% were not aware that there might be any legal or ethical implications to their personal social media use.

EDUCATION AND MENTORSHIP

As our taskforce worked through the available information and survey results, and engaged in conversations with frontline nurses, we were reminded that developing boundaries within an oncology practice setting is a learned skill. Boundary management is a skill with which each of us has different experience and develops over time. The practices we might employ as experienced nurses are very different than those we had when we first started nursing and were largely developed through trial and error. There are currently very few resources that exist to assist nurses in managing the complexities of being a professional nurse who uses personal social media. Nurse mentorship and education around the use of social media have been identified as priorities within the HOT program and the Alberta Children’s Hospital in an effort to better support our staff.

Knowledge translation activities include awareness, mentorship and guidance. The taskforce has undertaken multiple presentations to various nursing groups within and external to the Alberta Children’s Hospital to promote awareness and encourage discussion of these issues. A variety of educational activities are being developed, which can be implemented at orientation of new nurses and at regular intervals, as appropriate. Additionally, with the support of the Alberta Children’s Hospital Executive Leadership a social media guidance document is under development that can be implemented for nursing and allied health hospital-wide. This guideline will not only seek to provide clarity around appropriate personal social media activities but to support the critical appraisal of rationale and consideration of potential outcomes by staff before engaging in social media. The guideline will also offer specific scripting to assist staff in responding to requests from coworkers or clients that they may not wish to engage with online.

Additionally, the taskforce plans to further explore the challenges of social media use in healthcare settings from other angles. Future plans include examining the patient’s perspective on engaging in social media relationships with their healthcare team. What is their rationale for initiating these relationships? Have they considered potential consequences to the care dynamic? What resources or processes might be helpful for health professionals in initiating these conversations? Another consideration is developing some guidance for professionals on managing relationships when their social media ‘friends’ become patients. For example, a follower on a nurse’s personal social media page receives a cancer diagnosis. How might the nurse manage any questions or issues of privacy that arise? Online interaction and the use of social media continue to grow; the considerations and challenges that face health professionals are ever changing and increasingly complex.

SUMMARY

Well defined policies on social media usage must not only cover posting on behalf of an organization, but also be directive around the implications of personal social media use by health professionals. Due to the complexity of online interactions, as well as the nature of client-provider relationships within an oncology practice setting, oncology nurses are at a high risk for online boundary crossings. Oncology nurses need clear direction and mentorship from within their organization and from professional bodies. While clear delineation of expectations and potential consequences is valuable for defining professional conduct, nurses need assistance in developing the skills to evaluate their intentions and potential outcomes before hitting the ‘like’ button. Open dialogue and mentorship within oncology practice settings will not only minimize potential blunders and embarrassment, but promote a higher level of professionalism and, therefore, therapeutic relationships for patients and their family members across the cancer trajectory.