Professional Nursing Boundaries in a Facebook Age

By Rose O. Sherman, EdD, RN, FAAN

The rapid rise of social media such as Facebook, Google + and Twitter are changing the nature of social communication. Facebook alone has 800 million active users globally. With this increase in online networking, the traditional boundaries of the nurse-patient relationship may seem less clear and many health care organizations don’t have a social media policy. In a recent discussion that I had with a group of nurses in their first year of practice, 20% had allowed a patient who they had cared for in a hospital setting to friend them on a personal Facebook site when patient was discharged.

Nurse leaders increasingly face challenges in giving clear guidance to staff about the professional role of the nurse and nurse-patient boundaries.

Consider the following Case Scenario

Kaitlin Nelson, RN is a young pediatric nurse who is adored by her pediatric oncology patients. The first time she received a ‘friend’ request on her Facebook site from a former patient, she thought little about it and clicked confirm. She was happy to get updates from her young friend whose condition seemed to be improving. Recently, he was readmitted to her unit with new health complications. Kaitlin now begins to questions the wisdom of her actions. Her Facebook site had more personal information on it than she should would ordinarily feel comfortable sharing with patients and their families. She worries that she may have violated professional boundaries that she learned about in her nursing program.

Professional Boundary Principles

With or without facebook, the concept of professional boundaries remains the same. Professional boundaries are defined as the space between the nurse’s power and the patient’s vulnerability. Nurses are considered to have the power in the nurse-patient relationship and also the accountability to establish boundaries. The National Council of State Boards Nursing in the United State have provided the following guiding principles:

The nurse’s responsibility is to delineate and maintain boundaries.
The nurse should work within the zone of helpfulness.
The nurse should examine any boundary crossing, be aware of the potential implications and avoid repeated crossings.
Care settings and client needs may affect the delineation of boundaries.
When nurses overstep boundaries to meet their own needs, this is considered a boundary violation.
Nurses should avoide situations where he/she has a personal or business relationship, as well as a professional one.
Post-discharge relationships are complex because the client may at a later point need additional services and the nurse-patient relationship may resume.

Lessons Learned

Kaitlin does have reason to be concerned about whether her decision to friend her young patient could be seen as a boundary violation. Some may consider their relationships on Facebook as networking rather than a true personal relationship. It is important to remember that when a patient asks to friend a nurse a personal Facebook site, they are asking to engage in a secondary or social relationship in addition to the therapeutic one.

Kaitlin probably did believe that their nurse-patient relationship terminated when her young patient was discharged but there is rarely a 100% guarantee that they would never re-enter a nurse-patient relationship. She did not consider that in giving a patient access to her personal site, she allowed the patient to see parts of her life, values and attitudes that would have remained unexamined in a traditional professional relationship. It is easy to develop impressions about a professional from these sites and the information could be used if there were allegations of professional misconduct or negligence.

Advice from the Experts

Because of rising issues like the case discussed above, many healthcare organizations have established policies that explicitly warn nurses not to communicate with or friend past or present patients on personal social networking sites. Some units now have professional facebook pages to allow patients to update staff on their progress. These sites are monitored by the internet security staff of the organization. To provide additional guidance, the National Council of State Boards of Nursing released this summer a Nurse’s Guide to the Use of Social Media. Experts agree that the best response to a request such as the one that Kaitlin received would be Thanks for thinking of me but I use my Facebook site just for family and close friends. It protects both the patient and the nurse and sets boundaries that are easily understood.

Read to Lead

National Council of State Boards of Nursing (August 2011). A Nurses Guide to the Use of Social Media

Sherman, R.O. & Blum, C. (2010). Maintaining professional boundaries in a Facebook age. Nurses First. 3(5), 6-8.