Background
Therapeutic relationships are the foundation upon which nursing care is provided.1 Therapeutic relationships are defined as a range of professional behavior that extends the continuum of helpfulness.1 Professional boundaries are an essential component of therapeutic relationships.1 Since the beginning of nursing, professional boundaries have existed.2 Florence Nightingale has long been revered as a founder of modern nursing and set many standards for nursing practice, including professional boundaries.2 The Nightingale Pledge, which was written in 1893 as a tribute based upon Florence Nightingale's values and philosophies, now serves as an oath for those entering the nursing profession and includes the topic of professional boundaries.2
According to the American Nurses Association, the work of nursing is naturally personal and requires building relationships between the nurse and client.3 Owing to the intimacy of this nurse-client relationship, boundary lines can be blurred.4 Within the United States, each state's board of nursing clearly defines professional boundaries and the expectation that nurses maintain these established boundaries.5 Professional boundaries are borders that safeguard patients in their time of need against the perceived power of the nurse providing care.1 Professional boundaries help protect patients and provide a safe way to meet the patients' needs and deliver care.4 The National Council of State Boards of Nursing sets principles that further clarify that it is the nurse's responsibility to ensure and maintain these professional boundaries.1 According to the American Nurses Association Code of Ethics, "nurses establish a relationship of trust with clients and provide care based on need, setting aside any bias, prejudice or personal gain."3(p.1) In the modern nursing era, it is the nurse's responsibility to safely meet their patients' needs, not only in the physical environment but also in the virtual environment.6
Social media, according to Merriam Webster, is an electronic venue that allows communication among users.7 The National Student Nurse Association defines social media as "web based and mobile platforms for user generated content that create interactive and highly accessible and often public dialogs".8(p.1) Social media has a worldwide impact, as evidenced by the International Nurse Regulator Collaborative, which defines social media as "the online and mobile tools that people use to share opinions, information and experiences, images and video or audio clips, and includes websites and applications used for social networking".9(p.1) Social media includes but is not limited to social networking sites, social news sharing, personal and professional blogs, content-sharing websites, video hosting, discussion forums and message boards.8,9 Social media has become an additional form of communication throughout the world. For the purpose of this systematic review, the International Nurse Regulator Collaborative definition of social media will be used.
Communication has historically occurred verbally, either face to face or via phone, as well as the written form.10 In addition to the rapid growth of technology and the creation of personal computers, email and the internet, electronic communication is now a commonly used medium.10 In addition to the conception of electronic communication, social media is a communication method that is now used by nurses and clients alike.11 Initially created for personal and social use, social media has now evolved and infiltrated the professional world, which includes health care.11 Social media has a positive impact and beneficial use in health care as long as it is utilized and maintained in a professional manner.12 Baker states social media is a mode for "advocating for patients, disseminating professional scholarly works for education, and promoting evidence-based practice and research initiatives."12(p.503) It can also be a way to help find an identity for oneself, opportunity for engagement with others and opportunity for employment.12 Although social media has added the benefit of providing additional venues of communication, this has not been without the creation of issues. For nurses, these issues include the improper use of communication outside of the professional nurse-patient relationship, thus creating communication that mirrors a more peer-to-peer friendly dialogue rather than a professional dialogue.11 Although it has become apparent that social media has an important role in the professional realm, the issue becomes the nurse maintaining professional boundaries and therapeutic relationships with patients and families.11,12
Professional boundary lines are subjective and can be a challenge to therapeutically maintain.13 Nurses can find themselves attempting to balance just the right amount of involvement to sustain relationships with clients.13 Under-involvement can lead to providing inadequate care, whereas over-involvement can lead to boundary crossings and violations.13 When the professional boundary lines blur, a boundary crossing as well as a boundary violation may occur.4 These crossings and violations can occur both consciously and unconsciously by the nurse.4 According to the National Council of State Boards of Nursing, boundary crossings are deliberate brief excursions with perceived therapeutic purpose quickly returning back to the established limits of the professional relationship between the nurse and client.1 Crossings are made with good intent and at times have more than one occurrence before evolving to a violation.3 For example, a crossing is when a nurse briefly shares a personal experience about the same procedure or health issue as the patient, with the therapeutic intent to provide another perspective or experience.4,13 A boundary violation moves beyond the therapeutic relationship.1 It occurs when the needs of the nurse overshadow the needs of the patient and the relationship becomes social or personal in nature, such as the nurse sharing excessive personal information or spending additional time with the patient beyond the caregiving environment.1,4 Boundary violations can be considered an occupational hazard because it transcends the therapeutic relationship.5 Healthcare organizations as employers continue to utilize and refine policies regarding the use of social media.6 However, it is often outside the workplace and professional role and in the personal setting where these boundary crossings and violations occur.1 Social media is a conduit that has created the heightened risk of blurring professional boundaries.6
When the use of social media results in boundary crossings and violations, both the patient and nurse are placed at risk.1,4,12-14 The patient, being in their most vulnerable state, is at risk for potential harm, such as mismanagement of care and records, breach of confidentiality and at times exploitation.1,7,12,14 Exploitation can potentially manifest as emotional, financial or physical forms.12 The nurse is at risk for disciplinary action.13,14 The disciplinary action can potentially be from an employer and/or the nurse regulatory agency.13,14 The consequences can be as significant as to result in legal issues, such as civil and criminal pentalities.14 It is essential for nurses to understand the use of social media and the influence it can have on professional boundaries and therapeutic relationships to mitigate the potential risks.1,3-6,8-9,11-14
There has been an amplified awareness of social media and the role it plays in health care, positively and negatively, as well as evidence supporting the influence social media has had in regards to therapeutic relationships.1,4-6,8,9,11-13 The existing literature is rich in theoretical detail. A systematic review will provide and clarify the evidence surrounding the issue. A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports and the Cochrane Database of Systematic Reviews was conducted for existing systematic reviews on this topic, resulting in no findings. This qualitative systematic review will aim to identify the perceptions of the influence that social media has on professional boundaries and therapeutic relationships in health care between nurses and clients and their families.
Inclusion criteria
Types of participants
This review will consider studies that include nurses. A nurse is defined as an individual having authority to practice nursing within their home country as deemed by appropriate regulatory authorities.
Phenomena of interest
This review will consider studies that explore the perceptions of the influence of social media on therapeutic relationships and professional boundaries between nurses and patients and their families of all ages and abilities.
Context
The context for this review will be all healthcare settings where nurses practice. The healthcare settings will include both public and private health settings.
Types of studies
This review will consider studies that focus on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
In the absence of research studies, other text such as opinion studies and reports will be considered. The textual component of the review will consider expert opinion, discussion studies, position papers and other text.
Search strategy
The search strategy will aim to find both published and unpublished studies. A four-step search strategy will be utilized in this review. An initial limited search of MEDLINE (Ovid) and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Finally, a focused search will be conducted for studies by known authors who have written papers in this area to ensure complete works have been considered. Studies published in English will be considered for inclusion in this review. Studies published in 1995 to the present will be considered for inclusion in this review. Social media as defined in this review did not exist before the creation of the internet. Although there is documented use of interactions and communication through the use of computer networking as early as the 1960s, the internet as used today was created in 1995.10
The databases to be searched include:
CINAHL, Embase, MEDLINE (Ovid), Psychology and Behavioral Sciences Collection, Health Business Elite.
The search for unpublished studies will include:
ProQuest Dissertations and Theses, New York Academy of Medicine Grey Literature Report, GreyNet International, Open Grey
Initial keywords to be used will be:
Social media; therapeutic boundaries; therapeutic relationships; healthcare workers; professional boundaries; professional boundary crossing; boundary crossing; professional boundary violation; boundary violation; healthcare; social network; nurse; registered nurse; RN; licensed vocational nurse; LVN; licensed practical nurse; LPN; advanced practice nurse; APN.
Assessment of methodological quality
Qualitative studies selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Textual studies selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data extraction
Qualitative data will be extracted from studies included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.
Textual data will be extracted from studies included in the review using the standardized data extraction tool from JBI-NOTARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or syntheses of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to meta-syntheses to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Textual papers will, wherever possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorizing these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the conclusions will be presented in narrative form.
Appendix I: Appraisal instruments
QARI appraisal instrument
NOTARI appraisal instrument
Appendix II: Data extraction instruments
QARI data extraction instrument
NOTARI data extraction instrument
References