Position Paper on the Nurse's Use of Social Media

APHON Position Paper on the Nurse’s Use of Social Media


2018 Contributors and Reviewers Terri L. Boyce, DNP MSN RN CPNP-AC CPHON ® Dyane Bunnell, MSN APRN AOCNS CPON ® Joan O’Hanlon Curry, MS RN CPNP CPON ® Previous Contributors Terri L. Boyce, MSN RN CPNP-AC CPHON ® Megan M. Davis, MSN RN CPNP CPHON ® Cheryl Gerdy, MSN RN CPON ®

Anita Pool, RN CPN

Previous Reviewers Kathleen Adlard, MS RN CPNP CPON ® Deborah Echtenkamp, MSN RN CPON ® Lisa Fisher, MSN RN CPON ® Deborah Freiburg, MSN RN Cheryl Rodgers, PhD CPNP CPON ® Nancy Tena, MSN RN CPON ® Melody Ann Watral, MSN RN CPNP CPON ®

Social media sites such as Facebook, YouTube, Instagram, LinkedIn, Snapchat, CaringBridge,

and Twitter allow unprecedented opportunities for medical professionals to communicate with

patients, families, and colleagues. The informality and ease of these forms of communication

increase the likelihood that a nurse may unintentionally disclose privileged personal health

information. For example, a nurse may casually comment on how exciting it is that their son is

so close to engrafting on a family’s Facebook post . Conversely, nurses reading patient and

family blogs or social networking profile pages may inadvertently obtain information requiring

clinical intervention that otherwise may not be disclosed to the healthcare team (Guseh, Brendel,

& Brendel, 2009; Tunick & Mednick, 2009).

The widespread availability of healthcare providers ’ personal information on the Internet

and social networking sites threatens professional boundaries. Personal information about nurses

that can compromise the professional relationship between nurses and patients may be revealed

on the Internet (MacDonald, Sohn, & Ellis, 2010). The nature of social media is such that even if

a nurse intends to send information to only one person, unintended recipients often can view this

information. When patients and families have access to nurses’ personal web pages or social

media profiles, information can be taken as opposed to deliberately given. The effect of taken

information on a patient or family can be positive or negative and cannot be predicted

(MacDonald et al.). Social networking sites and personal blogs should be maintained with

privacy settings enabled to minimize the risk of personal information, opinion, and behavior

being disseminated to a large network of unintended recipients or misrepresented as professional


Despite the ability to engage privacy settings, information posted on social media sites is

not held to the same security standards to which healthcare agencies must abide, according to

Health Insurance Portability and Accountability Act (HIPAA) regulations (Terry, 2010). The

Nursing Code of Ethics (American Nurses Association [ANA], 2015) addresses issues of privacy

and confidentiality. Nurses have a duty to safeguard patient privacy. The Code of Ethics states,

“Because of rapidly evolving communication technology and the porous nature of social medi a,

nurses must maintain vigilance regarding postings, images, recordings, or commentary that

intentionally or unintentionally breaches their obligation to maintain and protect patients’ rights

to privacy and confidentiality” (ANA, 2015). Information is only to be shared with those directly

involved in a patient’s care who have a direct “need to know.” Likewise, HIPAA privacy rules

seek to define and limit information sharing to those who have a need to know to participate in

the care and treatment of patients (United States Department of Health & Human Services Office

of Civil Rights, 2007). This may include information sharing with family members or friends

who are involved in care or payment for care. Disclosure of information to other people or

entities is viewed as a violation of privacy. Under both codes, identifiable patient information

should be disclosed only on a need-to-know basis.

The ANA Code of Ethics describes professional therapeutic relationships and emphasizes

the importance of maintaining boundaries within the nurse-patient relationship (ANA, 2015).

Maintaining appropriate boundaries safeguards both patients/clients and nurses by controlling or

limiting this power differential. Setting boundaries allows for safe connections between nurses

and patients based solely on the needs of patients (Holder & Schenthal, 2007). Professional

boundaries help to safeguard the patient-nurse relationship and provide a framework for

interactions that benefit patients and families (Guseh et al., 2009). Nurses who care for patients

with chronic conditions are at higher risk for being overly involved and crossing professional

boundaries (Flaherty, 1998). Establishing friendships with patients and families is not a

customary aspect of therapeutic patient-nurse relationships. Internet-based friendships may open

the door to unprofessional interactions online or in person that are not in the best interest of

patients and may lead to potentially problematic self-disclosure of nurses (Guseh et al.). Due to

the length of treatment, long-term follow-up, and the potential for recurrence, there is no clear

indication of when a nurse-patient relationship is completely terminated or would transition to a

social relationship or friendship (National Council of State Boards of Nursing [NCSBN], 2014).

Modern nursing must combine clinical and technical competence with compassion,

empathy, and respect; it is interpersonal skills that allow nurses to establish therapeutic

relationships and build trust. This sensitivity to others is an integral part of the caring profession

of nursing (McHolm, 2006; Sabo, 2006). At the same time, this sensitivity makes nurses

vulnerable to the emotional toll of compassion fatigue. Nurses who have a high degree of

empathy can easily become overinvolved with patients and their families (Newsom, 2010;

Sherman, 2004). Pediatric hematology/oncology nurses are expected to be involved in caring for

patients as well as families, and this puts them at high risk for compassion fatigue. Stressors

specific to pediatric oncology nursing include complex treatments, the nature of cancer as a

diagnosis, high patient acuity, communication with family, ethical issues, lack of control, and

death and bereavement issues (Medland, Howard-Rubin, & Whitaker, 2004; Zander, Hutton, &

King, 2010).

The concept of compassion fatigue is relatively recent; it was coined by Joinson (Joinson,

1992) while studying burnout in nurses working in emergency departments. Compassion fatigue

differs from posttraumatic stress disorder in that it is precipitated by exposure to a traumatized or

suffering person rather than a traumatic event (Aycock & Boyle, 2008; Medland et al., 2004).

Compassion fatigue differs from the more general “burnout” in that it specifically is an

emotional response resulting from caring about and identifying with the suffering experienced by

patients and their families (Maytum, Heiman, & Garwick, 2004; Showalter, 2010).

The symptoms of compassion fatigue often follow classic stress patterns; consequently,

nurses and those around them may dismiss the signs. Difficulties may instead be attributed to

stressful scheduling, poor diet and exercise habits, or physical causes. Each nurse must assess his

or her emotional health and examine relationships to determine if compassion fatigue is present

(Joinson, 1992; Medland et al., 2004; Showalter, 2010). McHolm (2006) separates symptoms of

compassion fatigue into five dimensions: psychological, physical, professional, social, and

spiritual. Ironically, one of the recommended methods to avoid compassion fatigue is for nurses

to communicate with others who share their experiences, and one way to communicate is

through social media (Medland et al.; Perry, 2008). Many nurses who are members of social

networks are friends with patients, and their families. As a result, a connection with coworkers

through social media can also mean an inadvertent link to patients that extends beyond work

hours and can aggravate compassion fatigue.

An additional concern that arises from the nurse’s use of social media is its impact on

coworkers and care teams. Nurses who use social media to express negative feelings about

coworkers may be committing lateral violence, including bullying and intimidation. While there

may be legal protection for the nurse based on First Amendment rights, the nurse should consider

the potential detrimental effects of any form of lateral violence on team dynamics and

cohesiveness (NCSBN, 2018).

It is the Position of APHON That

Nurses should be aware of their specific institution’s social media policies and procedures, and

recognize their obligation and responsibility to protect patient privacy in all areas of social

media. Our first and foremost priority and responsibility is to our patients. To ensure that nurses

do not breech confidentiality, share protected health information (PHI), or violate HIPAA


Nurses should

 recognize their ethical and legal obligation to protect and maintain patient privacy and

confidentiality at all times

 have awareness of what constitutes a HIPAA violation and have an understanding of

legal consequences and ramifications if violations occur

 strive to project an online persona that is characteristic of a professional nurse

 use good judgment when posting any personal information and activities

 enable privacy settings to minimize public access to personal blogs and social media

 understand their specific institution’s social media policies and procedure s.

Nurses should not

 initiate an invitation to patients or their caregivers, friends, or relatives to become social

networking “friends” or follower s of a personal blog. This act can compromise the

therapeutic relationship. Nurses should be prepared to decline such networking requests

from patients and their families with a professional and thoughtful response (Guseh et al.,


 make posts that discuss patients, including any patient PHI. This includes descriptions of

patients (such as name, medical record numbers, room numbers, sex, age, address,

location, etc.), their treatments or conditions, pictures, videos, or diagnostic images of


 participate in any online conversation with patients or regarding patients, even if it is the

patient who is initiating the contact or conversation

 make public statements or social media posts describing details of their job or work day,

including patient specific events that happened within their unit, department, or


 refer to coworkers or supervisors in a negative, unprofessional, or derogatory manner

 post unauthorized content, speak on behalf of, or negatively comment about their

employer (NCSBN, 2018)

 allow the use of social media to interfere with work and professional responsibilities.

It is AP HON’s position that, for social media purposes, a patient and their family members are

no longer considered a patient once he or she is no longer seen in your clinic or institution more

than once per year. APHON does not endorse social networking with patients and family

members. Furthermore, APHON does not endorse social networking with minors (anyone less

than 18 years of age) at any time during or after treatment, regardless of frequency of visits.

APHON has provided a statement that may be used by nurses to explain to patients and their

families our position on social networking and our reasons for turning down any friend requests:

Thank you for the friend request. To maintain the integrity of our professional and

patient relationship, I must respectfully decline any friend requests on social

networking sites from any current patients. It is the position of the Association of

Pediatric Hematology/Oncology Nurses that one of our primary priorities is to

protect patient privacy and maintain professional boundaries. Please know that I

will always value the relationship that we do have and look forward to continuing

to be a part of your care. Thank you so much for your understanding.


Aycock, N. & Boyle, D. (2008). Interventions to manage compassion fatigue in oncology

nursing. Clinical Journal of Oncology Nursing, 13 (2), 183 – 191.

American Nurses Association. (2015). Code of ethics for nurses with interpretive

statements . Silver Spring, MD: Author.

Flaherty, M. (1998). Crossing the line: Pushing the limits of professional boundaries .

Retrieved May 3, 2010, from www.nurseweek.com/features/98-10/involve.html.

Guseh, J. S., Brendel, R. W., & Brendel, D. H. (2009). Medical professionalism in the age

of online social networking. Journal of Medical Ethics, 35 , 584 – 586.

Holder, K. V., & Schenthal, S. J. (2007, February). Watch your step: Nursing and

professional boundaries. Nursing Management , 25 – 29.

Joinson, C. (1992). Coping with compassion fatigue. Nursing 1992 ; April, 116 – 121.

MacDonald, J., Sohn, S., & Ellis, P. (2010). Privacy, professionalism and Facebook: A

dilemma for young doctors. Medical Education, 44 , 805 – 813.

Maytum, J. C., Heiman, M. B. & Garwick, A. W. (2004). Compassion fatigue and burnout

in nurses who work with children with chronic conditions and their families.

Journal of Pediatric Health Care, 18 (4), 171 – 179.

McHolm, F. (2006). Rx for compassion. Journal of Christian Nursing , 23 (4), 12 – 19.

Medland, J., Howard-Ruben, J., & Whitaker, E. (2004). Fostering psychosocial wellness in

oncology nurses: Addressing burnout and social support in the workplace. Oncology

Nursing Forum, 31 (1), 47 – 54.

National Council of State Boards of Nursing. (2018) A nurse’s guide to use of social

media. Chicago, IL: Author. Retrieved from www.ncsbn.org/NCSBN_SocialMedia.pdf

National Council of State Boards of Nursing. (2014). A nurse’s guide to professional boundaries.

Chicago, IL: Author. Retrieved from www.ncsbn.org/Professional Boundaries_Complete.pdf

Newsom, R. (2010). Compassion fatigue: Nothing left to give. Nursing Management , 41 (4) , 43 –


Perry, B. (2008). Why exemplary oncology nurses seem to avoid compassion fatigue.

Canadian Oncology Nursing Journal , 18 (2), 87 – 99.

Sabo, B. M. (2006). Compassion fatigue and nursing work: Can we accurately capture the

consequences of caring work? International Journal of Nursing Practice 2006 , 12, 136 –


Sherman, D. W. (2004). Nurses stress and burnout. American Journal of Nursing , 104 (5),

48 – 56.

Showalter, S. E. (2010). Compassion fatigue: What is it? Why does it matter? Recognizing

the symptoms, acknowledging the impact, developing the tools to prevent

compassion fatigue, and strengthen the professional already suffering from the

effects. American Journal of Hospital Palliative Care , 27 (4), 239 – 242.

Terry, N. (2010). Physicians and patients who “friend” or “tweet”: Constructing a legal

framework for social networking in a highly regulated domain. Indiana Law Review, 43

INLR 285.

Tunick, R & Mednick, L. (2009). Commentary: Electronic communication in the

pediatric setting — Dilemmas associated with patient blogs. Journal of Pediatric

Psychcology, 34 (5), 585 – 587.

United States Department of Health & Human Services Office of Civil Rights. Health

Insurance Portability and Accountability Act . (2007). (Publication No. 45CFR160).

Washington, DC: U.S. Government Printing Office.

Zander, M., Hutton, A. & King, L. (2010). Coping and resilience factors in pediatric

oncology nurses. Journal of Pediatric Oncology Nursing , 27 (2), 94 – 108.


The Association of Pediatric Hematology/Oncology Nurses (APHON) publishes its position

statements as a service to promote the awareness of certain issues to its members. The

information contained in the position statement is neither exhaustive nor exclusive to all

circumstances or individuals. Variables such as institutional human resource guidelines, state or

federal statutes, rules, or regulations, as well as regional environmental conditions, may impact

the relevance and implementation of these recommendations. APHON advises its members and

others to carefully and independently consider each of the recommendations (including the

applicability of same to any particular circumstance or individual). The position statement should

not be relied upon as an independent basis for care, but rather as a resource available to APHON

members or others. Moreover, no opinion is expressed herein regarding the quality of care that

adheres to or differs from APHON position statements. APHON reserves the right to rescind or

modify its position statements at any time.

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