Blurring the boundaries: technology
and the nurse-patient relationship
Abstract
Nurses, like the rest of the world’s population are increasingly
participating in online social media. Nurses must be mindful to avoid
situations that could ultimately compromise past, present and future
patient health and wellbeing, as well as their professional identities and
reputations and that of the nursing profession. Unprofessional uses
of social networking tools are common. This article aims to inform
nurses of the public accessibility to professionally inappropriate online
behaviour and activities. It asks nurses to carefully consider the risks
posed by online social media with a focus on boundary crossing in an
e-society. Forethought is required to ensure that private information
stays private and that the nature of the professional relationship
between nurse and patient continues to be respected.
Key words: Boundaries n Nurse n Patient n Relationship n Personal
n Professional n Internet n Social networking
T
he internet has been touted as enabling unlimited
access to information, irrespective of an individual’s
social situation and pervades many aspects of
life (Lyytinen and Yoo, 2002). People can now
communicate and interact through web-based social
networks (WBSNs) to have different, interesting and
worldwide experiences (Marriott, 2007). WBSN refers to
various, loosely-connected types of applications that allow
individuals to communicate with one another, and to track
discussions across the web as they happen (Tepper, 2003).
These applications include internet forums, blogs, wikis,
podcasts, picture-sharing, news-sharing, dating websites,
weblogs, pictures and video. Three of the most popular
WBSNs are Facebook®, MySpace®, Twitter® (Brockett,
2007), all of which now store large volumes of data about
their users. Latest reports estimate that ‘Facebook and
MySpace now carry details of around 12 million people in
the UK alone’ (Nuttall and Gelles, 2010).
With increasing use of the WBSNs by patients and
providers alike, it is not unexpected that their real-world
and online lives would someday intersect. Before the
days of internet search engines, patients knew little about
Marion Aylott is Senior Lecturer, Department of Nursing & Midwifery,
University of the West of England, Glenside Campus, Bristol
Accepted for publication: June 2011
810
Marion Aylott
their providers until they met face-to-face. Now, patients
can use WBSN to background-check staff and vice versa.
Anonymity, privacy, and boundaries are at risk in cyberspace
(Behnke, 2008). This article will explore the issues raised
today by WBSNs that impact the nurse-patient relationship.
The terms ‘nurse’ and ‘patient’ will be used and are intended
to include midwives and those receiving care who may not
normally be referred to as patients.
Online social networking
Although you might be quick to share moments from your
private life on WBSNs, you might hesitate if you think
about who is going to see this. You might share a post, a
link or a video with 50 friends. Each of those friends has the
ability to share what you have posted with their 50 friends
and so on. In a matter of hours, over 100 000 people could
be reading it. This is called going viral (Graham and Moore,
2008). Scientists consider internet privacy (or the lack of
it) one of today’s serious social issues (Beal and Strauss,
2010), forcing consideration of the question: has it become
necessary to constantly be on guard?
Problems can arise when nurses intentionally or
unintentionally fail to maintain the professional boundaries
(PB) that define the nurse-patient relationship (Doel et al,
2010). WBSNs increase the means by which nurse-patient
boundaries can be crossed. Like changing the sails of a ship
at sea changes the destination, blurring of PBs can change
the course of the nurse-patient relationship.
Professional boundaries
In terms of professionalism, the maintenance of boundaries
is important to maintaining order, rationality and
predictability within nurse-patient relationship (Holder and
Schenthal, 2007). Boundaries are constantly being crossed
or renegotiated by a variety of procedures, people and
technologies. Therefore, the boundary is a ‘live thing’. But
WBSNs give an appearance of separation, where in fact an
ambiguous continuity exists (Chen and Nath, 2005). PBs
define the limits of accountability, reliability and efficiency
and protect the space between the professional’s power and
the patient’s vulnerability (Nancarrow and Borthwick, 2005)
and should always be based on the patient’s needs (Peterson,
1992). A nurse’s power comes from their professional
position and knowledge of private details about the
patient. Therefore, maintenance of PBs remains the nurse’s
responsibility and is essential to delivering safe, ethical and
quality nursing care which is a fundamental element of the
therapeutic relationship (Sheets, 2001).
British Journal of Nursing, 2011, Vol 20, No 13

Research informs us that boundary violations occur
in increments. They begin with thoughts or fantasy, and
then crossings (Greenwood, 2009; Guseh et al, 2009). Brief
boundary crossings can be intentional for therapeutic
reasons, or inadvertent and thoughtless. Crossings generally
produce no long-term effects but should be evaluated
for potential long-term consequences or implications for
the patient and nurse. Unchallenged, these crossings may
become more frequent until a violation is committed
which could potentially harm a patient (Sheets, 2001).
Violations often result from confusion between the needs
of the nurse and those of the patient. A violation is usually
characterized by:
■■ Excessive disclosure
■■ Role reversal
■■ Secretive behaviour
■■ Super-nurse behaviour
■■ Singles-out patient for treatment/attention
■■ Selective communication
■■ Flirtations
■■ ‘You and me against the world’ behaviour
■■ Failure to protect the patient (Tariman, 2010).
Everyone has the potential to violate a boundary. This
Violation Potential (VP) fluctuates over time, in response
to life events and can be represented by the formula in
Figure 1. VPs are more likely to occur in situations where
the nurse’s vulnerabilities are high, such as in cases of
unresolved childhood traumas and shame-based injuries, or
when external risk factors are high, such as work setting,
patient type, and lack of experience. Risk factors and
vulnerabilities multiply and magnify each other. At the
same time, the nurse’s resistance may be low. This might be
exhibited as denial or refusal to see possible vulnerabilities
or risk factors (Thomas et al, 2001), a kind of psycho-social
‘blind spot’.The presence of a catalyst such as divorce,
and/or a provocative patient may cause the VP to increase
quickly. Indeed, a catalyst may cause an ethical nurse to
cross a boundary they would normally not cross. Personal
accountability of the nurse to a supervisor or manager
divides the risks, thereby reducing the VP. The higher a
nurse’s perception of accountability, the lower their VP
(McGuigan, 2007).
Boundary protection
The Nursing and Midwifery Council (NMC) ‘Code’
(2008) alludes to boundary issues stipulating that the nurse
must always act in the best interests of the patient and
not engage in behaviours that can harm the reputation of
colleagues or the profession. However, with regards to PBs,
the Council only focuses specific attention on sexually
inappropriate behaviour (NMC, 2009a). While there are
very few cases of inappropriate sexual relationships between
nurses and patients or their family members, they happen
nonetheless In the majority of cases, sexual misconduct
is not a one-time event but rather the culmination of a
long process which may even begin online (Council for
Healthcare Regulatory Excellence (CHRE), 2008).
Shutt (2009) asks why students are going to the NMC
for guidance on WBSNs when all that is required is the
British Journal of Nursing, 2011, Vol 20, No 13
TECHNOLOGY
Key:
Rr VP = violation potential
VP = RF x Vu
RF = risk factors
A
Vu = vulnerabilities
A = accoountability
R = resistance
c
C = catalyst
BV
BV = boundary violation
Figure 1. Boundary Violation Formula
Submitted by Anonymous (not verified) on 1 December 2010 - 10:18am.
Some people may be members of specific groups that have an online presence
(e.g. Cancer support, Mental health support, age-specific sites). These groups
typically expect that only members who join that group will have access to
information posted and shared amongst members of the group. These groups
might include Cancer support groups - aiming to support people with cancer and
recovering from illnesses, and encouraging people to share their experiences in
a safe, supportive environment. I am aware that students and staff have divulged
information obtained from those sites to other students thereby breaching the
privacy of the individual.
Figure 2. Post submitted to cancer self-help website on privacy and online materials
application of common sense and careful consideration
of the potential for harm to self and others. Yet, ongoing
media reports indicate that perhaps more specific guidance
is required.
The case for more guidance
The internet is a communication medium that has changed
perceptions of information sharing and interpersonal
interactions (Lazer et al, 2009). WBSNs have radically
redefined the nature of personal privacy. Figure 2 is
an anonymous comment posted on a cancer self-help
website. This is not to say that health professionals should
avoid using social media as their use can be personally
and professionally beneficial. Still, traditional expectations
regarding the conduct of health professions apply equally to
this non-traditional context; student and health professionals
have a duty to patients and the community to maintain
professional standards at all times, including time spent
online (Joinson, 2003). While there is a paucity of research
evidence in the literature about this, there is significant
evidence available in public electronic and newspaper
reports. These indicate that WBSNs have created a ‘virtual’
space where professional boundary violations occur.
Assuring patient confidentiality
Consider this scenario: a nurse makes a comment on a
WBSN site about an adverse outcome of one of their
patients. They are careful not to name the patient or
the hospital. However, they mentioned the name of the
hospital they are working at in a post the previous week.
Meanwhile, a relative of the patient searches the internet
for the hospital’s name in order to find its contact phone
number. In the search results, the patient’s relative is
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 presented with the nurse’s posting mentioning the hospital.
The relative then sees the subsequent posting regarding the
adverse outcome involving their loved one.
Nurses and other health professionals have an ethical
and legal responsibility to maintain their patients’
confidentiality (Montgomery, 2003). This still applies when
the communication is online. The anonymity potentially
afforded online is no excuse for unprofessional behaviour;
the NMC advises avoiding misuse of the internet and social
networking sites (NMC, 2010).
Before putting patient information online, it is essential
that due thought is given first to intention and rationale.
Secondly, express consent must be obtained and documented
as such in any online posts. If it is thought appropriate
to discuss a patient case, for example, to further that
patient’s care or the care of future patients, care must be
taken to ensure that the patient is properly de-identified.
Anonymizing through use of a pseudonym is not always
enough. Case information may need to be changed or the
discussion delayed. The accessibility and index ability of
online information means that although a single posting
may be sufficiently de-identified in its own right, this may
be compromised by other postings online. In maintaining
confidentiality, it must be ensured that any patient or
situation cannot be identified (NMC, 2010) by the sum of
information available online.
Humour at work interpreted as ‘negligent’
Protection of harm online is perhaps more difficult to
anticipate in advance, but is open to judgement in hindsight.
The risks of self-disclosure might reveal themselves after the
fact. Ucok (2006) identifies five types of self-disclosure;
1. Deliberate
2. Non-deliberate
3. Accidental
4. Inappropriate or counter clinical
5. Initiated by a patients’ deliberate actions
Consider this situation: a nurse posted a photograph. In
it, he or she is asleep during a nightshift in a chair next
to a four-month old infant. This infant died 11 days later
after accidentally being given a fatal dose of strong sodium
chloride by the same nurse. Having experienced the risks of
self-disclosure online, this same nurse posted messages after
the inquest about what had happened and asked friends for
‘luck’ in the inquiry. The day after being allowed back to
work from suspension, the nurse posted: ‘Had a fantastic
day! goin 2 treat myself 2 bottle wine!’ (Balen, 2010;
Daily Mail, 2010). Humour can be hard to interpret when
conveyed in writing. And what you consider as a funny,
harmless anecdote or sarcastic comment may be understood
differently by others. This one event included four types of
disclosure occurred with what appears to have been little
insight or experiential learning after the first, second and
third error of judgment.
‘Innocent’ photographs posted on a WBSN are open
to re-interpretation. For example, photographs of a nurse
flicking a V-sign over a patient during surgery, nurses
eating pizza in a hospital corridor, nurses’ naked bottoms
and a nurse posing while cleaning a pool of blood off
812
the floor were all presented as evidence of negligence in
the popular press about a hospital fighting a clostridium
difficile outbreak (Cohen, 2009; Dolan, 2010). It is worth
remembering that status and interest in online data changes
over time.
Online professionalism and the privacy illusion
Individuals believe actions online are private (Greysen et al,
2010). Disassociation or privacy paradox around perceived
anonymity of the internet is problematic. There is an
ongoing need for online professionalism, even when ‘off the
clock’. Nurses need to be aware of a constant, professional
presence. They cannot afford to think that it does not
matter what they do in their personal, online time. This is a
dangerous disconnect.
Privacy is not just about hiding things but also self–
possession, autonomy, and integrity (Sheets, 2001). It is also
people’s right to control what details about their lives remain
unknown ‘outside’. WBSNs provide what are misconstrued
to be ‘private spaces’. In reality. however, these are public or
‘nested utopic’ spaces (Bassett and O’Riordan, 2002). For
example, a lack of awareness led to the suspension of nurses;
they shared photographs of patients undergoing surgery
(Mackinnon, 2010; Pullin, 2010) and caused offence by
commenting on a WBSN that they had been ‘messing about
with dead bodies’ (Cooksey, 2010).
This illusion of privacy creates boundary problems. Nurse
fraternities probably do not expect ‘external others’ to use
their pledging photographs as evidence to reprimand their
behaviour. Unprofessional content and behaviour also led
to the suspension of staff who were playing the ‘lying down
game’ where they are photographed lying prone, arms by
their sides, in unusual places such as ward floors, gurneys
and air ambulance helipads. In another instance, a nurse
was reprimanded after posting a picture of herself at work,
topless, and another (clothed this time) with an identifiable
patient in the background (Britten, 2008).
WBSN exchanges between friends have now become a
way for trusts, universities and others to monitor behaviour
(Brown, 2008). Personal data about individuals are collected,
processed, stored and retrieved without their knowledge or
consent. This threatens their information security or right
to determine what information about themselves they want
shared. In reality, much of the erosion of individual privacy
occurs with the consent of the individual as they have
voluntarily posted information about themselves (Greysen et
al, 2010). Such information is then available to ‘data miners’
including future employers. According to a study conducted
by Paton (2007), 22% of 31  000 employers surveyed said
they search WBSN to screen candidates despite lobbying
antagonists. One third of those said they found information
that eliminated candidates from consideration. Figure 3
summarizes the top 10 areas of concern for potential
employers (Ceridian Corporation, 2010).
While students are notorious for antics during university,
the use of WBSNs make it ‘viral’, publicizing material that can
negatively impact an individual’s educational, employment,
financial and personal security. Although some of the
incidents identified in online surveys, such as photographs
British Journal of Nursing, 2011, Vol 20, No 13

1. Information about alcohol or drug use (41%)
2. Inappropriate photos or information (40%)
3. Poor communication skills (29%)
4. Bad-mouthing of former employers or fellow employees (28%)
5. Inaccurate qualifications (27%)
6. Unprofessional screen names (22%)
7. Notes showing links to criminal behavior (21%)
8. Confidential information about past employers (19%)
9. Prejudiced language, links, activities (15%)
10. Negative statements regarding the profession (12%)
Figure 3. Top 10 areas of concern employers found on social networking sites
depicting intoxication and sexually suggestive material,
appear to be clear-cut lapses in professionalism, others fall
into more ambiguous categories (Berry, 2007; Greenwood,
2009). Such behaviour may serve important coping and
stress-release functions but once disseminated, carries the
potential for significant public impact (Coutu, 2007).
Hempel and Lehman (2005) suggest that new graduates
who have grown up online often do not differentiate
between personal and professional. This can lead to them
unwittingly jeopardizing their careers. Instruction on how
to elect privacy settings can result in an 80% decrease in
publicly accessible accounts (Foster, 2007).
Free speech and the right to privacy (or lack
thereof) on the internet
Offensive comments and jokes, sharing information about
unprofessional activities involving alcohol or drugs, and
joining or creating groups that might be considered
derogatory or prejudiced can cause problems. Although
online groups or web-rings may seem innocuous, others
may not always treat these groups with the same humour.
Patients’ searches for information about their health
professionals and vice versa may vary from normal curiosity
or due diligence to a thorough or even intrusive search.
They may pay for online services to gather information;
this is known as ‘cyber-stalking’ (Zur, 2010). Patients can
also access WBSN sites in order to strike up inappropriate
relationships. This threatens the nurse-patient relationship
and confidentiality is breached (Behnke, 2008). It is
important to explain to patients that WBSNs are not
an appropriate channel for the therapeutic relationship.
Additionally, it is inappropriate to post patients’ or colleagues’
names, images, or any other identifying details on blogs or
personal webpages without first obtaining permission.
Always respect privacy and safeguard confidential and
proprietary information (NMC, 2009b).
Many individuals are unaware of how easily accessible
and durable their online information is despite the most
stringent privacy settings. Deleting information is not sure-
fire protection. It is almost certainly still stored somewhere
in cyberspace, and theoretically permanently accessible
(Thomas et al, 2001). Nurses must consciously manage their
online images by avoiding putting anything online that they
do not want certain people to see. WBSN actions leave a
digital footprint that can have a negative impact; online
behaviour passed off by some as ‘exuberance’ may be seen in
814
a less favourable light by others. Nurses must also consider
whether their online activities violate NMC regulations or
hospital trust policies relating to online behaviour, as this
could form the basis for disciplinary action (NMC, 2009b).
Entering the grey zone
Casual privacy settings have caused nurses to overlook
signs that they are crossing PBs. This has been identified
as a particular risk in home healthcare and long-term care
settings. For example, in cancer care it might be common
practice to receive emails from patients or their families
during their regular work hours (Avery and Baker, 2002).
When this leads to out-of-hours email correspondence, it
could arguably interfere with the patient/family’s ability to
develop independence. Equally, in intervention-related chat
rooms such as smoking cessation programmes, caution is
required, as the parameters of such health settings are blurred
(Bean and Eisenberg, 2006). The limits of the therapeutic
nurse-patient relationship in such settings must be openly
negotiated and agreed upon (Wilson and Greenhill, 2004).
Often, boundary crossings start with good intentions.
Accepting e-friendship with a former patient or from their
grateful family members might not seem like a big deal. But
what if this sets a precedent? Online boundary crossings
can be a slippery slope. Accepting that first invite could
make it easier to accept invites in the future. The idea that
because nothing went wrong, everything is all right is both
seductive and dangerous. Individuals flirt with the boundaries
of danger all the time; it is one way of discovering where
boundaries are (Wright, 2006). But repeated exposure to
potential hazards without obvious adverse consequences
leads to a numbing of the sense that a boundary has been
crossed, called ‘normalization of deviance’ (Reamer, 2001).
Repeated trespasses without visible consequences lead people
to embrace substandard practices as normal and boundary
crossing as acceptable. Thus, individuals come to behave in
ways that are more risky than they realize or would desire
(Browne and Russell, 2005). Accidents in such a climate are
not aberrant events but rather, the normal outcomes of an
individual’s learnt behaviour.
The internet blurs professional boundaries and technology
raises different ways in which boundary violations can occur:
■■ Difficulty in applying nursing professionalism to WBSNs
■■ WBSNs give the illusion of anonymity, encouraging many
to do or say things they would never do in person
■■ An online slip can be far reaching, magnified or distorted
as it gets forwarded and commented on.
Modern digital technologies have raised many complex
clinical, ethical and legal issues. One of the more potent
questions is whether it is acceptable for nurses to Google
their clients and if so, should they seek consent? Are we
violating patient trust if we start searching for them online?
Recommendations: be an online-savvy
practitioner
Adopt a proactive approach to controlling information
online. Establish clear professional boundaries about who
you connect with, and be judicious in disclosing personal
details. Be aware of privacy settings. Many sites offer control
British Journal of Nursing, 2011, Vol 20, No 13

Web-based social networks (WBSNs) offer resources to nurses but have also introduced hazards to nursing professionalism
to members regarding how much information they make
available to the public. Be discriminative and restrict your
privacy settings, but do not rely on that alone. Privacy setting
options can be changed by site owners without your prior
knowledge (Facebook, 2010). In this case, aspects of your
profile you have restricted may suddenly be available for all
to see.
Some online information is not under your control.
Friends can ‘tag’ pictures of someone on Facebook and
although options to ‘untag’ do exist, sometimes there is a time
lapse between the posting of a picture and the ‘un-tagging’
of the photo by the individual. Thus, it is impossible to say
how many people have already viewed the picture. This year
I cycled in a charity race and a friend took a picture of me
crossing the finish line for the website of my local cycling
club. When students and patients Google me, they not only
get my professional credentials, but also a photograph of a
dishevelled me in sweaty cycling shorts.This is not necessarily
a bad thing. Still, it highlights the blurred line between
professional and private spheres and raises important ethical
dilemmas for the nursing professional that have no clear-cut
solutions.
As we tread through the web, we must be aware that
we leave a visible footprint and that our actions reflect the
nursing profession at large. Before you publish anything
to a WBSN site, take a moment to reflect. Review your
submission using this simple PCA test:
Pause and process (recognize potential for boundary crossings)
Choices (evaluate the situation and options)
Act accountably (professional conduct)
British Journal of Nursing, 2011, Vol 20, No 13
TECHNOLOGY
geotrac/iStockphoto.com
If unsure, check with a colleague or supervisor. Managers
have a role to play in encouraging an environment where
these issues are discussed openly and nurses are supported
and helped by colleagues rather than criticized. Discussing
boundary issues can be part of an orientation programme in
professional development or the topic of clinical supervision
or in-service education. Nurses can use these avenues to
explore their relationships with patients and if a problem is
suspected, the manager can intervene immediately.
The professionalism curriculum in pre-registration
education should include a digital media component,
with instruction on managing the ‘digital footprint.’ There
are no overarching guidelines for nurses that define (un)
professional online behaviour. However, in the wake of
the above media articles, many trusts and universities are
drafting policies. Nevertheless, defining appropriate WBSN
conduct will be challenging regardless of policy guidance.
Trusts and universities are in the position to exemplify
online professionalism by using consensus-oriented dialogue
involving staff, students, patients, and educators to develop
standards for social media that reflect the positive values of
the nursing profession.
Finally, be your own ‘data miner’; periodically search
yourself, as others’ postings can also reflect poorly on you.
Enter your name into a search engine and see what surfaces.
Remove unprofessional posts and monitor your profile
going forward. Check the photographs in which you are
‘tagged’. Ensure they are appropriate, un-tag yourself from
any embarrassing or unprofessional photographs or even skip
tagging photographs altogether. Be vigilant about checking
815
 others’ posts for offensive or otherwise inappropriate elements
and choose your ‘friends’ carefully.
Use your WBSN proactively, and remember:
1. You have no control over what is forwarded by others
2. What is on the web can live forever.
Conclusion
WBSN sites have brought new hazards to nursing
professionalism. PBs must be a priority. When nurses are
clear about their roles, their judgment is less likely to become
clouded. This will allow them to deliver the best care and
make objective clinical decisions.
While WBSNs are formally public, there is a need to
respect conventions of privacy. Be especially sensitive to
context as this generates a unique set of ethical issues that
make it more difficult to gauge what is appropriate. Privacy
online is closely related to how the internet is governed
and there are challenges in devising a code of practice in
a global context. Data can be reconceptualized in new
settings by others. Our perceptions and regulations regarding
professional behaviour must continually evolve to encompass
these new and changing forms of media. BJN
Conflict of Interest: None
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Key points
n The nursing profession requires that you wear the mantel of
professionalism at all times - your online presence is no exception
n Anything you post online is public and visible to anyone
n Protect the rights of others - do not publish patient information
n Be mindful of your audience and communicate with sensitivity
n Do not add patients as ‘friends’ on social networking sites
n Stop, think, and if necessary consult before posting online
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