Patients, Professionals and Social Media – Where are the boundaries?

I was taking part in a nursing debate on Twitter yesterday evening, and the subject came around to boundaries, and nurses who had sexual relationships with their patients or their relatives. I was actually quite shocked when two students (one a student nurse, the other on an access course for social work) who took the view that this would be okay “so long as they’re in love”. When I remonstrated that it’s simply not allowed, I got replies like this.

“but we are human and can reflect and do it in a way that won’t harm!”

“yes I agree if you fall in love then you fall in love sometimes it happens”

“I’m going by feelings not a rule book!”

and most worrying of all…

“my best friends parents were formally teacher and pupil!Been together 30 yrs only just split up”

The person later confirmed that they had been teacher and pupil when the relationship started. Not only unethical but also illegal.

Despite the stereotypes about nurses romancing their patients (though how anyone can feel romantic after 8 hours of running around a hectic medical ward is beyond me) this is a strict no-no and is specifically banned by the Nursing and Midwifery Council Code. If it’s a current patient, their carer or relative then it’s always inappropriate. If it’s a former patient then it’s “often” inappropriate, though the NMC seems a little hazy on what defines “often”. I presume it would depend on things like how long ago they were a patient, whether they’re a vulnerable person, and so on.

I hope those two students wise up before they qualify.

Okay, we’re talking there about very clear and obvious boundary violations – obvious to all but the occasional numpty student, anyway. But what about in social media, where boundaries can be ill-defined?

I’ve been using social media for some years now to talk about mental health issues. Interestingly, as the years have gone on, the regulators have become more and more detailed in their guidance with regard to social media. The first mention they made of it that I recall was an article in the NMC News (gratifyingly, they recommended my then website, the now-defunct Mental Nurse, as an example of good practice.) Then actual guidance appeared, and this guidance got longer over time. A couple of years ago my NHS trust brought out a trust policy for social networking sites, which all staff had to read and sign.

Although my views have evolved to a degree as the guidance evolved, much of this guidance is actually fairly basic common sense. Don’t use social networking sites to breach confidentiality or slag off your colleagues. Don’t add your patients on Facebook. Don’t bring your profession into disrepute.

There’s a reason why all this guidance has developed – professionals have got into trouble because of social media. Again, a lot of these incidents have been what you’d expect. People forming inappropriate relationships through Facebook, or tweeting stuff that breaching confidentiality. There’s also been some odd ones. For example the doctors and nurses who got disciplined for posting pics on Facebook of themselves playing a lying down game while at work. There was also a recent case where a clinical scientist reported a doctor to the GMC for peddling dubious therapies, and she counter-complained about him to the Health Professions Council for making “derogatory and/or misleading comments” about her on the Bad Science forum. The HPC (possibly a tad harshly) decided that this was misconduct and sanctioned him. However, there’s some signs the HPC weren’t impressed by her complaint, as “derogatory and/or misleading comments” got amended to simply “derogatory comments”, and they imposed a two-year caution order, the lowest possible form of sanction. Basically a slap on the wrists and told not to do it again.

Hmmm, maybe I shouldn’t have called those students numpties.

In among all these pitfalls, it’s important to recognise that social media can be a force for good. I and other professionals have used this site and others to talk to people about mental health issues, many of whom are mental health patients. I don’t think that’s wrong or unethical. If I were expected not to speak to someone just because they have a mental health condition, then I’d have to actively avoid one in four of the population. At the risk of stating the obvious, people with mental health problems are not some separate “other”. They’re our friends, colleagues, loved ones, relatives. In some cases they’re mental health professionals as well as patients.

In my view, this absence of difference becomes particularly acute in social media. To quote One in Four Magazine editor Mark Brown, social media “creates a situation for mental health where it is less ‘them and us’ and more ‘just us’. There is something hugely satisfying in seeing someone who offline would be seen as a ‘patient’ discussing online with someone who would be seen as an ‘expert’ and both learning from that experience.”

What I wouldn’t do, of course, is use social media to talk to someone who’s my patient. A patient-professional relationship is one which involves a great deal of power. In talking to someone who’s a patient but not my patient online then that relationship either dissolves or never existed in the first place – hence why it becomes ‘just us’, as Mark says. If it was with one of my patients, then the power can be become magnified or distorted in all kinds of nasty ways.

I’ve never had one of my patients try to add me on Facebook, or start talking to me on a blog. If they did then I’d have to refuse the contact. There’s some fuzzy areas to consider. For example, there was a recent online debate by health professionals about Twitter. Although people tend to mostly read just the Twitter accounts they follow, unless it’s private then (theoretically, at least) your account could potentially be read by everyone in the world. I haven’t made my Twitter account private, but I also wouldn’t follow a patient or former patient on Twitter.

Social media is still very much evolving. My guess is that in future there’ll be more and more opportunities, dilemmas and risks in terms of the way it’s used between professionals and patients.

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About Zarathustra

Trained as a nurse, currently working in Child and Adolescent Mental Health Services (CAMHS). Co-editing the Not So Big Society blog. May possibly be an incorporeal being called Phil Dore. All views expressed are in a personal capacity and not necessarily the views of my employer.

20 Responses to “Patients, Professionals and Social Media – Where are the boundaries?”

  1. A professional who treated me in a UK psychiatric hospital several years ago has tried to add me on facebook a number of times. I have plenty of friends IRL who are mh professionals, but this person was a clinician involved in my inpatient care and I am uncomfortable about their requests for contact. I’ve so far avoided it but a friend I was in hospital with has added the person to their profile, and so I see comments they leave on my friend’s activity. Some of them seem to me to be inappropriate, especially in the context of a very vulnerable service user’s facebook activity – for example they have added very disparaging comments about their current role in mh, their previous ineptitude as a professional, and other aspects of mh services. They also alerted me to their blog in one attempted contact and at the time I looked at it, had said non-identifiable, but disparaging things about service users on there. I’ve unfortunately been subjected to far worse (and illegal) boundary breaches by professionals in my time in mh services, and have reported these where I was able to. But this person’s activity on social media has left me uncertain of what to do. I could report them to the NMC. But given the context of my previous (worse) experiences I feel this is an overreaction and have just ignored their attempts at contact. I am however concerned about the effect of all this on my vulnerable friend. Advice?

    • Was this person involved in your friend’s care as well? If so I recommend screenshotting the discussions and sending them to the NMC.

      • yes, my vulnerable friend (I don’t just say vulnerable because she has mh problems, she does meet the criteria for a vulnerable adult as defined by the various bits of legislation) and I met when we were in hospital, he was involved in both of our care as inpatients over a period of nearly a year. I feel bad NMC-ing him, as I feel I’m messing up someone’s career, but as a professional myself (different field, though we have strict social media guidelines too) if he were a junior who worked for me in my field I’d have the feeling he’s the one messing it up himself. Weird how contextual feelings about these things can be sometimes (perhaps evidence how pervasive power dynamics in mh can be, even after a period of time)?

        • In that context then that is very worrying. And if he’s tried to add you on Facebook too then that suggests it’s part of a pattern of behaviour rather than just a one-off.

          I appreciate the guilt you feel about damaging or possibly even ending his career, but I think it’s also important to think of the safety of your friend who, as you say, is vulnerable. And if he’s done it with your friend and tried to do it with you, then who else has he done it with.

          So, my advice would definitely be to screenshot it and report it.

          • Thanks Z, I appreciate your advice. It’s been on my mind for a few weeks so timely post of yours – thanks.

  2. It’s a dilemma, for sure. My employers have drawn up quite detailed guidelines for acceptable/unacceptable use of social media which basically come down to don’t say or do anything that could bring the company into disrepute and don’t badmouth colleagues or customers. My approach in practice has become I avoid naming or referring to said employers and I don’t fb-friend/tw-follow my work colleagues. Work begins and ends at the clocking in/out machine; social life stays separate; and thankfully I’m not “in love” with any of my colleagues, nor they with me.

  3. oh, for context, I was technically under CAMHS the first time I was treated by this person, and latterly (when over 18) was on a MHA detention, which to me adds an extra dimension of why I personally feel I don’t see them as a potential friend now.

  4. This is a really tricky area. I am a primary school teacher and we recently had to sign a document basically saying we would as a member of staff behave responsibly with regards to social media.
    Now being a teacher in the primary sector you would think I wouldn’t receive requests from pupils with them being underage-think again. Parents have also done so occasionally. Accepting such requests just leaves you wide open. My only problem is I live in Northern Ireland where everyone knows everyone and sometimes you discover a friend of a friend of a friend could be connected.
    I think its only a matter of time before professionals are limited in someway in using these sites. This is also another reason why I’ve never started a blog and if I did in the future it would have to be anonymous.

  5. I used to blog (2004-7), but stopped for professional reasons. In my current role it wouldn’t be appropriate. I think perhaps especially in mental health there is great potential for social media to be used for good, but as you say it has it’s downsides too (I found this paper quite interesting at summarising some issues recently, not so much the boundary issues you raise here, but interesting all the same: http://www.stir.ac.uk/2012/new-media-must-provide-support-for-self-harming-and-suicidal-young-people-says-stirling-researcher/name-27315-en.html ).

  6. *IGNORE* Just testing comments system

  7. The professional-client relationship is an odd one when it comes to mental health, you’re telling them your deepest, darkest secrets and it can be difficult not to get attached. I really bonded with my therapist and it felt weird to just suddenly have to stop seeing her; I wanted to do things like email her and tell her how I was getting on, kind of like a friendship, but I’m aware of the boundaries and think things can get messy if those boundaries are crossed. They’re there for a reason.

  8. Thanks for fixing the oh-so mysterious glitch I appeared to have that prevented me from commenting on TWOM since the last time I commented, had me perplexed, I can tell you!

    Interesting topic and a bit of a favourite of mine!

    I think a fundamental misunderstanding of how social media works is rife within the MH/social care profession. My own use of twitter and blogging has been raised many times, in spite of the fact I use both safely and productively- there is also the side issue for me of both being tools which allow some continuity/continuous narrative which otherwise wouldn’t exist due to dissociation. I’ve had to explain twitter to many professionals and they still treat it with suspicion. Those who understand me and know me well appreciate the role it plays in my life.

    Having said that I can see why some professionals may be concerned by some SUs use of social networking, I encounter people every day who are using social media in a way that’s just not appropriate or safe. I don’t blame social media for this- or SUs, I think that social media is such a big part of our lives in 2012 that it needs to be addressed as a form of interaction just as face-to-face meetings would be. Frontline MH/social care professionals wouldn’t shy away from checking their patients/clients were engaging in face-to-face encounters safely and appropriately but their inherent fear and misunderstanding of social media is crippling in this regard.

    Professionals own use of social media can be concerning at times if I’m honest and those that engage with SUs (even when this engagement is one-sided- as in they just read patients tweets/blogs) via social media are playing a very dangerous game. My own personal experience of this was being assessed under the MHA by someone who had read the blog. The blog is a very small part of who I am, tells only a fraction of the story- this professional liked the blog, told me so and sent me home from hospital at a time where it really would’ve been better not to. I’m not saying the blog was entirely to blame but it was a factor, I was asked “are you Zoe Smith? The one who writes the blog? I love your blog” which was all very nice and good but I had tried to kill myself and had been airlifted to hospital, I wasn’t looking for new fans but appropriate care and treatment. Similarly during all those months of ‘the wrong help’ my psychologist followed the blog and many sessions would be taken up with discussing the content- all the while missing the point that the ‘same person’ who wrote the blog and did it well was sitting in front of her, clearly deteriorating at an alarming pace. Similarly I have been treated by MH professionals who have been reading the blog for some time and they tend to have formed an opinion of me- based on that one tiny fraction of my life.

    I engage with many MH/social care professionals via social networking- but none who have ever been or will be involved in my care. I can’t and don’t want to stop anyone reading the blog but it is a factor taken into account when we do the internal editing!

    I’ve recently started using FB again- I am astonished and horrified at the number of health professionals who clearly have their FB accounts linked to their work email addresses! Due to dissociation, the majority of encounters I have with MH professionals et al have to be written so email is the main form of communication- you’d be surprised at how many pop-up in the “people you may know” column- and how many of those have very open FB profiles.

    I have no interest in the personal lives of those involved in my care, the internet is a very useful tool for checking credentials but I don’t want to see photos of my psychiatrist’s dinner.

    As you correctly point out, it’s all about boundaries and perhaps that’s how it needs to be framed in order to assist the understanding? Take out all the ‘scary’ technical stuff, use a nice analogy “Twitter as a coffee shop” or similar and educate professionals and SUs. It’s something I feel needs to be addressed urgently. Social networking is not going away; people need to learn how to use it and more importantly how not to use it.

  9. The ‘clinical scientist’ you mention has recently declared that, in complaining to the GMC, he was acting in the public interest …

    http://www.guardian.co.uk/science/2012/jun/27/libel-reform-campaigners-public-interest-defence?newsfeed=true

    … and yet down on Goldacre’s forum (aka the turkey farm) the ‘biochemist’ wrote,

    “yep, that’s exactly why I complained actually, to give SM (Dr Sarah Myhill) a bucket load of administration to wade through and increase anxiety levels in her patients, very pleasurable indeed.”

    I think it is reasonable to conclude that the term ‘clinical scientist’ is now the new euphemism for ‘numpty’.

    • I think you may be losing me when you decide to diss the consistently excellent Bad Science.

      Yes, I have read that quote, though I understand the scientist said it sarcastically, not as a literal statement of his intentions.

      I’ve also read the threatening solicitor’s letter that Dr Myhill sent Mr Jones, as well as the response letter explaining why any libel suit by her would be gutted and shredded.

      • Zara said,

        “I think you may be losing me when you decide to diss the consistently excellent Bad Science.”

        LOL! And you’re absolutely serious. Hilarious!

        And Zara then said,

        “Yes, I have read that quote, though I understand the scientist said it sarcastically, not as a literal statement of his intentions.”

        I take it you believe Mr Jones, the ‘clinical scientist’, acted only in the public interest. Is that true?

        • I don’t personally think it’s my job to defend Mr Jones. He seems to have a very good lawyer to do that for him.

          Considerably better than Dr Myhill’s lawyer, it would seem, from that letter exchange that got published.

  10. I really enjoyed this blog post and I think you are spot on when you quote Mark Brown. We have plenty of people working in our NHS Trust who have personal experience of mental health difficulties. Some of those experiences will be long in the past, some in the present, and some will be in the future. It isn’t clear cut in mental health and I’m keen that we avoid the stigmatising them-and-us that often exists both within services and in the general public, whilst always being focused on ensuring professional relationships aren’t compromised and power isn’t exploited. Here’s a blog post where I focus on some similar issues :-) http://digitalmentalhealth.co.uk/wp/?p=146

  11. This link …

    http://www.gaia-health.com/articles201/000243-doc-who-harms-no-one-is-punished-by-gmc-doc-who-killed-can-practice.shtml

    … may provide some balance to the blog post you offered. Who does the GMC really protect? Any thoughts?

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