The phrase ‘social media’ refers to a set of online tools that are designed for and centred around social interaction. According to Bertot, Jaeger and Hansen (2012:30) the intention of these online tools is to enable users to interact with one another and communicate, edit and share content. The content of social media is, therefore, user-generated, and allows large groups of geographically dispersed people to produce valuable resources of information and to access rare expertise (Bertot et al. 2012:30). Boyd and Ellison define social networking sites as:

Web based services that allow users to construct a public or semi-public profile within a bounded system, articulate a list of other users with whom they share a connection, and view their list of connections and those made by others within the system. (2008:211)

Social media include a mixture of Web-based technologies and services such as blogs, microblogs (e.g. Twitter), social video sharing services (e.g. YouTube), text messaging (e.g. Wikis), virtual worlds (e.g. Second Life) and social networking services (e.g. Facebook, MySpace). Information and communication technology, especially via the Internet, continues to play a significant role in shaping current and future social, economic and personal structures (Akoh 2012:3). According to Newbold and Campos (2011:6) healthcare facilities are taking advantage of the reach provided by social media to publish health information and to engage with their customers. Social media now seem to have replaced face to face contact as a means of communication between people (Crawford 2009:532). The Mayo clinic, for example, is one such pioneering healthcare facility that has used social media to allow patients to interact with one another and with health professionals to seek health information (Newbold & Campos 2011:6).

Social media have grown rapidly and have become a social communication tool of choice, especially for young professionals and students, because it is cost-effective and convenient to use (Cain & Fink 2010:1). The convenience of social media allows users to communicate with other people without any limitations of time, place and distance (Schmitt and Lilly 2012:181). The growth, of social media as emerging Internet communication tools, is expected to add value and benefit to existing methods of distance education (Akoh 2012:6). For students in tertiary education institutions, the convenience of social media as communication tools is an advantage because the student does not have to attend class, but can interact with the class colleagues and lecturers from home or at work. Social media can facilitate online learning, allowing flexibility that accommodates adult learning through convenience of time and place (Akoh 2012:9). Social media are viewed as enabling technologies that support blended learning solutions, and can encourage active learning and knowledge construction through peer-to-peer interaction (Holden & Westfall 2010:14). Another purpose that social media can serve is enhancing clinical expertise in healthcare. Expert guidance for learners and facilitators can be sought from specialists throughout the world; this is particularly beneficial for nurses who work in under-resourced areas, because they can send messages or even pictures to people in resourced areas in order to receive the best advice to deliver better patient care (Martinez-Garcia et al. 2013:978).

Whilst social media offer benefits for students and professionals, there are legal and ethical risks associated with their use. The improper and irresponsible use of social media carry significant risks for users, employers and organisations, such as tertiary education institutions and healthcare facilities (National Council of State Boards of Nursing 2013:14). Inappropriate use of social media can potentially damage personal integrity, nurse-patient relationships, nurse-colleague relationships, and current and future employment opportunities (New Zealand Nurses Organisation 2012:2). Privacy and online security risks pose new challenges which institutions, academic bodies and teachers should consider when they develop policies for social media use (Akoh 2012:18). Of late, there have been instances of inappropriate use of social media involving nursing students and other healthcare personnel in America (Chandra & Chatterjee 2011:453).

Despite the availability of information regarding the use of social media by nurses and nursing students in other countries, there is a paucity of research regarding the use of social media by nursing students in South Africa. The goal of this research project is, therefore, to investigate the perceptions of nursing students regarding the responsible use of social media.

As a lecturer at a South African Nursing Education Institution (NEI), the researcher witnessed and had been informed by his colleagues, in this and other NEIs, that misconduct might be taking place regarding social media usage. The researcher also became aware of the indiscriminate use of social media by nursing students when patient-related information (text and pictures) was sent to him, friends, colleagues and other nurse educators. On investigation, he also became aware of pictures – of patients, babies and other patient-related information – that were circulated between students and nurse educators, by students in clinical practice.

Nurses have a legal and ethical duty to maintain the privacy and confidentiality of their patients. The practice of divulging patient information is unethical and illegal because the students were not following the correct procedures when they took and disseminated photos of patients. The privacy and confidentiality of the patients were, thus, not upheld. When patients become aware that their information is being disseminated on social media, they might be reluctant to give full details of their medical conditions to healthcare personnel and might lose confidence in the healthcare system. It is, thus, crucial for the educators as bastions of professionalism, to guide the nursing students whilst protecting the dignity of the patient population.

The suspected improper use of social media by nursing students prompted the researcher to explore this problem further. The aim of this research study was, therefore, to gain a better understanding of students’ perceptions regarding responsible use of social media.

Having identified the problem, the researcher aims to answer the following research questions:

A qualitative, explorative, descriptive and contextual design was used to achieve the objectives of the research study.

The population for this study was the nursing students who were currently studying in the undergraduate nursing (degree) programme at an NEI. This population was comprised of the majority of the nursing students studying in this NEI and included native South African and international students. This was the appropriate population for the study because the researcher could draw conclusions about the perceptions of nursing students regarding the use of social media in the Eastern Cape NEIs.

Non-purposive sampling was used for this research study. The researcher relied entirely on his judgement, as the chosen sample was composed of the elements that contained the characteristics representative or typical attributes of the population, that best serve the purpose of the study (Strydom 2012). To obtain the sample, the following criteria for inclusion were used:

Students in their first, second, third and fourth year of the undergraduate nursing programme were included because the researcher wanted to understand their perceptions regarding the use of social media, and compare the students who have had clinical experience with those who had not had clinical exposure. However, none of the first year undergraduate nursing degree students volunteered to participant in the study.

Gate keepers were approached by means of a formal letter requesting permission to conduct research at the NEI. The aim of this formal letter was to gain permission to conduct the research study. The researcher requested class lists from the NEI where the research study was conducted and used electronic mail (email) to invite students who were registered in the undergraduate nursing degree programme to participate in the research study. The researcher put his contact details on the email to enable students willing to participate to contact him directly. After gaining ethical approval to conduct the research study, arrangements were made with the students who agreed to participate for the interviews to take place, at a time that was suitable for them, and in a setting that was convenient and comfortable. Students who indicated their willingness to participate in the research study were contacted by the researcher, using a contact method chosen by them.

Semi-structured individual interviews were used to collect data. The use of these interviews allowed the researcher to follow an interview schedule, or guide, with basic questions which provided enough flexibility to probe and explore deeper in order to gain clarity on issues that emerged during the course of the interview (Wagner, Kawulich & Garner 2012:134). The researcher used pre-determined questions which only served to guide rather than dictate the interview schedule. The number of participants interviewed for this research study was determined by data saturation, which is a point at which no new themes emerged from the interviews (Wagner et al. 2012:62). The perceptions of nursing students regarding the responsible use of social media were explored. The interviews were recorded electronically with an audio recorder and were transcribed verbatim by the researcher himself.

Data analysis was performed at the same time as data collection. Coding and data analysis were performed according to the eight steps suggested by Tesch (in Cresswell 2009:186). Coding was undertaken by the researcher and by an independent, experienced researcher and coder who holds a doctoral degree. The interviews were transcribed and coded in order to assess the themes that arose. The independent coder was given printed transcripts of each interview and the voice recordings by the researcher. The independent coder was asked to sign a declaration of confidentiality in order to safeguard the rights of the participants. After the coding of themes, the researcher and the independent coder reached a consensus regarding the final themes and sub-themes.

All the participants subscribed to two or more social networking sites for the purpose of communicating and keeping in touch with friends, relatives and colleagues. Facebook seems to be the most popular social networking site used by students, followed by WhatsApp, Twitter, YouTube, LinkedIn, Blackberry Messaging, Mxit, Instagram and Google+. Students mentioned that they use social media for academic purposes both in the classroom and clinical practice environments. All participants used a cellular phone and a personal or university computer to connect to social media. From the interviews two themes emerged:

Each theme and related sub-themes will be briefly elaborated on below and discussed in details in the discussion section.

All research studies must comply with sound ethical practices and standards, and there must be a balance between contributing to science and protecting the rights and dignity of human subjects (Pera and van Tonder 2012:326). Research ethics provide guidelines for responsible conduct. The researcher undertakes to consider and adhere to all ethical principles at every stage of the research process, to safeguard the integrity of the research study, and to protect the research participants. To achieve trustworthiness in this study, the following ethical principles were adhered to:

This research study shows that nursing students enjoy posting patient-related information on social media. Students acknowledged that they are not using social media responsibly. Students shared that they are not aware of any universally acceptable description of responsible use of social media. As a result students felt that this lack of a universally acceptable description of responsible use of social media leads them to have different perceptions of the responsible use of social media.

A number of articles about social media are emphasising the need for development of guidelines for responsible use of social media. Ventola (2014:498) encourages organisations to establish guidelines for appropriate use of social media in order to prevent legal and ethical violations. Policies for social media use should address issues like discrimination, harassment, productivity, use of cellular phones, damage to the organisation's reputation, amongst other issues (Ventola 2014:498). Baker (2013:505) states that there are no guidelines on how to deal with social networking as a first step to establishing policies for social networking.

The information about patients that students post on social media has large amounts of detail that could potentially expose the identity of the patients. The patients’ rights to privacy and confidentiality were, therefore, infringed by students. Chretien et al. (2009:1312) found that students posted information describing clinical experiences with enough detail that patients could potentially be identified. It is common for nurses to share information on social networks to impress other people and to share information about their professional experiences, but this must not take place at the expense of the patients’ right to privacy and confidentiality (Klich-Heartt & Prion 2010:58). In a study on teenage patients regarding privacy and social media, it was found that teenage patients used privacy settings in order to protect their medical information from being accessible to other people (Van Velden & El Emam 2013:20). The decision to protect their medical information from being in the public domain on social media shows how important privacy and confidentiality are to patients.

Students shared that the information they post online include pictures of patients’ genitals which they claim are posted to teach the public about sexually transmitted infections. Posting pictures of a patient's genitals is a direct infringement of the patient's right to dignity. A study exploring the administrative experience with online misconduct found that 60% of allopathic schools in the United States of America (USA) reported incidents of students posting unprofessional content online, including details that violate patient confidentiality, use of discriminatory language and behaviour, sexually explicit material and public displays of intoxication (Go, Klaassen & Chamberlain 2012:296). Whilst the use of social media is a tool for dissemination of health information, such a practice is not acceptable if it compromises the rights of other people to dignity. The teaching method students are proposing can, therefore, not be advocated for.

Students stated that they did not always obtain consent from the relevant stake holders before taking and posting patient information on social media. They also shared that they secretly took pictures of patients and distributed them if they felt that they were likely to experience opposition. Palacios-Gonzalez (2014:1) reports that a doctor was fired from a hospital for publishing information on her Facebook page, involving photographs of patients before a surgical procedure. The doctor did not have the patient's informed consent before taking the photographs and posting them online. Chretien et al. (2010:70) found that students who were advised to be cautious when using social media felt unfairly constrained. Nurses have an obligation in terms of the law to obtain informed consent from the patients before undertaking any clinical investigation, intervention or research (Stellenberg 2013). In order for the patient to give informed consent, the patient must be empowered with full, accurate and honest information regarding the act for which consent is necessary. Berglund (2007:89) states that giving full information also enables the patient to exercise autonomy in decision making.

Students shared that they befriended their patients in order to make them feel at ease before they took and distributed their pictures. Devakumar et al. (2013:4) found that getting consent was perceived to be important when a photo of a child is taken, and the request for consent must be accompanied by sufficient details stating the intended purpose of the photograph. Vasuthevan and Geyer (2013) state that this kind of behaviour amounts to exploitation of patients and a gross violation of human rights, as stated in the Bill of Rights.

Students shared that their colleagues did not play the advocacy role as expected of them. The information they post on social media includes video clips of patients with hallucinations and pictures of babies with congenital abnormalities. ‘Advocacy’ is described by Gilkey and Earp (2009:120) as efforts to support patients and their interests in healthcare. Nurses have a privileged relationship of trust with patients, which is based on the premise that the nurse will always act in the best interests of a patient (Vasuthevan & Geyer 2013). Henry and Molnar (2013:1428) found that second year dental students who were placed in clinical practice for the first time were more likely to engage in unacceptable social networking behaviour, such as taking pictures of patients sitting on dental chairs.

It is clear that students did not only take and distribute pictures, video and audio clips of patients, but recorded and posted video clips of clinical interactions such as psychotherapy sessions and surgical operations in operating theatres. Frankish, Ryan and Harris (2012:182) found that if doctors divulged details of their patients’ confidential medical information, patients would be less likely to reveal important information during a medical consultation. Posting of inappropriate and unprofessional content on social media can damage the reputation of the healthcare workers because potential employers can conduct background checks on the person on social media, and might discover these inappropriate or unprofessional postings (Pillow et al. 2013:28).

The posting of patient information on social media was perceived as competitive, motivating and bringing about a sense of accomplishment for nursing students. Research attributes this kind of behaviour to a lack of policies about acceptable social networking. Kind et al. (2010:3) found that medical schools that have social media policies guide students in understanding what is acceptable and appropriate social networking behaviour.

Students expressed an awareness of the digital footprint and the fact that they were misrepresenting the healthcare facilities and the NEIs:

‘A digital footprint’ is a trail left by an entity's interactions in a digital environment; including their usage of a mobile phone, the Internet and World Wide Web, mobile web and other devices and sensors. (Eke 2012:1)

Students unaccountably believed that they are smart enough to avoid being identified to have posted patient-related information on social media. The information one shares online can be viewed by other people and once the information is online, it remains there forever (Thatcher 2014:1769). Everything one posts online combines and makes one's digital footprint, which can be traced back to the person that posted the information (Ventola 2014:498). Students shared that they used social media to voice their concerns regarding non-availability of resources, such as linen savers at state hospitals. This could potentially jeopardise the relationship between NEIs and clinical facilities in which nursing students are placed for clinical practice.

Students shared that they experienced blurred lines between public and private roles when using social media because they could not differentiate between public and private personas online. Landman et al. (2010:383) found that the dual use of social media, for professional and for personal purposes, causes blurring of lines between one's role as a health professional and one's personal or social role. Cain, Scott and Akers (2009:4) found that students do not have a full understanding of what constitutes private versus public information and the consequences of making private information public. The Nursing and Midwifery Board of Ireland (2013:9) advises nurses to keep a separate personal and professional life online. The more health professionals in training separate their private and professional lives on social media, the less their professional lives will be misinterpreted (Farnan et al. 2013:624).

Students made it clear that their colleagues who were placed at mental health facilities established romantic relationships with their patients and took pictures of themselves and these patients and posted them on social media. Chretien et al. (2009:1311) also found in their research that medical students posted sexually provocative photographs and sexually suggestive comments requesting inappropriate friendships with patients on Facebook. Students are expected to conduct themselves with honour and integrity. Establishing casual relationships with patients is unprofessional and is against the values of the nursing profession.

Maintaining professional boundaries is important in nursing practice as these boundaries allow for a safe personal connection between the healthcare providers and the patients and clients. Gutheil and Simon (in Baca 2011:196) define a boundary as ‘the edge of appropriate or professional behaviour, transgression of which involves the therapist stepping out of the clinical role’. They add the following:

not all boundary crossings are boundary violations … A boundary crossing is a deviation from classical therapeutic activity that is harmless, non-exploitive, and possibly supportive of the therapy itself … A boundary violation is harmful or potentially harmful to the patient and therapy alike because it constitutes exploitation of the patient, using the therapist-patient relationship as its vehicle. (p. 196)

The researcher found that students cannot differentiate between private and professional roles when using social media. According to Von Muhlen and Ohno-Machado (2013:777), the posting of unprofessional information and breaches of patient confidentiality using social media, especially by healthcare workers, is common, and this behaviour sends the wrong message to students who could adopt inappropriate social networking behaviours as acceptable. Thompson et al. (2008:956) found that medical students do not associate negative professional consequences, of their social networking, with their current and future practice of sharing information that could be misinterpreted.

In the light of the findings and the limitations highlighted above, the following recommendations are suggested by the researcher:

This research study provided in-depth understanding of the way in which nursing students use social media. Evidence of the irresponsible use of social media by nursing students was identified. Social media is a communication tool for the future, which has been embraced by billions of people throughout the world including at NEIs. The irresponsible use of social media by nursing students in this research study is not and will never be a reason for calling for the banning of the tool at NEIs, but the guidelines have been put forward to guide the nursing profession to implement social responsibly and accountably. The guidelines developed in this research study can be used by the healthcare facilities as a basis for the development of policies for social media use by their staff.