Social networking in nursing education: integrative literature review

Abstract Objective: to identify the use of social networking in nursing education. Method: integrative literature review in the databases: LILACS, IBECS, Cochrane, BDENF, SciELO, CINAHL, Scopus, PubMed, CAPES Periodicals Portal and Web of Science, using the descriptors: social networking and nursing education and the keywords: social networking sites and nursing education, carried out in April 2015. Results: of the 489 articles found, only 14 met the inclusion and exclusion criteria. Most studies were published after 2013 (57%), originating from the United States and United Kingdom (77.8%). It was observed the use of social networking among nursing students, postgraduate students, mentors and nurses, in undergraduate programmes, hybrid education (blended-learning) and in interprofessional education. The social networking sites used in the teaching and learning process were Facebook (42.8%), Ning (28.5%), Twitter (21.4%) and MySpace (7.1%), by means of audios, videos, quizzes, animations, forums, guidance, support, discussions and research group. Conclusion: few experiences of the use of social networking in nursing education were found and their contributions show the numerous benefits and difficulties faced, providing resourses for the improvement and revaluation of their use in the teaching and learning process.


Introduction
Web-based social networking are activities resulting in connections and interactions between individuals and groups using a wide variety of tools. These tools include email, blogs, instant messaging, text messages and posts as well as programs that enable digital information sharing in video, audio or text format. Social networking websites integrate these tools in easy to handle formats and allow users to determine how and with whom they will share their information (1) .
The increase in the use of social networking, evidently, has become a common phenomenon in recent years and generated great impact on the development of forms of interaction and socialization among students (2) .
It is observed that students spend much of their free time in online social networking sites, which represents a great opportunity for educators co-opt their use for academic purposes (3) .
In this way, social networking represents an attractive tool for the educational field, because the students are thoroughly familiar with them and willing to establish more fluid communication with the aim to exchange knowledge, information and ideas (4) .
The educational use of social networking is growing among academics as a powerful tools for teaching and learning (5) . In education, the use of social networking enables the publication and information sharing, selflearning, teamwork, feedback and contact with experts (6) ; In adittion, its contributions include the interaction, collaboration, active participation, information, resource allocation and support in educational activities (7) .
Teachers have been engaged in using technology to make learning more personalized, interactive and dynamic, making it easier for students to work with audio, video, interactive games, and more recently, with blogs and social networking (3) .
In short, social networking can be a perfect tool for learning, however, despite the increase in their use, only few students use them for school purposes (6) , highlighting the need to better exploit the potential use of the social networking in higher education (8) .
Having knowledge of the possibilities of the use of social networking in teaching and taking into account the panorama of healthcare education, has social networking technology been used in nursing education?
That was the guiding question of this study, with the purpose of knowing the possibilities, ways, successes and failures of their use in this area of study.

Objectives
To identify the use of social networking in nursing education.

Method
The integrative literature review was the research method used to achieve the objective of this study, since it has as an advantage the possibility of synthesis and definition of concepts, review of theories and evidences, and analysis of methodological problems on a particular subject (9) .
The six steps followed to elaborate the integrative review were: definition of the research subject, establishment of the inclusion and exclusion criteria for the literature search, definition of the information to be extracted from the studies, evaluation of the studies included, interpretation of results and data synthesis (10) .
The inclusion criteria for this review were the studies published throughout the period allowed by the selected databases, aiming at including the largest possible number of articles, taking into consideration the contemporaneity of the subject studied.
According to the exclusion criteria, it was removed studies addressing the use of social networking with other approaches, such as: Aiming at analyzing any publication related to the theme and in order to expand the study sample, the keywords "social networking sites" and "nursing education" were also used as search strategy, with the main question and the inclusion and exclusion criteria previously established as guidelines to maintain the consistency in the search for articles and avoid possible bias.
In April 2015, therefore, a search using the descriptors and a second research using the keywords were carried out in all databases (Table 1).    Articles found n=25 Articles of the final sample n=14 Kakushi LE, Évora YDM.
The instrument developed and validated by Ursi and Galvão (11) , for the collection and analysis of articles in an integrative literature review, was adapted and used in this stage of the study (Figure 2), comprising the  Figure 2 -Instrument adapted for collection and synthesis of data (11) . Ribeirão Preto, SP, Brazil, 2015 In this integrative review of the 489 articles found, 14 articles met the inclusion and exclusion criteria and composed the sample, as shown in Figure 3.

Article Title
Year Authors Intervention studied Results

Recommendations/ Conclusions
Nursing Education 2.0: Poke Me. Where's Your Face in Space (12)

Recommendations/ Conclusions
The use of Facebook for online discussions among distance learners (16) 2010 Lim T Ismail JT Description of the use of Facebook as a platform for academic discussions at a distance, used in the hybrid education (blended-learning) in three courses in the Open University Malaysia: learning skills in an open distance learning course, Law and Renal Nursing The results show that interactions via Facebook were more frequent compared to the use of the forum and indicate that Facebook has the potential to be used in online academic discussions, but the quantity and quality of interactions depend upon the time, themes and teacher Further research must be conducted about the scope, level and intensity desired in the discussions using Facebook, as well as investigations concerning the immersion of students in online discussions Critical care training: using Twitter as a teaching tool (17) 2011 Mistry V Exploitation of Twitter as a teaching tool at the University of Glamorgan, with nursing students. It was used at two different times, in a synchronous time in the classroom and in an asynchronous time Twitter can be used as a tool in education, involving students in the refletion and clinical decision making. It allowed the connection between students, access to external resources, improved learning, supported the use of other means such as access to videos, providing opportunity for reflection, flexibility, collaboration and feedback. In the asynchronous time, the discussions were difficult to follow due to the lack of balance on the presence of the teachers, and in the synchronous time, it was also challenging for teachers, because students were not able to follow the discussions The limitation of 140 characters on Twitter was perceived as something restrictive by the participants, who had no space and time constraints, but should have the ability to write little. In addition, only few participants had a Twitter account before the project, and most of them faced difficulty in creating an account. Students were not identified in the Twitter accounts and were advised to use names of bones and organs, thereby protecting their identities, but the group was not impressed with the anonymity and expressed their wish to use Facebook An Interprofessional Diabetes Experience to Improve Pharmacy and Nursing Students' Competency in Collaborative Practice (18)

2013
Pittenger AL Westberg S Rowan M Schweiss S Improvement of the collaborative practice among students of nursing and pharmacy at the University of Minnesota, participating in a course of diabetes management through a social networking called Ning It was verified the feasibility and effectiveness of the integration of the interprofessional education, and most students showed interest in learning more about diabetes management from the perspective of both professions, in order to optimize patient care. It also led to a better understanding of the role of another profession and their own profession Content and interprofessional activities can be effectively integrated in a course and in remote campuses. One of the weaknesses reported was the need of using Ning along with Moodle (two different spaces) The Use of Social Networking to Improve the Quality of Interprofessional Education (19) 2013 Pittenger AL Assessment of the feasibility and effectiveness of using an online social networking platform (Ning) in interprofessional education at the University of Minnesota. Three groups of six students were formed, with a student of medicine, nursing, dentistry, pharmacy, veterinary medicine and public health in each group. Each group used a different collaborative educational model. The first group was only aided regarding to the overall project goals.
In the second group the teacher promoted the group discussions and resources, but did not direct the experience. In the third group the teacher facilitated all topics of the discussion, controlled the flow of interaction and mediated the whole process The first group was not successful in the interpersonal collaboration. In the second group there was greater participation and interaction between students, they had ideas and agreed or disagreed with the other members, besides discussing other topics off the programming such as travels and diverse experiences. In the third group, under the direction of the teachers, the context became very formal with posts assigned mainly to the activity. As a result, the second group was the one with greater interaction, discussion and collaboration and emotion exchange. Most students evaluated the interprofessional education experience as positive and effective A less expensive way of interprofessional education, with the possibility of implementing the interprofessional education on a large scale and in long term, within the education programme of the professions Kakushi LE, Évora YDM.

Recommendations/ Conclusions
Nursing students and Ning: using social networking to teach public health/community nursing in 11 baccalaureate nursing programs (20)  Implementation of Twitter in a nursing computer course at postgraduate level to facilitate an online course. The management of the content will be performed using the CMS system, videos will be accessed by YouTube and the discussions will be supplemented by the use of Twitter The research waits for the approval and the data will still be collected Regarding the studies that addressed other approaches on the use of social networking with nursing students, it was observed that two described social networking as tools to be used in nursing education, a study reported the benefits of using social networking

Discussion
Social networking can provide many opportunities to innovate the teaching and learning process and lead to a reflection on the choice of the methods for assessment of the use of these tools (23)(24) . However, attention should be paid to the characteristics of each social network and consider the purposes of their use, whether for carrying out discussions, rapid communications, guidance on a job or project, resolution of doubts, or interaction with students, and thus, the educators need to know their features to associate them with their objectives (21) .
It is important to highlight that some studies were conducted in order to provide to students freedom to choose the way of interaction, providing, along with social networking (Facebook, Twitter and Ning), other communication platforms such as Moodle, blogs and forums. Moreover, students gave priority to the access through social network, in relation to the other methods already known in the academic environment (15)(16)18,22) .
In addition, it was observed that not all students had, previously, an account in social networking (17,24) , which proved to be a limiting factor in the studies, showing the need to consider the familiarity of users with the virtual environment (20) . This familiarity facilitates the user navigation and makes communication so natural that students feel less intimidated to ask any question to the teacher, via social network, compared to sending an e-mail (24) , which demonstrates the presence of a horizontal interaction. Another important aspect is the immersion of students in virtual discussions (16) , highlighting that social networking has the ability to break down the barrier of intimidation, shyness and shame that many students present face to face with the teacher and other colleagues.
It is emphasized the need and importance of the presence of the teacher, both in the synchronous or asynchronous moments, in the use of social networking (17) , since he must realize the needs of students and retake or rearrange strategies in order to assist students in this process. The virtual presence of the teacher is as important as knowing how to manage the form of control of the activities in that environment (19) , allowing freedom of expression of participants in relation to issues beyond the school contents, thus, avoiding to make it a traditional teaching environment.
Other considerations were addressed in the studies analyzed, such as the importance of safety and ethics in the use of social networking (12) . In this sense, a study established the anonymity of the participants, creating imaginary identities, however, the students reported that they would like to have worked with another social network (Facebook) (17) , making clear the importance and the need for people to identify themselves and be identified in a virtual environment.
The types of interaction were used in various ways, with the students, between students, between students and former students, between students of different professions, between students and teachers, between students and experts, between students and professionals, with other audience, showing the possibilty to eliminate the barriers of time and space (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) . It is also a less expensive and financially viable process of teaching and learning (13,19,23) , considering the gratuity and freedom of access to social networking.
The benefits of using various social networking in nursing education are immense, both for the students and educators, which includes the interaction, integration and connection among students, socialization with teachers, work in network, discussions, social support, reflection and sharing their own learning and experience, possibility of interprofessional education and achievement of an active, interactive and a reflective learning (13)(14)(15)(16)(17)19) .
Besides allowing interaction with a wider audience, social networking helps students to explore their professional identity, enhancing their social and cognitive skills (21) . It allows a deeper approach, increases the time used for learning, supports the development and social learning (21,24) . It can also be used in research groups and as teaching tools, bringing changes in the dynamics of the learning process (12,22) .
Social networking is a subject of study that is still beginning to gain space and the analysis of the articles can also identify the difficulties encountered in the use of each social network (Facebook, Twitter and Ning) (17,(20)(21) , and its implementation was observed in undergraduate and hybrid (blended) programmes and in interprofessional education, involving students, mentors and nurses (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) .
The recommendations and gaps of the studies show that more research must still be carried out to better understand the use of social networking by students and understand their immersion in online discussions groups (16) , as well as the safe use of social networking as teaching tools (12) and the teacher's autonomy in using them (16,21) , demonstrating the need to deepen the assessments of their effectiveness for achieving a meaningful learning (23) .
The limitation of this study is related to the small number of international publications found and absence of national publications, which may be related to the keywords used. The social media descriptor, defined in MeSH as a platform that offers the ability and tools to create and publish information accessed through the Internet, was not used in this study because of the lack Kakushi LE, Évora YDM.
of articles employing this descriptor in the searches carried out.

Conclusion
The