Social Isolation
Diana Luskin Biordi
Nicholas R. Nicholson
INTRODUCTION
Most of us actively seek human companionship or relationships. The lives of hermits or cloistered, solitary existences are extraordinary because they so vividly remind us that, usually, life is richer for the human contact we share. As valuable as life may be when we engage in a variety of relation-ships, time reserved for solitude is also necessary as we seek rest or contemplative opportunity in “our own space.” The weaving together of indi-vidual possibilities for social engagement or soli-tude develops a certain uniqueness and texture in personal and community relationships. These dis-tinctive personal configurations of engagement and disengagement have consequences for our work and social lives. It is critical, therefore, that healthcare professionals understand the value of social engagement and of solitude.
Isolation: A Working Definition
“Belonging” is a multidimensional social con-struct of relatedness to persons, places, or things, and is fundamental to personality and social well-being (Hill, 2006). If belonging is connectedness, then social isolation is the dis-tancing of an individual, psychologically or physically, or both, from his or her network of desired or needed relationships with other per-sons. Therefore, social isolation is a loss of place within one’s group(s). The isolation may be voluntary or involuntary. In cognitively intact persons, social isolation can be identified as such by the isolate. While some may consider isolation as purely subjective, the various dimensions of isolation argue against this singu-lar position, as will be seen in this chapter.
The literature portrays social isolation as typically accompanied by feelings related to loss or marginality. Apartness or aloneness, often described as solitude, may also be a part of the concept of social isolation, in that it is a distanc-ing from one’s network, but this state may be accompanied by more positive feelings and is often voluntarily initiated by the isolate. Some researchers debate whether apartness should be included in, or distinguished as a separate con-cept from, social isolation. As seen in the litera-ture that follows, social isolation has several definitions and distinctions, dependent upon empirical research and the stance of the observer.
When Is Isolation a Problem?
Social isolation ranges from the voluntary isolate who seeks disengagement from social intercourse for a variety of reasons, to those whose isolation is involuntary or imposed by others. Privacy or being alone, if actively cho-sen, has the potential for enhancing the human
psyche. On the other hand, involuntary social isolation occurs when an individual’s demand for social contacts or communications exceeds the human or situational capability of others. Involuntary isolation is negatively viewed because the outcomes are the dissolution of social exchanges and the support they provide for the individual or their support system(s). Some persons, such as those with cognitive defi-cits, may not understand their involuntary isola-tion, but their parent, spouse, or significant other may indeed understand that involuntary social isolation can have a negative and profound impact on the caregiver and care recipient.
psyche. On the other hand, involuntary social isolation occurs when an individual’s demand for social contacts or communications exceeds the human or situational capability of others. Involuntary isolation is negatively viewed because the outcomes are the dissolution of social exchanges and the support they provide for the individual or their support system(s). Some persons, such as those with cognitive defi-cits, may not understand their involuntary isola-tion, but their parent, spouse, or significant other may indeed understand that involuntary social isolation can have a negative and profound impact on the caregiver and care recipient.
When social isolation is experienced nega-tively by an individual or his or her significant other, it becomes a problem that requires management. In fact, according to much of the literature, only physical functional disability ranks with social isolation in its impact on the client and the client’s social support network (family, friends, fellow workers, and so forth). Therefore, social isolation is one of the two most important aspects of chronic illness to be managed in the plan of care.
Distinctions of Social Isolation
Social isolation is viewed from the perspective of the number, frequency, and quality of con-tacts; the longevity or durability of these contacts; and the negativism attributed to the isolation felt by the individual involved. Social isolation has been the subject of the humanities for hundreds of years. Who has not heard of John Donne’s exclamation, “No man is an island,” or, conversely, the philosophy of exis-tentialism-that humans are ultimately alone? Yet the concept of social isolation has been systematically researched during only the last 50 years. Unlike some existentialists and social sci-entists, healthcare professionals, with their prob-lem-oriented, clinical approach, tend to regard social isolation as negative rather than positive.
The Nature of Isolation
Isolation can occur at four layers of the social concept. The outermost social layer is commu-nity, where one feels integrated or isolated from the larger social structure. Next is the layer of organization (work, schools, churches), fol-lowed by a layer closer to the person, that is, confidantes (friends, family, significant others). Finally, the innermost layer is that of the person, who has the personality, the intellectual ability, or the senses with which to apprehend and inter-pret relationships (Lin, 1986).
In the healthcare literature, the primary focus is on the clinical dyad, so the examination of social isolation tends to be confined to the levels of confidante and person, and extended only to the organization and community for sin-gle clients, one at a time. For the healthcare pro-fessional, the most likely relationships are bound to expectations of individually centered reciprocity, mutuality, caring, and responsibility. On the other hand, health policy literature tends to focus on the reciprocity of community and organizations to populations of individuals, and so it deals with collective social isolation.
At the level of the clinical dyad, four pat-terns of social isolation or interaction have been identified; although these were originally for-mulated with older adults in mind, they can be analogized easily to younger persons by making them age-relative:
Feelings that Reflect Isolation
Social isolation can be characterized by feelings of boredom and marginality or exclusion (Weiss, 1973). Boredom occurs because of the lack of validation of one’s work or daily rou-tines; therefore, these tasks become only busy work. Marginality is the sense of being excluded from desired networks or groups. Other feelings ascribed to social isolation include loneliness, anger, despair, sadness, frustration, or, in some cases, relief.
Description and Characteristics of Social Isolation
The existence of social isolation increases our awareness of the need for humans to associate with each other in an authentic intimate rela-tionship, whether characterized by caring or some other emotion, such as anger. When we speak of social isolation, we think first of the affected person; then we almost immediately consider that individual’s relationships. This chapter will demonstrate that, as a process, social isolation may be a feature in a variety of illnesses and disabilities across the lifecycle.
As an ill person becomes more aware of the constricting social network and declining par-ticipation, he or she may feel sadness, anger, despair, or reduced self-esteem. These emotions factor into a changed social and personal iden-tity, but are also separate issues for the person who is chronically ill. Moreover, depending on their own emotional and physical needs, friends and acquaintances may drop out of a person’s social support system until only the most loyal remain (Tilden & Weinert, 1987). Families, however, are likely to remain in the social network. As the social network reaches its limitations, it may itself become needful of interventions, such as respite care for the par-ents of a child who is chronically ill or support groups for the siblings of children with cancer (Heiney et al., 1990).
Social Isolation versus Similar States of Human Apartness
Social isolation has been treated as a distinct phenomenon, or it has been combined or equated with other states relating to human apartness. The literature is replete with a variety of definitions of social isolation, many of which are interrelated, synonymous, or confused with other distinct but related phenomena.
Social Isolation and Alienation
Social isolation and alienation have been linked together or treated as synonymous in much of the healthcare literature, although these two concepts differ from one another. Alienation encompasses powerlessness, normlessness, iso-lation, self-estrangement, and meaninglessness (Seeman, 1959). Powerlessness refers to the belief held by an individual that one’s own behaviors cannot elicit the results one desires or seeks. In normlessness, the individual has a strong belief that socially unapproved behaviors are necessary to achieve goals. Isolation means the inability to value highly held goals or beliefs that others usually value. Self-estrangement has come to mean the divorce of one’s self from
one’s work or creative possibilities. Finally, meaninglessness is the sense that few signifi-cant predictions about the outcomes of behavior can be made. Thus, one can see that isolation is only one psychological state of alienation. However, authors frequently merge the finer points of one or more of the five dimensions of alienation and call the result isolation.
one’s work or creative possibilities. Finally, meaninglessness is the sense that few signifi-cant predictions about the outcomes of behavior can be made. Thus, one can see that isolation is only one psychological state of alienation. However, authors frequently merge the finer points of one or more of the five dimensions of alienation and call the result isolation.
Social Isolation and Loneliness
Although social isolation is typically viewed today as a deprivation in social contacts, Peplau and Perlman (1986) suggest that it is loneliness, not social isolation, that occurs when an indi-vidual perceives her or his social relationships as not containing the desired quantity or quality of social contacts. In an even more subtle dis-tinction, Hoeffer (1987) found that simply the perception of relative social isolation was more predictive of loneliness than actual isolation. Loneliness has been referred to as an alienation of the self and is sometimes seen as global, gen-eralized, disagreeable, uncomfortable, and more terrible than anxiety (Austin, 1989). Loneliness differs from depression in that in loneliness, one attempts to integrate oneself into new relation-ships, whereas in depression, there is a surren-dering of oneself to the distress (Weiss, 1973).
Nonetheless, loneliness does relate to social isolation. In fact, loneliness is the one concept most invoked when social isolation is consid-ered (Dela Cruz, 1986; Hoeffer, 1987; Mullins & Dugan, 1990; Ryan & Patterson, 1987). However, to use social isolation and loneliness as interchangeable terms can be confusing. To maintain clarity, loneliness should be considered the subjective emotional state of the individual, whereas social isolation is the objective state of deprivation of social contact and content (Bennet, 1980). Therefore, loneliness refers to the psychological state of the individual, whereas social isolation relates to the sociologic status. Although it is true that social isolation might lead to loneliness, loneliness is not, in itself, a necessary condition of social isolation. Both conditions can exist apart from each other.
Peplau and Perlman’s (1986) view of loneli-ness is distinct from the current North American Nursing Diagnosis Association’s (NANDA) nursing diagnosis of social isolation (Carpenito-Moyet, 2010). The NANDA diagnosis extends from the person to include the possibility that a group could also experience a “need or desire for increased involvement with others but is unable to make that contact” (p. 30). Attached to that must be feelings of rejection or aloneness, insecurity in social situations, a desire for more contact with people or lack of meaningful rela-tionships. In the NANDA definition, the model combines psychological feelings with the socio-logic state of isolation, and thus blurs the distinctions so carefully treated by others. As will be demonstrated in this chapter, social iso-lation becomes cause, process, or response, depending on analysis and circumstances. The complex sets of variables that figure into social isolation lend themselves to a variety of assess-ments, diagnoses, and interventions.
Social Isolation and Aloneness
Tightly linked with social isolation is the need for social support, which is the social context or environment that facilitates the survival of human beings (Lin, 1986) by offering social, emotional, and material support needed and received by an individual, especially one who is chronically ill. Although social support litera-ture has focused on the instrumental and mate-rial benefits of support, recent literature on social isolation relates isolation more to the
negative feeling state of aloneness. This feeling is associated with deficits in social support net-works, diminished participation in these net-works or in social relationships, or feelings of rejection or withdrawal.
negative feeling state of aloneness. This feeling is associated with deficits in social support net-works, diminished participation in these net-works or in social relationships, or feelings of rejection or withdrawal.
Social Isolation as a Nursing Diagnosis
Social isolation is defined by NANDA (Carpenito-Moyet, 2010) as a state in which a client or group experiences or perceives a need or desire for increased involvement with others but is unable to make that contact. The NANDA definition has moved beyond the per-son to the possibility that a group experiences social isolation. Yet the defining characteristics are those of a person’s subjective feelings of aloneness. In the current NANDA definition, only one of the major characteristics must be present for the diagnosis, and several minor characteristics are further described. Four major characteristics are noted: insecurity in social situations, a lack of meaningful relation-ships, expressed feelings of aloneness or rejec-tion, and a desire for contact with more people. Of the 12 minor characteristics, most relate to uncommunicativeness, whether in affect or decision making, or expressions of withdraw-als. These are mostly personal characteristics, and although some may be generalizable to a group, not all are.
In the NANDA description, social isola-tion is a cause or contributing factor to loneli-ness, but it is not a response of loneliness. Related to social isolation are several other factors, for example, diseases, social situa-tions, or secondary sequelae to social factors or environments. The current nursing diagno-sis of social isolation, combining as it does both psychological and sociologic states of isolation for both persons and groups, requires systematic empirical bases for refined distinc-tions of isolation. Nurses should continue to build on earlier studies (see Lien-Gieschen, [1993] for a validation study of major identi-fying characteristics of social isolation in the older adult) to empirically identify and distin-guish the truly defining characteristics of social isolation. As it presently stands, the nursing diagnosis of social isolation is rather holistic and resonates strongly with earlier dimensions of the concepts of alienation and loneliness. Carpenito-Moyet (2010) suggests that nurses change diagnoses from social iso-lation to the diagnosis of loneliness or risk for loneliness, which is conceptually a clearer approach. However, the sociologic reality of social isolation remains, and can require inter-vention in its own right.
PROBLEMS AND ISSUES OF SOCIAL ISOLATION
Regardless of how social isolation occurs, the result is that basic needs for authentic intimacy remain unmet. Typically this is perceived as alienating or unpleasant, and the social isolation that occurs can lead to depression, loneliness, or other social and cognitive impairments that then exacerbate the isolation.
Several predisposing reasons for social isolation have been proposed: status-altering physical disabilities or illnesses; frailties asso-ciated with advanced age or developmental delays; personality or neurologic disorders; and environmental constraints, which often refer to physical surroundings but are also interpreted by some to include diminished personal or material resources (Tilden & Weinert, 1987).
The Isolation Process
A typical course of isolation that evolves as an illness or disability becomes more apparent in the change in social network relationships. Friends or families begin to withdraw from the isolated individual or the individual from them. This process may be slow or subtle, as with indi-viduals with arthritis, or it may be rapid, as with the person with AIDS. Unfortunately, the pro-cess of isolation may not be based on accurate or rational information. For example, one woman with cancer reported that, at a party, she was served her drink in a plastic cup while everyone else had glasses (Spiegel, 1990).
Individuals with serious chronic illnesses come to perceive themselves as different from others and outside the mainstream of ordinary life (Williams & Bury, 1989). This perception of being different may be shared by others, who may then reject them, their disability, and their differentness. Part of this sense of being differ-ent can stem from the ongoing demands of the illness. For example, social relationships are interrupted because families and friends cannot adjust the erratic treatment to acceptable social activities. From such real events, or from social perceptions, social isolation can occur, either as a process or as an outcome.
Individuals with chronic illness often face their own mortality more explicitly than do oth-ers. For example, unmarried or younger clients with cancer express a loss of meaning in life, suggested to be due to cancer’s threat to their lives as they grapple with the meaning of life; they may withdraw from their networks or the networks may withdraw from them (Noyes et al., 1990; Weisman & Worden, 1976-1977; Woods, Haberman, & Packard, 1993).
Even if death does not frighten those with chronic illness, it frequently frightens those in their social networks, which leads to guilt, and can lead to strained silences and withdrawal. In the case of individuals with cancer (Burnley, 1992; House, Landis, & Umberson, 1988; Reynolds & Kaplan, 1990) or heart disease (Kaplan et al., 1988; Orth-Gomer, Unden, & Edwards, 1988), social support is significant to their survival. For those who lack this social support, social isolation is not merely a meta-phor for death but can hasten it.
Social Isolation and Stigma
Social isolation may occur as a result of stigma. Many persons will risk anonymity rather than expose themselves to a judgmental audience.
Because chronic illnesses can be stigmatiz-ing, the concern about the possibility of reveal-ing a discredited or discreditable self can slow or paralyze social interaction (see Chapter 3). In a study examining chronic sorrow in HIV-positive patients, stigma created social isolation. Women with children, particularly African American women, were more stigmatized and isolated than gay men because others perceived the women as associated with “dirty sex,” contagion, and moral threat (Lichtenstein, Laska, & Clair, 2002). Therefore, social roles and the robustness of network support affect social isolation.
Individuals with chronic illness and their families grapple with how much information about the diagnosis they should share, with whom, and when (Gallo et al., 1991). If the ill-ness is manageable or reasonably invisible, its presence may be hidden from all but a select few, often for years. Parents of children with chronic illnesses were reported to manage stressful encounters and uncertainty by disguis-ing, withholding, or limiting information to others (Cohen, 1993), an action that may add to limiting their social network. Jessop and Stein
(1985) found that invisible illnesses of children with chronic illness led to greater difficulty in social interactions because of the uncertainty of ambiguity (disagreement about revealing or passing, or what courses of action to take). For example, parents of a child with cystic fibrosis may tell a teacher that the child is taking pills with meals because of a digestive disease (Cohen, 1993).
(1985) found that invisible illnesses of children with chronic illness led to greater difficulty in social interactions because of the uncertainty of ambiguity (disagreement about revealing or passing, or what courses of action to take). For example, parents of a child with cystic fibrosis may tell a teacher that the child is taking pills with meals because of a digestive disease (Cohen, 1993).
As siblings of children with cancer deal with the isolation of their brother or sister, they become vulnerable to being socially isolated themselves (Bendor, 1990). Social isolation not only burdens those with chronic illness, it also extends into family dynamics and requires the healthcare pro-fessional to consider how the family manages. Nurses must explicitly plan for the isolation in families with children who are chronically ill (Tamlyn & Arklie, 1986). Thus, with social isola-tion being a burden for the family, it requires the healthcare professional to consider how the family manages the illness and the isolation.
Where the stigmatized disability is quite obvious, as in the visibility of burn scars or the odor of colitis, the person who is chronically ill might venture only within small circles of under-standing individuals (Gallo et al., 1991). Where employment is possible, it will often be work that does not require many social interactions, such as night work or jobs within protected envi-ronments (sheltered workshops, home offices). Regardless of what serves as reminders of the disability, the disability is incorporated into the isolate’s sense of self; that is, it becomes part of his or her social and personal identity.
Social Isolation and Social Roles
Any weakening or diminishment of relationships or social roles might produce social isolation for individuals or their significant others. Clients who lose family, friends, and associated position and power are inclined to feelings of rejection, worthlessness, and loss of self-esteem (Ravish, 1985). These feelings become magnified by the client’s culture if that culture values community (Litwin & Zoabi, 2003; Siplic & Kadis, 2002). An example of social isolation of both caregiver and care recipient occurred in a situation of a woman whose husband had Alzheimer’s disease. The couple had been confined for more than 2 years in an apartment in a large city, from which her confused husband frequently wandered. Her comment, “I’m not like a wife and not like a sin-gle person either,” reflected their dwindling social network and her loss of wifely privileges but not obligations. This ambiguity is common to many whose spouses are incapacitated. Moreover, after a spouse dies, the widow or widower often grieves as much for the loss of the role of a mar-ried person as for the loss of the spouse.
The loss of social roles can occur as a result of illness or disability, social changes through-out the lifespan (e.g., in school groups, with career moves, or in unaccepting communities), marital dissolution (through death or divorce), or secondary to ostracism incurred by member-ship in a “wrong” group. The loss of social roles and the resultant isolation of the individual have been useful analytic devices in the examination of issues of the aged, the widowed, the physi-cally impaired, or in psychopathology.
The Older Adult and Social Isolation
Older age, with its many losses of physical and psychological health, social roles, mobility, economic status, and physical living arrange-ments, can contribute to decreasing social networks and increasing isolation (Creecy, Berg, & Wright, 1985; Howat, Iredell, Grenade,
Nedwetzky, & Collins, 2004; Ryan & Patterson, 1987; Trout, 1980; Victor et al., 2002). This will become even more of an issue as the number of older adults is expected to increase arithmeti-cally and proportionately in the next 2 decades (Fowles & Greenberg, 2009). Older adults cur-rently make up 12.9% of the overall U.S. popu-lation (Administration on Aging, 2010). The prevalence of social isolation in older adults has been approximated to be at 2-20% (Victor, Scambler, Bond, & Bowling, 2000) and even as high as 35% in assisted-living arrangements (Greaves & Farbus, 2006).
Nedwetzky, & Collins, 2004; Ryan & Patterson, 1987; Trout, 1980; Victor et al., 2002). This will become even more of an issue as the number of older adults is expected to increase arithmeti-cally and proportionately in the next 2 decades (Fowles & Greenberg, 2009). Older adults cur-rently make up 12.9% of the overall U.S. popu-lation (Administration on Aging, 2010). The prevalence of social isolation in older adults has been approximated to be at 2-20% (Victor, Scambler, Bond, & Bowling, 2000) and even as high as 35% in assisted-living arrangements (Greaves & Farbus, 2006).
Social isolation has been linked with functional disability. One definition of func-tional disability is “the degree of difficulty or inability to independently perform basic activ-ities of daily living (ADLs) or other tasks essential for independent living” (Mendes de Leon et al., 2001, p. S179). Social networks may influence the functional disability process by preventing decline or facilitating recovery (Mendes de Leon et al., 1999). Consequently, functional disability may impact social net-works by preventing older adults from seeking engagement with other members. Network size and social interaction are significantly associated with functional disability risk (Mendes de Leon et al., 2001). Older adults who are more socially engaged report less functional disability (OR = 0.84, 95% CI 0.75-0.95) (Mendes de Leon, Glass, & Berkman, 2003), and those who are a strong part of a social network have been found to have reduced risk of functional disability (p < 0.01) (Mendes de Leon et al., 1999).
Social isolation has been shown to be a seri-ous health risk for older adults (Findlay, 2003), with studies indicating a relationship between all-cause mortality (Ceria et al., 2001), coronary disease (Eng, Rimm, Fitzmaurice, & Kawachi, 2002), and cognitive impairments (Barnes, Mendes de Leon, Wilson, Bienias, & Evans, 2004; Holtzman et al., 2004; Zunzunegui, Alvarado, Del Ser, & Otero, 2003; Beland, Zunzunegui, Alvarado, Otero, & Del Ser, 2005). In a converse finding, older adults with extensive social networks were protected against dementia (Fratiglioni, Wang, Ericsson, Maytan, & Winblad, 2000; Fratiglioni, Paillard-Borg, & Winblad, 2004; Seidler, Bernhardt, Nienhaus, & Frolich, 2003; Wang, Karp, Winblad, & Fratiglioni, 2002). And, as described earlier, although low social engagement may not be a form of social isolation per se, it is a psychologi-cal isolator and thus a risk factor in social isola-tion (Howat et al., 2004). For example, depressive symptoms in older adults were shown to be decreased by social integration (Ramos & Wilmoth, 2003). Isolated older adults were shown to have increased risk for coronary heart disease (Brummett et al., 2001; Eng et al., 2002), and death related to congestive heart failure was predicted by social isolation (Murberg, 2004). Similarly, post-stroke outcomes, for example, additional strokes, myocardial infarction, or death, were predicted by pre-stroke isolation (Boden-Albala, Litwak, Elkind, Rundek, & Sacco, 2005). Isolated women before a diagnosis of breast cancer, when compared with socially integrated women, were found to have a 66% increase in all-cause mortality (Kroenke, Kubzansky, Schernhammer, Holmes, & Kawachi, 2006). Quality of life among breast cancer survivorship is impacted negatively by social isolation (Michael, Berkman, Colditz, Holmes, & Kawachi, 2002). Finally, and perhaps most relevant to health and cost outcomes, socially isolated older adults were found to be four to five times more likely to be re-hospital-ized within a year from their previous hospital-ization (Mistry et al., 2001).
The extent (from local to community and integrated to contained) and nature (positive or negative social relationships) of a social nework (Litwin, 1997; Wenger, Davies, Shahtahmasebi, & Scott, 1996), affect health as well as social isolation (Seeman, 2000; Wenger, 1997). In fact, the quality of the social relationship may have more impact than the number of ties (Pinquart & Sorensen, 2001), which suggests that a few solid relationships may be more beneficial than many ties of poor quality.
CASE STUDY
Thomas is an 85-year-old man who has severe COPD, depression, and Type II diabetes. He currently smokes cigarettes and has smoked for the last 45 years. Thomas is a widower, but he has a live-in unmarried partner named Gretchen who has lived with him in their home for the past 8 years. Gretchen is very needy due to a recent Cerebral Vascular Accident (CVA), which left her with expressive aphasia and incontinence. Tom is a member of the local men’s club and was in charge of fundraising until recently. He had to give up his position because he needed to be at home more to watch over Gretchen. When talking about his home situation, Thomas states, “I hate to give up all the time with my buddies. I’ve been a member for 50 years, but since she can’t tell me she’s wet, I have to check all the time. If I’m not at home, who’s going to check?” Despite the fact that she is a lot of work physically and sometimes her inability to speak is discouraging, Thomas says he loves her company. He states that it is won-derful to have a constant companion even though direct conversations are extremely difficult, but you are unsure if this is really how he feels.
Prior to retirement, Thomas was a certified public accountant who worked for a local office. He enjoyed the interaction with his clients and was described as a very social person with numerous friends. He had made lots of new friends through his skills in bringing in high returns on taxes for his clients. In fact, the best man at his wedding, Frank, initially was his tax client. Frank had bought Thomas a steak dinner to thank him for saving him and his wife lots of money, after which, the two became best friends. The two men and their wives had shared many social occasions, but when Frank died years ago, Thomas became depressed and stopped wanting to go out socially. At that time, Thomas’s wife of 50 years, Frances, had encouraged him to continue to go out and meet new people. He began to get out more and started to feel like his old self, when Frances died suddenly of a myocardial infarction. After her death Thomas refused to be social. He said, “What’s the point of going out and meeting people, if they are just going to die on you? I’d rather stay in.” He was also a man who had gone to church services every week and now doesn’t go anymore; instead he watches the services on TV. Thomas says, “God knows I’m still dedicated, so I don’t need to go out and chat about how great things are with a bunch of busybody church types-especially when things aren’t that great at all.” About a year after his wife Francis died, he met Gretchen in the supermarket, and they have been partners ever since-both are happy to stay in most of the time.
Thomas was functioning at a moderate to high level, but recently had a fall secondary to shortness of breath related to emphysema and an acute syncopal episode. He was hospitalized for the shortness of breath, the mild abrasions from the fall, and to have a neurological work up. His respiratory status returned to baseline with the addition of a new inhaler, his neuro-logical status checked out well and, thankfully, there were no broken bones. Because he is Gretchen’s primary caretaker, her granddaughter flew in from out of town to take care of her until Thomas was released. He was released after 3 days in the hospital with an admission to the local visiting nurses’ agency for an estimated time of 4 weeks of visits.
As you sit in the car, having completed your reading of Thomas’ chart, you wonder how this man turned from a social accountant to someone who has been hospitalized for an injurious fall. Additionally, you wonder about how the many psychosocial factors play into his well-being and the well-being of Gretchen. Thomas has stopped seeing his friends, has stopped attending church, has had a decline in his overall health, has implied he doesn’t really belong anywhere, and, aside from Gretchen, has a lack of fulfilling relationships-all leading to a possible diagno-sis of social isolation. As you walk to the front door with your chart and admission paperwork, you see Thomas through the window silently crying by himself on the porch.
Discussion Questions
1. Given Thomas’s history, identify the factors that put him most at risk for social isolation.
2. When considering nursing interventions for Thomas, what would be the number one health issue to address? In your opinion, is Thomas a social isolate? Why or why not?
3. Do you consider Gretchen, Thomas’s live-in partner, a positive or negative influence on his life? Explain your answer.
Although much of the current research in social isolation with older adults has focused on community-dwelling adults, one growing segment of study is assisted-living arrange-ments, which is one of the fastest growing seg-ments of senior housing (Hawes, Phillips, Rose, Holan, & Sherman, 2003). In assisted-living settings where there are many internal (to the setting) social networks, life satisfac-tion, quality of life, and perception of home were positively reported (Street, Burge, Quadagno, & Barrett, 2007). Assisted living has the potential to focus on health promotion and function maintenance, such as the identifi-cation of social isolation and appropriate inter-ventions (Resnick, 2007).
Strictly speaking, social isolation is not con-fined to a place. The socially isolated are not necessarily homebound or place-bound, although that is typically the case. That being said, how-ever, environments that are removed (such as rural locations) or those not conducive to safety (such as high-crime areas) can contribute to social isolation (Klinenberg, 2001). Social isolation as a
function of location has been demonstrated, par-ticularly for the older adult in urbanized settings, in a number of countries other than the United States (Klinenberg, 2001; Russell & Schofield, 1999). In these cases, elderly individuals cannot leave their homes because of lack of transporta-tion or for fear of assault, so they increasingly iso-late themselves from others. This situation is intensified by distrust, socioeconomic status, or locale, and it is worse if the older adult has a chronic illness compounding their constraints. Vehicular driving cessation may be an eventual reality as one ages. Limited or no driving con-fines activities outside the home (Marottoli et al., 2000) and thus limits interactions with others for the older adult.
function of location has been demonstrated, par-ticularly for the older adult in urbanized settings, in a number of countries other than the United States (Klinenberg, 2001; Russell & Schofield, 1999). In these cases, elderly individuals cannot leave their homes because of lack of transporta-tion or for fear of assault, so they increasingly iso-late themselves from others. This situation is intensified by distrust, socioeconomic status, or locale, and it is worse if the older adult has a chronic illness compounding their constraints. Vehicular driving cessation may be an eventual reality as one ages. Limited or no driving con-fines activities outside the home (Marottoli et al., 2000) and thus limits interactions with others for the older adult.
One objective of planned senior housing is to provide individuals with a ready made social network within a community (Lawton, Kleban, & Carlson, 1973; Lawton, Greenbaum, & Liebowitz, 1980; Lawton, Moss, & Grimes, 1985), although this objective is not always met. The frail elderly are found to be less interactive with more mobile, healthier older adults, possi-bly because healthier older adults have few extra resources to expend on others who may have even fewer resources, or they may have better health and networks that are incongruent with, and less likely to cross, those of the frail elderly (Heumann, 1988).
Nursing home residents with chronic ill-ness or sensory impairments tend to be more isolated than other elderly persons. In England, for instance, those in residential care who are ill or disabled are considered socially dead, impov-erished by the inactive nature of institutionaliza-tion and unable to occupy any positive, valued role in the community (Watson, 1988). Stephens and Bernstein (1984) found that older, sicker residents were more socially isolated than healthier residents. The investigators found that family and longer standing friendships served as better buffers to social isolation than did other residents. Impressionistically, however, the number of research citations about social isola-tion in England and Ireland, as well as in other European countries, seems to have increased since the 1980s and 1990s in contrast to the research in social isolation in the United States. More recent social isolation research in the United States focuses on policy that seems to incorporate the socially isolated individual into more viable social networks.
Social Isolation and Culture
As globalization and sensitivity to U.S. multicul-turalism increases, with its concurrent absorption of multiethnic, multilingual, and multi-religious individuals into yet other cultures, there is an overlap into mainstream healthcare systems. This is especially true of cultural groups that have not assimilated into the dominant culture. Language differences and traditional living arrangements may impede social adaptation. In addition, many immigrants, especially those who are chronically ill, are less able to engage in support networks, given their long working hours, low-paying jobs, lack of health insurance, and changes in family lifestyles and living arrangements. Changes may occur over the second and third generations, but this is less true where the immigrants’ home cul-tures are geographically close, such as Mexican Americans who live along the U.S.-Mexican border, or when reminders of traditions are more visible (Jones, Bond, & Cason, 1998).
An extensive literature review on health care and its relationship with culture demon-strated two overarching issues: 1) the defini-tions of culture are conceptually broad and/or
indistinct, and 2) mainstream health care strug-gles to integrate these multicultural groups with varying degrees of success. When one speaks of “culture,” many concepts are mixed, or even confused (Habayeb, 1995). The dominant white society in the United States and its healthcare system is secular, individualistic, technology-and science-oriented, and tends to be male dom-inated (Borman & Biordi, 1992; Smith, 1996). Other European-based cultures have similar situations. Social isolation must be viewed from the client’s cultural definition of the number, frequency, and quality of contacts, the longevity or durability of these contacts, and the negativ-ism attributed to the isolation felt by the indi-vidual involved.
indistinct, and 2) mainstream health care strug-gles to integrate these multicultural groups with varying degrees of success. When one speaks of “culture,” many concepts are mixed, or even confused (Habayeb, 1995). The dominant white society in the United States and its healthcare system is secular, individualistic, technology-and science-oriented, and tends to be male dom-inated (Borman & Biordi, 1992; Smith, 1996). Other European-based cultures have similar situations. Social isolation must be viewed from the client’s cultural definition of the number, frequency, and quality of contacts, the longevity or durability of these contacts, and the negativ-ism attributed to the isolation felt by the indi-vidual involved.
Studies conducted since 1990 indicate how women, minority groups, the poor, and others have not received the same care as the dominant male Caucasian middle or upper classes (Fiscella et al., 2000). Fortunately, current cul-tural healthcare literature indicates a greater awareness of cultural groups and their values. One factor that may be influencing this change is that since 1990, other healthcare providers, including nurses, psychologists, case managers, and a variety of technical support personnel, have made significant advances in providing higher quality health care to formerly disenfran-chised groups (Biordi, 2000).
Many ethnic and religious groups in the United States value community closeness, fam-ily kinship, geographic proximity, and social communication. They seek acknowledgment of their right to mainstream or alternative care (Cheng, 1997; Helton, 1995; Keller & Stevens, 1997; Kim, 1998; Kreps & Kreps, 1997). The task of attempting to deliver “tailored,” cultur-ally competent care to so many groups is over-whelming and lacks an integrating strategy that appeals across all groups. One can now find a large number of articles targeting mainstream healthcare providers that provide hints, tips, or insights into cultural groups.
Social Components of Social Isolation
Mere numbers of people surrounding someone do not cure negative social isolation; an individ-ual can be socially isolated even in a crowd if one’s significant social network is lost. This situ-ation is true for such groups as those living or working in sheltered-care workshops, residents in long-term care facilities, or people in prisons. What is critical to social isolation is that, because of situations imposed on them, individuals perceive themselves as disconnected from mean-ingful discourse with people important to them.
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