Journal of Gerontological Nursing

Elderly Lonelines and it's Relation to Residential Care

Avie James Rainwater

Abstract

In an attempt to make the two groups as matched as possible, this present study acted on Kasls* suggestion of comparing two residential populations to each other to obtain a more realistic comparison. In turning now to a discussion of the implications found within the data gathered, it is seen that the Kasls' suggested design was beneficial.6

The two facilities that were compared were very similar and dissimilar in important ways. Both facilities charged approximately the same financially; however, group A was in an established neighborhood while group B was located on a frontage road to an interstate. The nurse-to-resident ratio in group B was exactly one-half of that of group A. Group A's facility allowed them to live in apartment-like dwellings, with their own furniture and appointments, while group B offered only semiprivate rooms with a minimum allowance for personal furnishings. All in all, a stark difference was visibly evident between the two facilities.

From the beginning, attention must be brought to the fact that no scientifically validated instrument to measure actual incidence of loneliness was applied to either group. Therefore, the statement of acceptance of the alternate hypothesis comes as a significant amount of statistical difference was found in the areas that were related to, and traditionally indicative of loneliness. The study assumes loneliness is experienced when those emotions associated with loneliness are present. This limitation must be continually considered as all data are reviewed.

Gathering all the data together for the two groups, a composite of the two groups' similarities is easily composed. All of the similarities serve to validate the quality of matching between the two groups because they are things normally expected to be found within the groups. It is the fine distinctions of reactions to loneliness between the two groups, not the lack of these similarities that point to the different levels of loneliness for the two groups.

Both groups experienced loneliness only one to four times per week, and that loneliness lasted only a few hours. Both felt loneliness was worse when they were feeling blue and both felt loneliness was worse during the day. This finding is not surprising when it is considered that, to a person, every subject stated they were easy-to-bed, good sleepers. They all stated they "slept too well" to be bothered with problems at night. Both groups experienced sadness when lonely, but not fear. Neither group felt their friends would look down on them for experiencing loneliness. Interestingly enough, neither group reported they felt their friends cared about them, to any significant degree, when they were experiencing loneliness.

As the statistically significant differences for the two groups are viewed, some interesting and enlightening distinctions become apparent. First of all, in the insufficient nursing facility the care would be poor at all times, thus when a resident was sick there would be no noticeable difference in how they were treated. In essence, if residents have become accustomed to poor care, and feeling physically worse than necessary is a result of that poor care, the impact of illness is not as great. On the other hand if, as in a "good care" facility, the residents do receive good nursing care and feel generally good physically, then the impact of the physical illness would be great (because the variance is greater) and this would easily compound the severity of the illness.

Essentially, we see that group B is kept at a lower than necessary standard of health and functioning. This lower level shows up again in the fact that they have significantly less energy in group A when loneli\ ness does…

a time to be alone is a time sought by most people in an effort to relax and collect the thoughts of life. Truly, the need for this quality experience within today's high-stress society is matched only by the zest with which it is sought. However, whereas chosen aloneness is beneficial, its counterpart of loneliness is one of the most destructive forces within today's society.1 The force of this counterpart is felt particularly hard by society's elderly because of a unique set of circumstances. Simultaneously, the older person is told that he/she should get out and be active to ward off loneliness; and then subtly told that he/she is too old and useless to be involved in anything.

Loneliness, as it applies to the aging, encompasses a dimension that causes the emotion to be felt more deeply. For in a society that is constantly turning to technology, the past skills, knowledge, and values of the elderly are disregarded as obsolete.2 Thus, the loneliness is intensified as the elderly person becomes isolated not just from his/her peers, but from society at large.

The residential home (nursing or retirement) in which the older person lives offers a place where there is still a possibility to commune with others of similar experiences. Society becomes relevant only as it applies to the residential population. Francis and Odell3 found that residents who were over 50 years old were less lonely than the under 50-year-old residents. The reason for this was that they were less attached to society and had less energy invested in the outside world. The over 50 group had found a new society. Typically, this was found in homes that molded the structure of daily life around the resident's needs.

Unfortunately, not all residential facilities seek to foster this positive use of community and friendship among residents. This is not done even though it has been shown that friendship and neighboring do more to eliminate loneliness and worry than family contact does.4 The less than adequate home often elevates the situational secondary loneliness of the new resident by restricting the amount of personal possessions he/she is allowed to bring to "his/ her" new dwelling. Not surprisingly, this was found in homes that "help" the resident fit into the system instead of altering the system to help the resident.3

Figure 1REASONS FOR LONELINESS CHOSEN

Figure 1

REASONS FOR LONELINESS CHOSEN

In short, it seems that the type of residential care the aging person receives can play an important part in the onset of loneliness. In following this possibility it is predicted that there is a significant difference in the amount of loneliness found in residents of "good care" versus "insufficient care" residential facilities. This alternate hypothesis will be studied in hopes of gaining insight into the loneliness of the elderly.

Method

Subjects

Eight females were chosen from two separate residential facilities. The two homes constituted the two groups, A 8c B, each group having four members. All of the women had lived in their respective dwellings for at least one year. All of the subjects, with the exception of one who was never married, were widows. The mean age for group A was 77.75 years, with a range of 71 to 83. Group B held a range of 62 to 76 years, with a mean age of 70.25. The combined population grand mean age was 74 years.

Materials

A list of common "reasons for loneliness" was presented to the subject from which the subject was to choose reasons that applied to them personally (Appendix A). To aid the subject in obtaining the appropriate number of reasons, printed instruction sheets were given to each subject (Appendix B). Questions were asked of the subject regarding each reason for loneliness chosen. These questions and their possible answers are available in Appendix C. A cassette tape recorder was used to record the interviews, and signed consent forms were obtained from each subject.

Procedure

In order to secure the independent variables of a "good care" facility and an "insufficient care" facility, two methods were used. First, the report of an investigative broadcast journalist's expose of nursing home care in Oklahoma was consulted.* A listing of good and insufficient homes and substantiation of these categorizations were secured through personal communication. Secondly, the target homes chosen from this list were verified as to quality status with the Department of Complaints, Oklahoma State Board of Nursing Homes.f With this information, operational definitions were composed for the two groups:

1. Good care-nursing home found in "good standing" rating with the Oklahoma State Board of Nursing Homes; no complaints had been filled with the OSBNH; and no infractions of state regulations were found on improptu visits by investigative reporting team.

2. Insufficient care-nursing home found in "poor standing" rating with OSBNH; at least two formal complaints^: had been filed against the facility with the OSBNH within the last 12 months; and at least two infractions of state regulations were found on impromptu visits by the investigative reporting team.

Admissionn into the homes was granted by the proper authorities, and subject's cooperation was secured previous to the interviews by the activities department of each facility. The interviews were done one-on-one by the experimenter on an informal basis in the subject's room.

The experiment was explained to the subject as to its content and its rationale. A consent form was then presented to the subject and signed consent was obtained. At this point the experimenter presented the subject with a list of reasons for loneliness and the instruction sheet. The instruction sheet was then read to the subject by the experimenter. The instructions asked the subject to choose the five reasons from the list that were most likely to cause them to feel lonely. The next step asked the subject to look over the list again and choose the five reasons that were the least likely to cause them to feel lonely. The final part of the instructions required the subject to list these reasons in a loneliness hierarchy beginning with the reason that was the most likely to cause them to feel lonely, and progressing in a descending manner to the reason that was the least likely to cause them to feel lonely.

When the subject's hierarchy was formed, a series of eleven questions (Appendix C) were asked of the subject in the context of each reason in the subject's hierarchy. The tape recorder was switched on at this point of the interview so each subject's comments could be analyzed later in a correct fashion. Each question required a dichotomous answer, however, in an effort to gain insight into each subject's state of mind, they were asked spontaneous disclosure-seeking questions that were deemed appropriate and necessary by the experimenter.

Using the means values attached to each reason for loneliness, grand means were computed for each group. The similarity of these two means was such that no statistical test for significance was applied.

Each of the eleven questions was looked at as to applicability to statistical treatment. Question nos. two and eleven did not lend themselves to strict statistical analysis, thus only percentages were tabulated. The remaining questions: one, three, four, five, six, seven, eight, nine, and ten were each treated with the test for Significance of Difference Between Two Proportions. Analysis was applied and Z scores were obtained.

Results

Final analysis of the data supported the alternate hypothesis, that there is a significant difference in the amount of loneliness found in residents of "good care" versus "insufficient care" residential facilities.

There was no significant difference between the grand means of reasons for loneliness chosen for the two groups. Both groups chose reasons that produced essentially equal composites as they related to loneliness. The grand mean for group A was 3.1405, and the grand mean for group B was 5.191; a difference of .051. Figure 1 shows the range of the reasons for loneliness (Appendix A) chosen, and the frequency with which these reasons were chosen by the two groups.

As can be seen from the graph, no one reason stands out significantly from the others in the frequency with which it was chosen. Also, when the groups' responses were looked at across their hierarchies and across their "most likely" and "least likely" reasons, significant differences or consistencies were found.

Looking now at the individual question analyses, the frequency of loneliness for the two groups was found to be identical. Both groups reported feeling lonely only one to four times per week with 100%interand intra-group consistency. Question two did not conform to statistical treatment, but the percentages of how long the loneliness episode lasted were found to be exactly similar for the two groups (Table I).

Question three shows no significant difference between the two groups for severity of loneliness experienced in the day as opposed to the night (Table II).

Question four yielded a statistically significant difference in how physical illness related to loneliness for the two groups. Group A (Table III) rated themselves more likely to experience loneliness when feeling physically ill significantly more often than group B.

Question five showed feeling low emotionally ("blue") does not significantly make one group experience loneliness more often than the other. A breakdown of the data can be seen in Table IV.

Question six yielded a statisti cally significant difference in the effect loneliness has on the amount of energy that the two groups feel. The clear division can be seen in Table V.

Table

TABLE IDURATION OF LONELINESS

TABLE I

DURATION OF LONELINESS

Table

TABLE IIDIURNAL AND NOCTURNAL LONELINESS

TABLE II

DIURNAL AND NOCTURNAL LONELINESS

Table

TABLE IIIPHYSICAL ILLNESS AND LIKELIHOOD OF LONELINESS

TABLE III

PHYSICAL ILLNESS AND LIKELIHOOD OF LONELINESS

Table

TABLE IVLOW EMOTIONS AND LIKELIHOOD OF LONELINESS

TABLE IV

LOW EMOTIONS AND LIKELIHOOD OF LONELINESS

Table

TABLE VENERGY LEVEL AND LONELINESS

TABLE V

ENERGY LEVEL AND LONELINESS

APPENDIX C

APPENDIX C

Question seven showed no statistically significant difference in the group's tendencies to feel that their friends would look down on them for feeling lonely. As can be seen in Table VI, both groups felt their friends would not look down on them for feeling lonely.

Question eight revealed group B to be significantly more likely to experience loneliness because they felt they had no control over its onset. This sharp difference is shown in Table VII.

Question nine found group B significantly more likely to experience (b) hopelessness and (c) rejection while feeling lonely. Group A was more likely to feel (d) selfcentered, while there was no difference between the amount of likelihood between the groups to experience (a) sadness or (e) fear. Table VIII shows how the groups compared.

Question ten revealed that group B felt, in a statistically significant manner, that no one cared about them when they experienced loneliness. Group A felt significantly that family and God cared about them when they experienced loneliness. There was no difference in the feeling that friends cared for them. Data analysis can be seen in Table IX.

Table

TABLE VIJUDGMENT OF FRIENDS AND LONELINESS

TABLE VI

JUDGMENT OF FRIENDS AND LONELINESS

Table

TABLE VIILONELINESS AND CONTROL OF ONSET

TABLE VII

LONELINESS AND CONTROL OF ONSET

Question eleven did not lend itself to statistical treatment other than percentage tabulations. From those tabulations a trend could be seen within group A to (a) get out and do something to get over loneliness. Group B considered (d) prayer to be the most helpful. Option (b), doing something for someone else was the second most helpful item chosen by both groups. The frequency with which this item was chosen was essentially the same for both groups. Neither group felt (c) taking a few drinks to be helpful in combating loneliness. The choice distribution can be seen in Table X.

Discussion

Comparing the lifestyle of institutionalized elderly people to agematched persons living independently in the community, Kraus et al5 found the institutionalized residents with much less recent involvement in social and recreational activities and much more depression and loneliness. However, as pointed out by Kasls6 this comparison makes it impossible to assess the true effect of the residential subjects.

Table

TABLE VIIILONELINESS AND OTHER EMOTIONS

TABLE VIII

LONELINESS AND OTHER EMOTIONS

Table

TABLE IXLONELINESS AND BEING CARED FOR

TABLE IX

LONELINESS AND BEING CARED FOR

Table

TABLE XLONELINESS AND SELF-THERAPY

TABLE X

LONELINESS AND SELF-THERAPY

In an attempt to make the two groups as matched as possible, this present study acted on Kasls* suggestion of comparing two residential populations to each other to obtain a more realistic comparison. In turning now to a discussion of the implications found within the data gathered, it is seen that the Kasls' suggested design was beneficial.6

The two facilities that were compared were very similar and dissimilar in important ways. Both facilities charged approximately the same financially; however, group A was in an established neighborhood while group B was located on a frontage road to an interstate. The nurse-to-resident ratio in group B was exactly one-half of that of group A. Group A's facility allowed them to live in apartment-like dwellings, with their own furniture and appointments, while group B offered only semiprivate rooms with a minimum allowance for personal furnishings. All in all, a stark difference was visibly evident between the two facilities.

From the beginning, attention must be brought to the fact that no scientifically validated instrument to measure actual incidence of loneliness was applied to either group. Therefore, the statement of acceptance of the alternate hypothesis comes as a significant amount of statistical difference was found in the areas that were related to, and traditionally indicative of loneliness. The study assumes loneliness is experienced when those emotions associated with loneliness are present. This limitation must be continually considered as all data are reviewed.

Gathering all the data together for the two groups, a composite of the two groups' similarities is easily composed. All of the similarities serve to validate the quality of matching between the two groups because they are things normally expected to be found within the groups. It is the fine distinctions of reactions to loneliness between the two groups, not the lack of these similarities that point to the different levels of loneliness for the two groups.

Both groups experienced loneliness only one to four times per week, and that loneliness lasted only a few hours. Both felt loneliness was worse when they were feeling blue and both felt loneliness was worse during the day. This finding is not surprising when it is considered that, to a person, every subject stated they were easy-to-bed, good sleepers. They all stated they "slept too well" to be bothered with problems at night. Both groups experienced sadness when lonely, but not fear. Neither group felt their friends would look down on them for experiencing loneliness. Interestingly enough, neither group reported they felt their friends cared about them, to any significant degree, when they were experiencing loneliness.

As the statistically significant differences for the two groups are viewed, some interesting and enlightening distinctions become apparent. First of all, in the insufficient nursing facility the care would be poor at all times, thus when a resident was sick there would be no noticeable difference in how they were treated. In essence, if residents have become accustomed to poor care, and feeling physically worse than necessary is a result of that poor care, the impact of illness is not as great. On the other hand if, as in a "good care" facility, the residents do receive good nursing care and feel generally good physically, then the impact of the physical illness would be great (because the variance is greater) and this would easily compound the severity of the illness.

Essentially, we see that group B is kept at a lower than necessary standard of health and functioning. This lower level shows up again in the fact that they have significantly less energy in group A when loneli\ ness does occur. They are low to1 begin with and the extra strain of loneliness is too much for them. It drains them and leaves them without energy with which to combat the loneliness. Accordingly, group A functions at an acceptable rate and when loneliness threatens they can muster the necessary energy toa significant degree over group B.

It can easily be argued that the philosophy of group B's facility is within itself defeating to the potential well-being of its residents. The facility is controlling and since the nurse/resident ratio is lower, the resident must fit within the system and await his/her turn to receive the insufficient care that is available. The resident becomes both dependent on the facility and lacking in independence with which to perform self-care. The potential resident anomie is seen in the loss of control group B experienced at the onset of loneliness. This group felt significantly that loneliness was worse because they could not control its onset. Thus, a serious trend by the resident's facility in aiding the development of (if not causing) loss-of-independence in the group B residence is seen.

The severity of this problem is seen within the fact that group B felt, with statistical significance over group A, that no one cared for them when'they experienced loneliness. In contrast to this fact group A felt, with statistical significance over group B, that family and God eared for them when they were lonely. What is seen here is an experiencing on group A's part of normal, possibly situational loneliness whereas group B is significantly more likely to experience loneliness in a more pathological way. This is exemplified in the fact that group A experienced the normal emotions associated with loneliness (eg, self-centeredness) while group B delved into pathologically more severe emotions (eg, rejection and hopelessness).

Even the form of "self-therapy" chosen by the two groups points to the difference that exists between them. Whereas group A felt getting out and doing something was the most beneficial thing for them to do, group B stated prayer was the most beneficial to them. Without straying too far into speculation, it could easily be argued that group B chose prayer because the insufficient care they received, and the insufficient philosophy of their facility, prohibited them from getting out and doing something when and as they needed to. Within the dependent, helpless, and hopeless feeling of group B, the comfort of prayer becomes an understandable first "alternative."

For the aging population there exists a cycle that leads to loneliness that is different from any other age group. In essence, the older person experiences a cycle of unmet needs which lead to greater demands, which in turn lead to self-pity, and finally lead to resentment and more unmet needs.7 There is little doubt that insufficient care within a resident's facility would only serve to hasten the onset of the cycle and increase its severity. In short, the poor care the resident receives serves to intensify the loneliness felt. And the mental stress thusly experienced undermines any professional help given.8 In short, the course of loneliness for the elderly person is transformed into a vicious cycle by the poor care received in the insufficient facility.

Acknowledgment

The author wishes to express his appreciation to Dr. William W. Finley for his statistical help.

References

  • 1. Slater PE: The Pursuit of Loneliness: An American Culture at the Breaking Point. Boston, Beacon Press, 1970.
  • 2. Williams LM: A concept of loneliness in the elderly. J Am Geriatr Soc 26:185187, 1978.
  • 3. Francis G, Odell SH: Long-term residence and loneliness: Myth or reality? J Gerontol Nurs 5:9-11. 1979.
  • 4. Arling G: The elderly widow and her family, neighbors and friends. J Marriage Fam 38:757-768, 1976.
  • 5. Kraus AS, Sapsoff RA, Beattie EJ, et al: Elderly applicants to long-term care institutions. I. Their characteristics, health problems, and state of institutions. J Am Geriatr Soc 24:117-125, 1976.
  • 6. Kasl SV: Physical and mental health effects of involuntary relocation and institutionalization on the elderly-A review. Am J Pub Health 62:377, 1972.
  • 7. Jacob BP: Social care: Loneliness. When age brings a crisis, the nurse can restore hope. Nurs Mirror, 147:25-27, 1978.
  • 8. Foster J: Social care: Loneliness. The group solution to isolation. Nursing Mirror 147:28-29. 1978.

TABLE I

DURATION OF LONELINESS

TABLE II

DIURNAL AND NOCTURNAL LONELINESS

TABLE III

PHYSICAL ILLNESS AND LIKELIHOOD OF LONELINESS

TABLE IV

LOW EMOTIONS AND LIKELIHOOD OF LONELINESS

TABLE V

ENERGY LEVEL AND LONELINESS

TABLE VI

JUDGMENT OF FRIENDS AND LONELINESS

TABLE VII

LONELINESS AND CONTROL OF ONSET

TABLE VIII

LONELINESS AND OTHER EMOTIONS

TABLE IX

LONELINESS AND BEING CARED FOR

TABLE X

LONELINESS AND SELF-THERAPY

10.3928/0098-9134-19801001-07

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