Social isolation, and the loneliness that usually results, seldom appears on a list of problems for systematic intervention and re-evaluation in any health care setting. Yet they may result in physical deterioration, mental illness, and even death (Berkman, 1979; Copel, 1988; Murphy, 1982). For nurses providing direct care to institutionalized elders, an adequate response to this concern requires assessment and consistent, structured intervention using the growing body of research about the human necessity for social support.
Institutionalized patients are usually surrounded by people with whom they feel little commonality. Social loneliness results from the lack of a group with which to affiliate and identify as an accepted member. Associated "feelings of boredom, aimlessness, and marginality" may lead to an anxious, compulsive search for activities or groups. Emotional loneliness results from the lack of a close, intimate attachment to one other person, such as a spouse or confidant. Choice, mutuality, reciprocity, trust, and delight develop cumulatively as intimacy matures. Separation from this person increases the likelihood that depression may accompany such challenging events as institutionalization and declining health, but may not result in the anxiety associated with social loneliness (Russell, 1984; Weiss, 1973). In isolation from family and friends, both these ways of being "lonely in a crowd" may result in rage, shame, self-doubt, and withdrawal (Copel, 1988; Meddaugh, 1991).
Guide to Patient Assessment
ASSESSMENT AND PLANNING
The nurse must thoroughly assess the existence and availability of social support, the need and desire for supportive relationships, and the ability to establish and maintain social contacts (Figure 1). The Omnibus Budget Reconciliation Act (OBRA) mandated Minimum Data Set (MDS) provides some of this data throughout Sections B-1 and Background Information Parts I and III. Additional information can be obtained from the resident, the Activities Director, and the Social Worker. To assess social support adequately requires that information from these various sources be analyzed for their interconnections and viewed as a whole. It is the nurse who will ensure that all problems of social isolation are identified and a plan be developed for adequate intervention.
It is important to identify existing relationships within the resident's social network, both outside and inside the institution, that are emotionally supportive or through which come gifts or assistance. These relationships may be found in a variety of contacts in your resident's social network. A social network consists of a "range of social relationships, both positive and negative, which an individual experiences over time," such as spouses, close friends, relatives, neighbors, church members, and formal and informal group associations that include institutional residents and staff (Cole, 1985).
It is also useful to evaluate the quantity (number and frequency of contacts) and quality (congruity between the type and intensity of interactions desired and experienced by the resident) for all these social contacts. Previous studies suggest that the longer a person resides in a long-term care facility, the fewer visits and the fewer visitors they receive from "outside" (Greene, 1982; Powers, 1988). "The issue for nursing practice is how to monitor accurately the fluctuations in levels and types of support available and accessible to clients over time" (Powers, 1988).
The nurse must depend upon the resident to evaluate the amount of support a particular relationship provides, a subtle and very subjective factor. Quantifiable aspects of support include directedness, durability, intensity, and frequency. Directedness indicates who is giving, who is receiving, or whether the relationship is reciprocal. Durability indicates its length, intensity refers to the strength of their bond, and frequency denotes the average time interval between visits. The negative aspects of interpersonal relationships must be weighed as well as positive factors in determining the social support available (Cole, 1985; Powers, 1988).
Duration and Intensity of Social Support Require for Institutionalised Elders
All people have an innate psychological need for intimacy (Sullivan, 1953). However, a few people who lacked adequate care, protection, and encouragement from their mothers during childhood may have developed strong defenses against social contacts to avoid the pain of possible and expected rejection (Sullivan, 1953; Welt, 1987). It may not be useful to interfere with an established pattern of defensive selfsufficiency.
Most elders, like most people of all ages, deeply desire positive human connections; symptoms of inadequacy require a nursing diagnosis of social isolation. Longstanding interpersonal relationships enhance well-being more profoundly than new friendships (Norbeck, 1981). Determine whether a lonely resident is feeling a need for a close one-to-one relationship, or a group of more casual friends, before deciding upon appropriate interventions. A resident who has recently lost contact with a family member or a close friend will be at significant risk for loneliness. Residents who desire and seek close relationships but fail in their efforts face an even greater risk for depression and loneliness than before the attempt was made (Murphy, 1982).
Social isolation is such a painful experience that a resident may not verbalize it directly. This diagnosis should be considered with observations of the following:
* aggression or other interpersonal problems,
Intervention to Combat Loneliness
* poor self-image or signs of powerlessness,
* confusion of the past with the present,
* complaints about feeling confined or deserted, or
* difficulty setting goals and making decisions (Copel, 1988; Meddaugh, 1991).
Your assessment must evaluate the duration and intensity of support required. A new resident with a good self-image and strong social skills may need only short-term intervention; others will require it continuously. Indicate in the nursing care plan whether minimal intervention will suffice, or whether a higher level of intensity is required, as may be the case during an acute illness (Figure 2).
The resident's ability to establish and maintain social contacts may be significantly affected by mental functioning, communication ability and skill, vision, mobility, and needs for personal assistance (Bitzan, 1990). Observation is required to assess such an ability in a particular disabled resident. Such disabilities can be affected by compensatory interventions that require detailed planning.
For instance, a sociable elder with mental deficiencies needs arranged contacts with someone understanding and sensitive to his or her limitations, or who has a similar level of intellectual functioning. When the ability to speak has been damaged, a speech therapist can provide devices, techniques, and alternative methods of communication. People with visual handicaps need tactile activities and assistance from a better-sighted person; having a friend provide this assistance could provide a bonding experience. Assistive listening devices for hearing-impaired elders might significantly enhance their relationships (Thibodeau, 1989). Residents unable to move themselves require transportation assistance from staff, relatives, or other residents. Psychosocial deficits such as discomfort when interacting with people or attending structured activities inherent to your resident's personality are not easily compensated for (Copel, 1988; Norbeck, 1981).
Pilisuk (1982) uses the term social inoculation to describe interventions that enhance social support. He urges professionals to seek and value the opinions of nonprofessionals, identifying them as people more knowledgeable on this subject who should be adequately compensated for "facilitating natural helping networks." Nursing Assistants (NAs) are frequently concerned about the social support of residents and can be a resource for generating valuable intervention ideas.
In the fall of 1990, NAs at Linda Manor Nursing Home in Leeds, Massachusetts, participated in a forum to identify social support interventions for residents. Because they believed interesting activities would enhance socialization, they requested that the materials for such activities be provided for each nursing unit (the area served by a single nurses' station) (Figure 3).
The development of structured activities programs has been a significant improvement in long-term care institutions, and most formal activities have been organized at the institutional level for reasons of economy. This has benefited highly functional elders for whom larger groupings of people and less staff involvement encourage initiative and greater resident participation (Lemke, 1989).
However, disabled residents are more likely to be overwhelmed by these same factors of size, complexity, and necessity for initiative. They may rarely be taken off their unit, but transported only as far as their own lounge or dining room where opportunities for interesting activities are limited and where surprisingly few friendships are made. Since boredom and loneliness could be considered "epidemic" in institutions, it is reasonable to experiment with interventions that might reduce both these factors.
Impaired residents will participate more readily in events that involve a smaller number of people and where the staff take more initiative and establish greater rapport with each resident (Lemke, 1989). Developing the resident's personal care unit as a location for interesting activities is an appropriate response to their special needs.
People who live in the same institutional unit see each other more frequently and share a wider range of experiences than do residents from different units. These factors can be used for encouraging friendships among impaired elders who can access unit-based activities more frequently and regularly than facilitybased activities that require transportation. Positive social interactions will be enhanced by grouping residents according to activity preferences, abilities, age, life situations, personal and cultural characteristics, and social networks (Norbeck, 1981). However, personality factors that are difficult to predict affect the success of social groupings. This will require the development and display of an elaborate seating chart for the common areas of each personal care unit, and a process for both identifying needed changes and executing them promptly.
A recognized intervention for loneliness is to provide opportunities and assistance for making choices, setting goals, and making decisions (Copel, 1988). Offering residents a choice of activities and people with whom to sit and socialize will contribute significantly to their acceptance of placement in a nursing home and to their general life satisfaction. As in any context, thorough introductions for strangers are essential, and may require several repetitions for the cognitively impaired. Seating two residents by themselves in a small room will enhance their relationship more than if they are seated together in a highly populated lounge. They are more likely to interact when they have privacy, choices, and a sense of control over their environment (Lemke, 1989; Rodin, 1985).
Happily engaged people can appear more attractive, feel better about themselves, and be more successful in making friends. Productive involvement seems to be infectious; active residents stimulate activity in others (Lemke, 1989). Since few long-term care institutions currently provide unit-based activities, there is room for creativity and innovation. Imagine how it would enhance the life of a resident if the common rooms on each unit were equipped with materials for producing crafts, art and sewing projects; videos; large-print books and magazines; games; musical instruments; and assistive listening devices. Imagine a room decorated with artwork produced by residents who are busily interacting in their own "living room." Such an environment would provide more enjoyable choices, enrich solitude, and enhance relationships with other residents, staff, and visitors.
In addition to enhancing social relationships, creative activities reduce loneliness even in the absence of such relationships. Torrence (1976) has found evidence that those for whom opportunities for creative behaviors are absent are at greater risk for feelings of desolation; "creativity serves as an immunity to the experience of loneliness."
The implementation of unitbased activities would require a few alterations in traditional job descriptions, and the transition would benefit from interdisciplinary management. The activities department would provide equipment, materials, and training for each unit, particularly those serving impaired elders. When NAs complete routine tasks, they would be expected to assist their residents with activities and projects, setting goals, making choices, and making friends. Activities that NAs and residents enjoy doing together would supplement activities residents could manage on their own. Enjoyable interactions between NAs and residents would provide the aids with diversion and rest from the strenuous aspects of personal care and might have a positive effect on their relationships. Bed making and organization of the resident's belongings would no longer be assigned to the NA, who is a trained personal care attendant. The activities director would make rounds on participating units late each morning; the social worker would assist in identifying problems for individual patients and request program adjustments.
Nurses are in a unique position to identify socially isolated residents, develop a problem description and a therapeutic unit-based intervention plan, and request the structural and personnel changes necessary to support such innovation. Research is essential to determine whether such a strategy will actually reduce loneliness and increase satisfaction with residents' treatment and their lives in an institution. Studies that test specific nursing interventions for a diagnosis of loneliness are exceedingly rare.
Of the four foundational elements of nursing theory and practice, (person, environment, health/illness, and nursing intervention), the component of social support that has been least studied and theoretically developed is the environment. Public attention has been drawn to the deep inadequacies in the quality of institutional life. A study of unit-based activities ; would contribute significantly to a knowledge base required for the scientific practice of gerontological nursing, and might contribute to ameliorating the desolation of the institutional environment.
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Guide to Patient Assessment
Duration and Intensity of Social Support Require for Institutionalised Elders
Intervention to Combat Loneliness