Our society is witnessing an increased volume of older adults. According to the 2010 census, there were 40.3 million people older than 65 in the United States, which reflects an increase of 5.3 million from 2000 (U.S. Census Bureau, 2010). This critical expansion demands that heightened attention be paid to the population’s needs as they age. Aging brings a multiplicity of changes, such as diminished muscle mass, decreased skin turgor, and graying of hair. Aging may also precipitate a loss of health, social status, friends, and/or spouse. These losses can prevent older adults from engaging in many of their usual activities, such as driving, participating in various volunteer commitments, or spending time with friends. Meaningful social contacts are an integral part of successful aging; without these, older adults may experience social isolation and loneliness. Loneliness is a significant phenomenon to study, as it can have a detrimental effect on physical, spiritual, and emotional health (Donaldson & Watson, 1996).
The North American Nursing Diagnosis Association (NANDA) recently identified risk for loneliness as a clinically significant problem in older adults (Carpenito-Moyet, 2006). Loneliness has been called to attention as an important public health issue, as it has a significant impact on the quality of life among older adults (Chalise, Saito, & Kai, 2007; Theeke, 2009; Thurston & Kubzansky, 2009). Some authors even refer to loneliness as an epidemic (Newson, 2006; Shearer & Davidhizar, 1999). It has been defined as an individual’s perceived lack of intimate relationships with others, a sense of increased dependency, as well as a feeling of extreme loss (Hicks, 2000). Sadler and Johnson (1980) noted that a key element in loneliness is that it incorporates the entire self. The lonely person is acutely aware of this distressing condition. Weiss (1975) added that loneliness is a time of “excruciating awareness” of one’s self and how one is situated in the world (p. 14).
A literature search was conducted, which included the computerized databases CINAHL, from 1982 to 2011, and Ovid MEDLINE, from 1950 to 2011. Using the search terms loneliness and social isolation, articles were limited to human research studies in English, with all participants 65 and older. An ancestry approach in which the reference lists of articles obtained was also used to retrieve articles. The search was completed prior to the design and implementation of this study, as it was part of the requirements of the author’s dissertation process.
Loneliness has been associated with old age because of the multitude of age-related changes and losses involved in growing old (Aebischer, 2008). Older adults are at a greater risk of loneliness for several reasons, including loss of spouse, friends, income, and health (Balandin, Berg, & Waller, 2006). Loss of a spouse was found to be one of the most prevalent reasons for loneliness among older adults (Dykstra, van Tilburg, & de Jong Gierveld, 2005). Both loneliness and isolation were more consistent among widowed older adults (Havens, Hall, Sylvestre, & Jivan, 2004). Some researchers have shown that a reduction in social support and lack of social integration are catalysts for loneliness (Pinquart, 2003). The role of friendship in preventing loneliness is significant, as friends provide a critical source of support, especially for nonmarried and widowed older adults (Eshbaugh, 2009). Numerous studies have linked poverty to loneliness, as it limits the ability to buy food, medications, and participate in social activities (Cohen-Mansfield & Parpura-Gill, 2007). Loneliness was also reported in older adults with poor perceived health (McInnis & White, 2001). Increased physical limitations have added to lonely feelings (Pinquart, 2003), and those with visual or auditory impairments were lonelier than those without these disabilities (Murphy, 2006).
Loneliness can affect both physical and emotional health in older adults. It has been associated with high blood pressure, sleep disorders, pain, depression, and anxiety (Cacioppo & Patrick, 2008). It has also been recently studied in relation to cognitive health. Research indicates that loneliness is a risk factor for cognitive decline (Cacioppo & Hawkley, 2009). A recent study demonstrated how different types of group activities improved cognition among lonely older adults (Pitkala, Routasalo, Kautiainen, Sintonen, & Tilvis, 2011). This randomized controlled trial involved 235 adults older than 75, who participated in interventions including art, therapeutic writing, and exercise. These activities facilitated new friendships, lively discussions, and engagement among lonely older adults. Both the art and therapeutic writing groups showed a significant improvement in cognition compared with their control groups; however, the exercise group did not achieve statistical significance (Pitkala et al., 2011).
The majority of studies on loneliness are quantitative, with limited exploration of older adults’ understanding of loneliness (Murphy, 2006). Very few qualitative studies have explored the depth of experiences and the social world of older adults who are isolated (Victor, Scambler, Bond, & Bowling, 2000). The rationale for the current study was the gap in the loneliness literature with regard to understanding the meaning of loneliness in older adults. Therefore, a qualitative study using the interpretive phenomenological approach was designed to more fully understand the meaning of loneliness in a sample of 12 older adults.
This qualitative study attempted to answer the following research questions:
- How do older adults living in the community experience loneliness in their everyday lives?
- How do older adults living in the community cope with loneliness?
- How do these older adults perceive loneliness and its effect on their health and well-being?
The purpose of this article is to discuss how an interpretive phenomenological study was instrumental in uncovering the meaning of loneliness in older adults, how they coped with loneliness, and how their loneliness was manifested as an embodied experience. The phenomenon of embodiment suggests that we, as human beings, live our feelings, emotions, beliefs, and relationships to things and people through our bodies, whether we realize it or not. Hence the lived body is never just an object in the world but becomes the very mode from which one derives meaning (Leder, 1990).
Interpretive phenomenology, or hermeneutics, focuses on uncovering the everyday practices of people as lived, or embodied. The goal of interpretive phenomenology is to understand what is meaningful to individuals (Moran, 2000). This qualitative study explored the meaning of loneliness in the older adult participants. Many study participants experienced loneliness as a result of disrupted meaningful engagement with others. Factors such as diminished health, impaired mobility, and loss of vision and/or hearing interfered with their ability to stay connected with others. The participants coped with their loneliness primarily by re-engaging with others to restore disrupted connections. Some of the ways they re-engaged included reaching out to others, volunteering, and seeking companionship with pets. Lonely feelings, emotions, and patterns of relating to others were subtly expressed through participants’ bodies. This article addresses the background and significance of the philosophical tradition of phenomenology. It also includes a brief overview of the study design, sample, recruitment process, data collection procedures, and data analysis. A summary of findings from this study is also described, and implications for nursing are reviewed.
Background and Significance
Interpretive phenomenology is a method of research that probes into everyday human concerns, habits, and patterns of being. These everyday habits and patterns are based on shared practices that are embodied. Embodied responses are “holistic impressions” that the body recognizes as important (Raingruber & Kent, 2003, p. 451). The body tells stories about one’s life that one cannot possibly articulate. In the everyday lived experience, individuals take their embodied selves and practices for granted. The participants in this study embodied loneliness in several ways, including expressions of fatigue, tension, withdrawal, and emptiness. Some participants described sleeping as beneficial, because it was a form of withdrawal from the world when they felt lonely.
The interpretive phenomenological method is an excellent choice for this research, as hermeneutics provides nurses the chance to understand loneliness as it fully comes to life within the older adult. Understanding loneliness from a phenomenological perspective is important for nursing, because loneliness exists within the holistic framework of the sociocultural, historical, and contextual background of the person. Through a phenomenological lens, the mind and body are one; there is no subject-object dichotomy. The person and body are intertwined as beings with a mind-body unity (Benner & Wrubel, 1989). Understanding can be jeopardized when trying to examine symptoms in terms of this mind-body split (Benner & Wrubel, 1989). Loneliness is misunderstood if it is viewed strictly from an objective, descriptive approach of a biomedical disease or disability. As nurses become more educated about the problem of loneliness in older adults, they can gain a better appreciation of this phenomenon. A better understanding of loneliness is preliminary to the promotion of health and well-being in older adults.
This research was approved by the institutional review board. The design of this study was interpretive, with the purpose of exploring the meaning of loneliness in older adults. The aims of this study were threefold, to: (a) describe how these older adults experience loneliness in their everyday lives, (b) explore their coping practices associated with loneliness, and (c) discover how participants’ perceptions of loneliness affect their health and well-being. This article will describe critical findings from all three research aims.
Recruitment efforts were targeted at older adults within the community who attended local senior centers, as well as those who received home-delivered meals from the senior centers. The snowballing technique was also used to recruit lonely older adults living within the community.
The sample included a total of 12 older adults (8 women, 4 men), ages 74 to 98. (Greater detail about the participants is published elsewhere [Smith, 2012].) Saturation was achieved with 12 participants, as major themes were consistently reported. Pseudonyms were assigned to preserve anonymity and are also used throughout this article to describe the participants. Older adults who responded positively to the question, “Have you experienced loneliness within the past 6 months?” were eligible to participate in the study. The Short Blessed Orientation-Memory-Concentration Test (Katzman et al., 1983) and the short form of the Geriatric Depression Scale (Kurlowicz & Greenberg, 2007) were used to identify the appropriate sample. Older adults were excluded if they were unable to articulate their feelings of loneliness or if severe depression conflated feelings of loneliness.
The 20-item UCLA Loneliness Scale, version 3, was chosen because it has been widely used in loneliness research, with Cronbach’s coefficient alpha values ranging from 0.89 to 0.94, and a test-retest correlation of 0.73 (Russell, 1996; Russell, Peplau, & Ferguson, 1978). All scores are added together, with a higher score indicating a greater degree of loneliness. This tool was used to describe participant scores, which ranged from 29 to 60.
Narrative data were collected using three different author-developed interview guides: the History Interview, Loneliness Coping Interview, and Daily Life Interview. These interviews included questions with clarifying probes to obtain a holistic perspective from each participant. The purpose of these interviews was to garner background sociohistorical and cultural context, as well as to gather data on mechanisms of coping with lonely experiences from a phenomenological approach. The phenomenological view of coping seeks to understand how daily practices, habits, and patterns are shaped by meanings (Benner & Wrubel, 1989). The guides also explored current relationships with friends and significant others to expose how the participants are situated within their everyday lives. Personal narratives that emerged from the interviews provided a sense of coherence and understanding within the life-world of the participants (Mishler, 1990). All interviews were digitally recorded and transcribed.
Included in the guides were a demographic survey and health history, with questions directed to participants’ health-wellness continuum. The interviews were conducted every 3 to 4 weeks for a total of three visits. Multiple accounts obtained over several interviews are critical to be able to articulate what is often hidden or taken for granted in everyday activities (Benner & Wrubel, 1989).
The digitally recorded interviews were carefully checked for accuracy. Multiple sessions of reviewing and listening to the transcripts were involved in data analysis. This included jotting down thoughts or key words in the margins when a significant passage was noted. Eventually, meaningful chunks of data were coded and segmented. Code development was instrumental in identifying different themes and patterns in the data. Within the three aims, different themes emerged. These themes were helpful in furthering understanding of the loneliness experience. For example, one of the widowed participants expressed anxiety over facing an empty chair when going to a social event. “Empty chair” was segmented and eventually coded into the word emptiness, as this became a recurring theme among participants. Data analysis also included interpretive sessions with colleagues to discuss findings.
The Experience of Loneliness
The first aim of this study was to describe how older adults living in the community experience loneliness in their everyday lives. A critical finding from this first aim was that many participants experienced loneliness as a result of disrupted meaningful engagement with others due to different age-related changes. Declining health was a prominent theme and included impaired mobility and loss of vision and/or hearing. For example, Al was a participant who was wheelchair bound due to several strokes. He reported how he missed getting together with his golfing friends. He was no longer able to play the game because of his impaired mobility post-stroke. William, another participant with impaired vision, could no longer read the newspaper print. He reported feeling isolated because his impaired vision reduced his ability to remain connected to his world via the daily news. Rose experienced hearing loss and reported feeling lonely because she missed out on conversations.
Half of the participants in the study gave up driving the car because they no longer felt confident on the road. This lack of transportation created barriers to their ability to maintain connections with others. For example, Martha, who was now wheelchair bound due to her idiopathic peripheral neuropathy, missed being able to get in the car and drive to meet friends for lunch.
Loneliness related to retirement and widowhood were also major themes from the first study aim. Retirement seemed to impact the men more than the women in this study, perhaps because their identity was more strongly shaped by the world of work than it was for older women. Half of the participants were widowed and expressed loneliness because they were no longer able to share daily events with their spouse. For example, Sally and her husband had enjoyed each other’s company and went to many social activities together. Now widowed for 5 years, she described her experience of attending social functions without him. She dreaded seeing the “empty chair” at the table where he would have sat. She reported feeling lonely and alone in the crowd.
The second aim of this study was to explore the coping practices in the lives of lonely older adults. A striking theme that emerged from the data was the importance of maintaining connections with others. The participants reached out to sustain engagement with others by visiting friends, going to lunch, or telephoning family. Volunteering was another avenue to reach out and help others, which was empowering and satisfying for many. For example, Rose was a widow who had cared for her husband for 9 years while he was very ill. After her husband’s death, Rose spent one day per week at the hospital helping others. She reported that this volunteer work was rewarding and lessened her loneliness. Others spent time with their pets, which helped in the lonely moments. Helen, another widow, marveled that her cat “is always there for me, and is something there that cares.” Other participants reported how television helped them remain connected to the local news. This medium of communication provided information on the weather, current events, or even the ball game; having something to look forward to helped lighten the loneliness.
How Loneliness Affects Health and Well-Being
The third aim of this study was to discover how perceptions of loneliness affect the health and well-being of community-dwelling older adults. The participants’ narratives demonstrated how declining physical health and functional limitations interfered with their ability to maintain meaningful engagement with others, which contributed to loneliness. This third aim shifted because the participants did not describe a direct causal relationship between perceived loneliness and physical health. In addition, they did not attribute their loneliness to ill health. Instead, the participants perceived loneliness as interwoven into the daily practical involvements in their lives. Loneliness was lived through their bodies; it was embodied. Four minor themes emerged from the third aim and were powerful in providing vivid descriptions of the embodiment of loneliness: fatigue, tension, withdrawal, and emptiness.
Fatigue. Many of the participants expressed fatigue when experiencing loneliness. Grace expressed lonely feelings throughout her body. When asked about how her body felt when lonely, Grace responded, “Usually tired. That’s a kind of general feeling. When I don’t feel real comfortable with things or maybe it’s lonely, I do feel tired because my inclination is very often, ‘Let’s go to sleep, go to bed.’” Grace had remarked how retreating to her bed was helpful when she felt lonely. Fatigue was one way Grace embodied loneliness. Rose also embodied her loneliness through fatigue. She expressed feeling tired, “achy and blah” when lonely. Helen also sensed fatigue when lonely; she would allow her body time to sit in a chair and rest at least twice daily. Martha described feeling exhausted and deflated when lonely, as if someone had “pulled the plug.”
Tension. Sally described an episode of loneliness when driving home in a torrential rainstorm. She felt upset and tense because she wished someone were with her in the car. Sally stated, “I was hugging that wheel like crazy. I don’t know if I had white knuckles but I was holding on to that wheel pretty much, and it was mainly because of the rain.” The downpour of rain challenged her driving ability on the highway, and she longed for company and support. Sally’s loneliness was embodied and manifested itself as tension.
Similarly, Grace acknowledged feeling uncomfortable in her loneliness, noting, “I squirm in my chair. I know I do that. And I try, when I become conscious, I try not to do that because I don’t think that’s polite.” As Grace became aware of her bodily movements, she tried to control the squirming, so that other people would not notice. Nonetheless, she admitted that at times she was unaware of her bodily movements.
Withdrawal. Grace was one of the participants who had difficulty hearing, and she acknowledged that being unable to hear others made her feel left out and lonely. Grace discovered that she automatically withdrew into herself when she was unable to hear others talking:
What I try to do is be gracious when I say “I can’t hear you” or “Would you speak more loudly?” I do that here and I have to do it at work sometimes too because we’re in that big room down there. I also sometimes just withdraw from the conversation, especially if the conversation isn’t overly interesting, or if I think it’s repetitive. I find myself just withdrawing from the conversation.
Sally also recognized that she “draws back” and becomes more isolated as a widow:
You do build a cocoon around yourself. Sometimes you draw back and you don’t know why you’re drawing back but you just do. You look at the situation and say “No, I’m not gonna go through the process.” But you do build something around yourself after a few years of being on your own.
When probed, Sally admitted that she drew back without consciously thinking about it. Both Grace and Sally withdrew into themselves as an embodied response to loneliness. The bodily response of withdrawal helped both women conceal their lonely feelings. Heidegger (1962) believed that a phenomenon does not show up at all but remains hidden. Grace and Sally were skillful at hiding their loneliness by withdrawing when these feelings occurred.
Emptiness. Emptiness was another embodied response participants experienced when lonely. Lily described an emptiness in her chest when questioned about how her body felt when loneliness took over: “It’s an emptiness. I almost feel it in my chest, just a little heaviness. I’m not gonna cry. I’m not going to be outwardly sad, but I can feel it in my body.” When queried further to expand on this statement, she explained:
Like pressure, that’s the best way I can describe it, pressure in my chest. I probably would not think of it consciously unless I’m really just focusing on what is happening to me. In our conversation, in retrospect, it was there.
Lily’s loneliness was being lived throughout her body as a painful, empty feeling. Emptiness was embodied within Lily’s being.
Martha also embodied her lonely feelings and described a certain emptiness. She explained that she felt as if she were in a “vacuum” and that she felt alone and isolated in an empty space. She described her body as feeling “motionless and floating” when lonely feelings engulfed her body. Martha also explained how she felt empty and “limp, like a rag doll.” Several of the other widowed participants, including Rose, Helen, and Audrey, also described similar feelings of emptiness, as if there was nothing left of them after their husbands had died.
Audrey was a strikingly powerful exemplar of how loneliness was embodied as emptiness. A widow of 15 years, Audrey still cried herself to sleep every night because she desperately mourned her husband’s death. Audrey and her husband had been married a very long time; his death from an automobile accident was a needless tragedy from which she had never completely recovered. Audrey was unable to view herself as separate from her husband; part of her world collapsed when she lost him. She reported, “only half of me is here”:
Well he’s laying out at the cemetery and there’s a headstone. And the other half of it is empty, and that’s where I want to be, next to him. That’s what I mean, he’s out there and I’m here but there’s one headstone between them.
When gently probed, Audrey’s loneliness over the loss of her husband was uncovered as feelings of emptiness. Audrey denied feelings of depression or suicide, and she scored a 3 on the short form of the Geriatric Depression Scale, which is not indicative of clinical depression. Despite her loneliness, Audrey spoke on the telephone with her children every week.
In addition to the embodied responses of fatigue, tension, withdrawal, and emptiness, there were several other bodily expressions of loneliness, such as feeling “stuck,” “trapped,” “cut off,” “isolated,” “claustrophobic,” and “out of place.” Martha defined loneliness as feeling “lost in yourself.”
The study findings demonstrate the importance of narratives from older adults who depict images of loneliness as a result of multifactorial losses, including health, transportation, job, and/or spouse. Factors such as impaired mobility and decreased sensory abilities (vision and hearing) also prevented older adults from maintaining social connections with others. These findings were consistent with the existing literature on loneliness, which addresses how physical, psychological, and social problems are regularly reported as correlates of loneliness (Theeke, 2010). Existing literature also reports how limited access to transportation creates difficulties getting outside of the home, which contributes to loneliness (Aebischer, 2008). Loss of spouse has also been documented as a major trigger for lonely feelings among older adults (Dykstra et al., 2005).
Exploration of the loneliness experience with older adults through interviews revealed how they coped by reconnecting with friends and family. These narratives were beneficial to understanding the intricate connections between mind, body, and world when trying to uncover loneliness. Listening to the participants’ narratives revealed how the emotional and physical sensations of loneliness were experienced simultaneously. For example, Grace withdrew from situations when lonely feelings crept in. She attributed her lonely feelings to her inability to hear, which made her feel left out. Older adults with sensory impairments, such as vision and hearing, are at a heightened risk for loneliness because of the social isolation such impairment creates (Carpenito-Moyet, 2006). Sally also withdrew when feeling lonely. Both Grace’s and Sally’s unconscious withdrawals facilitated a type of disengagement from their everyday situations. Phenomenology uncovers the hidden meanings (Welch, 1999). This phenomenological lens of viewing loneliness is extremely helpful to understand how loneliness can be expressed throughout the entire body.
Implications for Nursing
Loneliness is a significant issue in older adults, as it can negatively impact the physical health and well-being of those at risk. This study complements the existing body of knowledge by empowering nurses who are in a key position to identify those older adults at risk for loneliness, both in acute care settings and in the community. Several study participants experienced loneliness as a result of their sensory deficits. Nurses can advocate for an increase in hearing and vision screenings in older adults. Hearing loss is rarely screened for in primary care settings (Bogardus, Yueh, & Shekelle, 2003), so it is important for nurses to educate older adults and their families about the importance of screening for hearing loss. Many causes of vision loss in older adults can be prevented (Pelletier, Thomas, & Shaw, 2009). Vision screenings should also be included in health examinations. As hearing and vision screenings become more routine, these sensory deficits could be identified and treated earlier.
Half of the participants in this study were no longer able to drive a car and therefore experienced loneliness because they could not maintain those vital connections with others. Nurses can become actively involved with their local Area Agencies on Aging to learn more about the wealth of valuable resources they provide for older adults. These agencies can provide assistance such as transportation, home-delivered meals, help with household chores, or even a volunteer to stay with the older adult in the home. Nurses employed by home health agencies need to be educated about the prevalence of loneliness in older adults. Use of loneliness screening tools could be added to home assessments for early identification. In addition, visits to the home are critical in identifying other health issues, such as fall risk, nutritional needs, and medication management.
Half of these participants were widowed and experienced loneliness because of loss of spouse. Nurses can refer their widowed clients to support groups if they detect the risk of loneliness related to loss of spouse. Not only can these groups provide support while the older adult is grieving, but they can also connect them to other widowed adults, with the possibility of forging new friendships.
Many of these participants coped by telephoning friends and relatives. Many communities and local parishes have volunteer telephone support programs that check on older adults who live alone. In addition to telephone support, nurses need to educate older adults about the benefits of using the Internet, as it has been reported to enhance life satisfaction and loneliness in older adults (Slegers, van Boxtel, & Jolles, 2008). Nurses should consider the use of computer-assisted support programs, such as Skype™ and web cameras, as well as emerging technologies like digital tablets, to support both short- and long-distance interactions (Cutler, Hendricks, & Guyer, 2003; McCausland & Falk, 2012).
Many participants reported enhanced well-being with a pet to comfort them. It is important for nurses to recognize pets as a social support and advocate for changes in public policy to allow pets in assisted living facilities (Krause-Parello, 2008). Recognition of the benefits of volunteering is also critical for nurses who work with older adults. Nurses can educate their clients about getting involved in their local community, with programs such as reading to young children at the library or volunteering at a garden. Staying engaged within the community empowers older adults to feel rewarded and satisfied.
Loneliness can easily be overlooked or even dismissed by nurses, who may be unable to focus on the unique needs of their clients because they are so overwhelmed with other health care demands. Loneliness is often hidden or may be disguised as a physical symptom, such as discomfort, fatigue, anxiety, tension, or even withdrawal. For example, in this study, Grace’s loneliness was manifested by feeling uncomfortable in her chair, and she squirmed so others would not notice. Nurses may observe that their older clients seem restless, uneasy, or uncomfortable. Perhaps the underlying issue is that their client is indeed lonely. Similarly, nurses should consider loneliness if their older client reports feeling tired or is constantly requesting to go back to bed, as this study found that many of the participants felt tired or wanted to go to sleep when they were feeling lonely. Loneliness may also be masked by ill-defined complaints of feeling anxious or tense. In addition, older adults who withdraw from daily activities may be doing so because they already feel left out and lonely; they may not be doing so intentionally to be noncompliant or “difficult.”
Nurses have the unique opportunity to attend to older adults and actively listen to their stories and concerns. Older adults’ narratives about their sociocultural and historical background provide evocative and meaningful portraits of the human experience (Sandelowski, 1993). Active listening is an important part of therapeutic communication and provides nurses with a heightened awareness of older adults’ needs. When nurses remain open to the shared meanings of experiences, new possibilities of care emerge that can direct relevant nursing interventions (Benner & Wrubel, 1989).
Nurses must attend to each older adult’s history to understand the person’s strengths and limitations while responding to his or her losses, such as declining health, loss of friend and/or spouse, or disability. Similar to pain and suffering, loneliness is part of human beings’ embodied condition. The notion of embodiment is essential to the phenomenological view of what it is to be a person (Chan, 2010). Narratives that provide rich descriptions of loneliness can enhance nurses’ ability to appreciate the daily habits and patterns of lonely older adults, so they can provide more effective care.
- Aebischer, J. (2008). Loneliness among home-bound older adults: Implications for home healthcare clinicians. Home Healthcare Nurse, 26, 521–524. doi:10.1097/01.NHH.0000338510.54828.89 [CrossRef]
- Balandin, S., Berg, N. & Waller, A. (2006). Assessing the loneliness of older people with cerebral palsy. Disability and Rehabilitation, 28, 469–479. doi:10.1080/09638280500211759 [CrossRef]
- Benner, P. & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness. Menlo Park, CA: Addison-Wesley.
- Bogardus, S.T. Jr.. , Yueh, B. & Shekelle, P.G. (2003). Screening and management of adult hearing loss in primary care: Clinical applications. Journal of the American Medical Association, 289, 1986–1990. doi:10.1001/jama.289.15.1986 [CrossRef]
- Cacioppo, J.T. & Hawkley, L.C. (2009). Perceived social isolation and cognition. Trends in Cognitive Sciences, 13, 447–454. doi:10.1016/j.tics.2009.06.005 [CrossRef]
- Cacioppo, J.T. & Patrick, W. (2008). Loneliness: Human nature and the need for social connection. New York: Norton & Company.
- Carpenito-Moyet, L.J. (2006). Nursing diagnosis: Application to clinical practice (11th ed.). Philadelphia: Lippincott Williams & Wilkins.
- Chalise, H.N., Saito, T. & Kai, I. (2007). Correlates of loneliness among older Newar adults in Nepal. Japanese Journal of Public Health, 54, 427–433.
- Chan, G. (2010). Understanding end-of-life caring practices in the emergency department. In Chan, G., Brykczynski, K., Malone, R. & Benner, P. (Eds.), Interpretive phenomenology in health care research (pp. 91–112). Indianapolis: Sigma Theta Tau International.
- Cohen-Mansfield, J. & Parpura-Gill, A. (2007). Loneliness in older persons: A theoretical model and empirical findings. International Psychogeriatrics, 19, 279–294. doi:10.1017/S1041610206004200 [CrossRef]
- Cutler, S.J., Hendricks, J. & Guyer, A. (2003). Age differences in home computer availability and use. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 58, S271–S280. doi:10.1093/geronb/58.5.S271 [CrossRef]
- Donaldson, J.M. & Watson, R. (1996). Loneliness in elderly people: An important area for nursing research. Journal of Advanced Nursing, 24, 952–959. doi:10.1111/j.1365-2648.1996.tb02931.x [CrossRef]
- Dykstra, P.A., van Tilburg, T.G. & de Jong Gierveld, J. (2005). Changes in older adult loneliness: Results from a seven-year longitudinal study. Research on Aging, 27, 725–747. doi:10.1177/0164027505279712 [CrossRef]
- Eshbaugh, E.M. (2009). The role of friends in predicting loneliness among older women living alone. Journal of Gerontological Nursing, 35(5), 13–16. doi:
- Havens, B., Hall, M., Sylvestre, G. & Jivan, T. (2004). Social isolation and loneliness: Differences between older rural and urban Manitobans. Canadian Journal on Aging, 23, 129–140. doi:10.1353/cja.2004.0022 [CrossRef]
- Heidegger, M. (1962). Being and time: A translation of Sein und Zeit (, Trans.). New York: Harper and Row.
- Hicks, T.J. Jr.. (2000). What is your life like now? Loneliness and elderly individuals residing in nursing homes. Journal of Gerontological Nursing, 26(8), 15–19.
- Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R. & Schimmel, H. (1983). Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. The American Journal of Psychiatry, 140, 734–739.
- Krause-Parello, C.A. (2008). The mediating effect of pet attachment support between loneliness and general health in older females living in the community. Journal of Community Health Nursing, 25, 1–14. doi:10.1080/07370010701836286 [CrossRef]
- Kurlowicz, L. & Greenberg, S.A. (2007). The Geriatric Depression Scale (GDS).Try This: Best Practices in Nursing Care to Older Adults with Dementia, Issue 4. Retrieved from the ConsultGeriRN.org website: http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf
- Leder, D. (1990). The absent body. Chicago: The University of Chicago Press.
- McCausland, L. & Falk, N.L. (2012). From dinner table to digital tablet: Technology’s potential for reducing loneliness in older adults. Journal of Psychosocial Nursing and Mental Health Services, 50(5), 22–26. doi:10.3928/02793695-20120410-01 [CrossRef]
- McInnis, G.J. & White, J.H. (2001). A phenomenological exploration of loneliness in the older adult. Archives of Psychiatric Nursing, 15, 128–139. doi:10.1053/apnu.2001.23751 [CrossRef]
- Mishler, E.G. (1990). Validation in inquiry-guided research: The role of exemplars in narrative studies. Harvard Educational Review, 60, 415–442.
- Moran, D. (2000). Introduction to phenomenology. London: Routledge.
- Murphy, F. (2006). Loneliness: A challenge for nurses caring for older people. Nursing Older People, 18(5), 22–25.
- Newson, P. (2006). Loneliness and the value of empathetic listening. Nursing & Residential Care, 8, 555–558.
- Pelletier, A.L., Thomas, J. & Shaw, F.R. (2009). Vision loss in older persons. American Family Physician, 79, 963–970. Retrieved from http://www.aafp.org/afp/2009/0601/p963.pdf
- Pinquart, M. (2003). Loneliness in married, widowed, divorced, and never-married older adults. Journal of Social and Personal Relationships, 20, 31–53. doi:
- Pitkala, K., Routasalo, P., Kautiainen, H., Sintonen, H. & Tilvis, R. (2011). Effects of socially stimulating group intervention on lonely, older people’s cognition: A randomized, controlled trial. American Journal of Geriatric Psychiatry, 19, 654–663. doi:10.1097/JGP.0b013e3181f7d8b0 [CrossRef]
- Raingruber, B. & Kent, M. (2003). Attending to embodied responses: A way to identify practice-based and human meanings associated with secondary trauma. Qualitative Health Research, 13, 449–468. doi:10.1177/1049732302250722 [CrossRef]
- Russell, D., Peplau, L.A. & Ferguson, M.L. (1978). Developing a measure of loneliness. Journal of Personality Assessment, 42, 290–294. doi:10.1207/s15327752jpa4203_11 [CrossRef]
- Russell, D.W. (1996). UCLA Loneliness Scale (version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66, 20–40. doi:10.1207/s15327752jpa6601_2 [CrossRef]
- Sadler, W.A. Jr.. & Johnson, T.B. Jr.. (1980). From loneliness to anomia. In Hartog, J., Audy, J.R. & Cohen, Y.A. (Eds.), The anatomy of loneliness (pp. 34–64). New York: International Universities Press.
- Sandelowski, M. (1993). Rigor or rigor mortis: The problem of rigor in qualitative research revisited. Advances in Nursing Science, 16, 1–8. Retrieved from http://journals.lww.com/advancesinnursingscience/Abstract/1993/12000/Rigor_or_rigor_mortis__The_problem_of_rigor_in.2.aspx
- Shearer, R. & Davidhizar, R. (1999). Conquering loneliness. Elderly Care, 11(2), 12–15.
- Slegers, K., van Boxtel, M.P.J. & Jolles, J. (2008). Effects of computer training and Internet usage on the well-being and quality of life of older adults: A randomized, controlled study. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 63, P176–P184. doi:10.1093/geronb/63.3.P176 [CrossRef]
- Smith, J.M. (2012). Portraits of loneliness: Emerging themes among community-dwelling older adults. Journal of Psychosocial Nursing and Mental Health Services, 50(4), 34–39. doi:10.3928/02793695-20120306-04 [CrossRef]
- Theeke, L.A. (2009). Predictors of loneliness in U.S. adults over age sixty-five. Archives of Psychiatric Nursing, 23, 387–396. doi:10.1016/j.apnu.2008.11.002 [CrossRef]
- Theeke, L.A. (2010). Sociodemographic and health-related risks for loneliness and outcome differences by loneliness status in a sample of U.S. older adults. Research in Gerontological Nursing, 3, 113–125. doi:10.3928/19404921-20091103-99 [CrossRef]
- Thurston, R.C. & Kubzansky, L.D. (2009). Women, loneliness, and incident coronary heart disease. Psychosomatic Medicine, 71, 836–842. Retrieved from http://www.psychosomaticmedicine.org/content/71/8/836.full.pdf doi:10.1097/PSY.0b013e3181b40efc [CrossRef]
- U.S. Census Bureau. (2010). American factfinder. Retrieved from http://factfinder2.census.gov
- Victor, C., Scambler, S., Bond, J. & Bowling, A. (2000). Being alone in later life: Loneliness, social isolation and living alone. Reviews in Clinical Gerontology, 10, 407–417. doi:10.1017/S0959259800104101 [CrossRef]
- Weiss, R.S. (1975). Loneliness: The experience of emotional and social isolation. Cambridge, MA: MIT Press.
- Welch, M. (1999). Phenomenology and hermeneutics. In Welch, M. & Polifroni, C.E. (Eds.), Perspectives on philosophy of science in nursing: An historical and contemporary anthology (pp. 235–246). Philadelphia: Lippincott Williams & Wilkins.