This guide is on social Isolation, social isolation nursing diagnosis, and social isolation nursing interventions. It can be used to create educational nursing care plans for social isolation.
What is social isolation?
Social isolation is the lack of interaction with other people and society as a whole. This state of aloneness can be intentional or unintentional. If the absence of any social contact is not on purpose, the affected individual might experience loneliness and other negative feelings.
Social Isolation Nursing Diagnosis
How can a nurse diagnose for social isolation?
- Impaired cognition such as Alzheimer’s disease
- Psychological disorders
- Terminal illness
- Physical limitations/ impairment
Common Signs & Symptoms …. (evidenced by)
- Flat affect
- Impaired social interaction
- Previous diagnoses of mental or physical disorders
- Expression of feeling lonely and lack of social interaction
- Expression of self-doubt and lack of self-worth
- Difficulty in engaging in a conversation
- Lack of support
- Patient will seek appropriate treatment for underlying factors causing social isolation
- Patient will acquire social skills to interact with society
- Patient will express the feeling of increased self-worth and appear more confident
- Patient will practice communication skills to improve social interactions
Social Isolation Nursing Assessment
What are the assessment options for social isolation?
|Subjective Data: Your patient might state…
… that he or she does not have many friends and does not go outside very much
|Objective data: your assessment and other data might show…
…that the patient has a previous history of mental illness (such as depression)
Social Isolation Nursing Interventions
What are the nursing interventions for social isolation?
Although the terms “treatment” and “intervention” are often used synonymously, they actually refer to different things. An individual suffering from an illness or disease receives treatment from a health care provider to mitigate the disease and its symptoms. Interventions, on the other hand, are designed to improve health status or encourage behavior change and are applied in the larger community by public health authorities. While only a few treatments have been suggested to mitigate social isolation or loneliness, a variety of interventions targeting isolation and loneliness have been proposed.
Direct interventions are those that explicitly target social isolation, loneliness, or related social concepts. Direct interventions can fall into one of several categories: changing cognition, social skills training and psychoeducation, supported socialization, and wider community groups that create a broader sense of social integration. Outside of the health care system, these types of interventions often include one-on-one befriending approaches in which volunteers reach out through phone calls to individuals identified as being socially isolated or lonely.
Within the health care system, this may include reaching out to individuals identified as being at risk for social isolation or loneliness in order to connect them to needed services. Alternatively, interventions may include convening groups of at-risk individuals, in part to provide opportunities for social interaction. However, these types of approaches do not necessarily help individuals develop high-quality relationships, and lonely people in particular may withdraw, for example, due to an unconscious predisposition or hypervigilance to social threat.
Indirect interventions are those that do not specifically aim to mitigate isolation or loneliness but may nonetheless have significant effects on an individual’s perceived or objective isolation. For example, a physician may recommend hearing aids to assist an individual with impaired hearing; as a result, the individual may find it easier to interact in social environments and make connections with others, thereby reducing social isolation and loneliness. Similarly, participation in an exercise program for health may lead to reductions in social isolation or loneliness due to the social nature of the program rather than the exercise itself.
The following sections describe several types of interventions that aim to address social isolation or loneliness that are particularly relevant for the health care system.
No agreed-upon definition of social prescribing currently exists, though it is widely accepted that social prescribing helps patients access non-clinical sources of support, which are often provided by the community sector. Social prescribing has been defined as a “non-medical referral, or linking service, to help people identify their social needs and develop ‘well-being’ action plans to promote, establish, or re-establish integration and support in their communities, with the aim of improving personal well-being” (Carnes et al., 2017, p. 2).
While community-based organizations have traditionally employed social prescribing as a way to help support individuals in their communities, social prescribing has been suggested as a way for health care practitioners to respond to isolation and loneliness in their patients. In her comments to this committee in 2018, Helen Stokes-Lampard, the chair of the Royal College of General Practitioners in the United Kingdom, described social prescribing as “a fancy name for what good doctors have always done, which is navigate our patients towards other resources outside of the health care sector that can help them.” Community-based organizations have long used this approach. For the purposes of this report, social prescribing will refer to the steps that health care providers can take to link patients with existing social services programs.
Connecting people with volunteer organizations and community groups has the potential to affect health and well-being both directly (e.g., lowering stress) and indirectly (e.g., improving access to social services) and may be seen as a way of extending primary care. Social prescribing attempts to prevent worsening health by commissioning secondary services that can help alleviate social concerns that affect health (e.g., food or housing insecurity), thereby reducing the costly interventions provided in specialist or inpatient settings.
Various interventions to mitigate the negative effects of isolation and loneliness fall within the realm of the community sector. Community-based groups such as social welfare systems, community organizations, religious groups, and government groups may be natural partners for the health care system when it comes to addressing social isolation and loneliness. Because social prescribing is tailored to existing voluntary and community-sector-led programs, it is believed to result in better social and clinical outcomes for people with chronic conditions and their caretakers, a more cost-efficient way to use health and social care resources, and a wider and more diverse and responsive local provider base. However, despite the promising nature of many community-based programs, this type of support often remains underused due to the weak or nonexistent link between health care practitioners and community-based services.
Different models of social prescribing interventions are presented in. Little evidence exists concerning the results of social prescribing interventions on social isolation and loneliness, and what evidence does exist is mixed. However, social prescribing interventions do have a number of promising features, including that they are long-term in nature, they address the existence of mental and physical comorbidities and social isolation simultaneously, they target specific groups (e.g., women, caretakers, or people with diabetes), they involve affected individuals in the intervention design process, and they address related socioeconomic issues
One social prescribing tool tested in the United Kingdom, the Patient-Led Assessment for Network Support (PLANS), attempted to consolidate up-to-date information about health-relevant local resources into one website for people living with chronic health conditions. The conceptual basis of PLANS was the notion that the needs of people with chronic health conditions cannot be adequately met through small targeted interventions that are not integrated into everyday life. The website included a self-assessment questionnaire, the results of which provided users with a tailored set of social and health resources available in the community. The resources were grouped into the areas of providing relevant health information, well-being (time spent doing meaningful and enjoyable things),
practical support (help with every day, independent living), and services related to diet and exercise
Another example of a social prescribing system was piloted in Rotherham, United Kingdom, from 2012 to 2014, with the aim of increasing the capacity of general practitioners to meet the non-clinical needs of patients with long-term conditions. The pilot employed a team of voluntary and community sector advisors who received referrals from general practitioners, completed an assessment of referred individuals to identify their needs, and then linked
individuals with appropriate social services. Referrals were made to a variety of social service providers, and the services addressing isolation or loneliness included befriending services, group activity programs, home visits, and group therapy sessions. An analysis of the pilot found that among the patients who received social prescribing services, inpatient admissions were reduced as much as 21 percent and accident and emergency attendance were reduced by as much as 20 percent. However, the sample size and length of the pilot were both small, so these results were not statistically significant.
Support Groups and Group Membership
In general, peer support groups, such as those for individuals with a common illness or condition, have proved to be of value. For social isolation and loneliness, group interventions may be aimed directly at those who are socially isolated or lonely. One approach is to provide guidance for improving social skills. For example, a “friendship enrichment program” in the Netherlands (that included training in skills relevant to friendship), which was aimed at women aged 55 and older, resulted in 63 percent of the participants reporting having made new friends through social and education activities (compared to 33 percent among women who did not participate in the program, but were interested in improving their friendships). However, the execution of social skills may be complicated by issues of performance anxiety. Support groups may also be directed at people who share common underlying causes of social isolation and loneliness, such as bereavement or widowhood.
On the other hand, the reduction of social isolation or loneliness may result from an individual’s participation in group activities aimed at other purposes, such as education, volunteerism, or health promotion activities. For example, a study of SilverSneakers a fitness program for older adults, found that “membership directly increased physical activity and self-rated health, directly decreased social isolation, and indirectly decreased loneliness” (Brady et al., 2020, p. 301). A study of the “hidden elderly” in Hong Kong (defined as “older adults who are socially isolated and refuse social participation”) found that participation in a tai chi qigong program resulted in improvement in loneliness (as measured by the de Jong Gierveld Loneliness Scale).
Key elements of the program included the training of community elders to act as “health ambassadors” of the project; these individuals lived near the hidden elderly and helped to create a sense of neighborhood and peer-to-peer relationships. A clinical trial, Leveraging Exercise to Age in Place (LEAP), is now under way to evaluate the impact of a participation in a community exercise program on social isolation. The LEAP study plans to evaluate changes in the Duke Social Support Index at 26 weeks after enrollment. However, a recent AHRQ rapid review (discussed earlier in this chapter) states
Physical activity interventions to reduce social isolation showed the most promise at improving the health of older adults; however, effects were inconsistent and short-term.
Cognitive Behavioral Therapy and Mindfulness
The ways in which humans think and perceive involve both conscious and unconscious mechanisms. As a result, loneliness can generate a vicious cycle in which lonely people withdraw further because they perceive social interactions as negative or unfriendly. found that lonely individuals perceive greater negativity in social interactions than do non-lonely individuals and that lonely individuals perform more poorly on tests of executive functioning than non-lonely individuals Loneliness is also associated with hypervigilance for social threat. Taken together, biased
Hypervigilance to social threats is “an assumption in line with the evolutionary model of loneliness that indicates feeling socially isolated (or on the social perimeter) leads to increased attention and surveillance of the social world and an unwitting focus on self-preservation” (Cacioppo et al., 2016, p. 138), perceptions and hypervigilance toward negativity may cause lonely individuals to unconsciously withdraw from social connections, even though they may consciously desire to connect with others. This reaction creates problems in particular when lonely individuals attempt to connect with others but perceive the interactions negatively and become discouraged, leading to a vicious cycle of loneliness and withdrawal.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a type of psychotherapy that is used to help patients deal with a variety of issues ranging from more serious mental health disorders such as depression and posttraumatic stress disorder to day-today stressors and anxieties. The goal of CBT is to teach individuals to identify their own faulty perceptions and irrational beliefs in order to approach and respond to challenging or stressful situations in a more clearheaded and effective way. By challenging automatic and negative thought patterns, CBT may be useful in helping lonely individuals reframe the way they think about their relationships, their assumptions about others’ views, or their expectations of success at overcoming loneliness. CBT has been found effective in addressing social anxiety disorder, insomnia, and unipolar depression.
Few CBT-based interventions for loneliness or isolation have been tested in RCTs, and those that have been tested through RCTs have found mixed results identified 10 published RCTs on cognitive approaches to improving loneliness or related concepts (e.g., social support, social network, social isolation) in people with mental health problems. Of the interventions considered, most therapies showed no effect on loneliness; however, two online CBT interventions for individuals suffering from depression were found to be successful at decreasing depressed mood and loneliness at 12-month follow-up. While there is limited evidence of the effectiveness of CBT in mitigating social isolation and loneliness, many consider CBT to be a promising path forward.
CBT and interpersonal psychotherapy are both recognized as being “empirically-based psychotherapeutic interventions for mood disorders,” and “both are diagnosis-targeted, time-limited, present-focused treatments that encourage the patient to regain control of mood and functioning” (Markowitz and Weissman, 2004, p. 136). Interpersonal psychotherapy was originally developed as a treatment for depression. Interpersonal psychotherapy differs from CBT in that its focus is on maladaptive thinking specifically related to interpersonal relationships.
Interpersonal psychotherapy for depression focuses on two principles: viewing depression as a medical illness (not the fault of the patient) and making the connection between mood and triggering life events, such as bereavement. While interpersonal therapy has not been extensively studied as an intervention specifically for social isolation or loneliness, its focus on maladaptive thinking and interpersonal relationships could be an approach to explore.
Mindfulness, a way of being in which an individual maintains openness, patience, and acceptance while focusing on life situations in a non-judgmental way, has also been suggested as a way to mitigate the negative effects of isolation and loneliness. Lindsay and colleagues (2019) conducted an RCT in which smartphone-based training was used to train participants in mindfulness techniques of awareness and acceptance for 2 weeks. The study found that individuals who received mindfulness training reported a 22 percent reduction in daily loneliness compared with the control group; thus, mindfulness training may be a promising way to mitigate the subjective risk factors associated with loneliness.
Currently, nearly all interventions that have been proposed to treat isolation and loneliness are behavioral or psychological in nature. However, the interventions that focus solely on increasing the time spent socializing or increasing the number of social contacts may be greatly hindered by lonely individuals’ negatively biased perceptions and tendency toward interacting defensively with others. To boost the possible success of behavioral interventions, adjunctive treatments or therapies that target the biological underpinnings of biased cognition have been suggested as a potential tool. Adjunctive therapy is a form of treatment used in tandem with a primary treatment with the goal of assisting the primary therapy.
In theory, pharmaceuticals could be used to minimize some of the negative behavioral effects of social isolation and loneliness (e.g., anxiety, fear), allowing individuals to maximize the satisfaction gained from their social interactions and building relationships with others, which in turn may increase the success of behavioral therapies (e.g., CBT). However, consideration is needed for whether decreasing symptoms of loneliness, for example, might mitigate motivation to increase human connection, and thereby lead to increased isolation.
Research in animal models suggests that behavioral or psychological interventions for isolation and loneliness may benefit from adjunctive biological treatments that target the underlying neurobiology. This includes the potential use of selective serotonin reuptake inhibitors (e.g., fluoxetine), neurosteroids (e.g., allopregnenolone), or oxytocin . Fluoxetine has been associated with improving behaviors related to anxiety and fear. In animal models, isolation of the animals has been associated with a decrease in the concentration in the brain of pregnenolone, a hormone that has been associated with memory enhancement.
In humans pregnenolone has been shown to improve depressive symptoms in individuals with bipolar disorder, though evidence of its effects on memory is contradictory. The use of pregnenolone for loneliness is currently in a phase II clinical trial. Oxytocin is associated with social affiliation, and its use in animal models suggests it could mitigate the harmful effects of social isolation. The use of oxytocin in humans has been suggested to promote positive social behaviors, but the evidence for its use is mixed, and more research is needed about which individuals might benefit the most.
Interventions That Target Social Determinants of Health Broadly
Social determinants of health are often interconnected, and therefore social isolation and loneliness may be addressed through efforts to address the social determinants of health more holistically. For example, many Medicaid programs are moving toward screening for social determinants of health and connecting individuals to needed supports. An example of a program targeting the social determinants of health broadly is AIRnyc. This community-based organization uses community health workers to link patients to services in order to address social determinants related to diabetes prevention and management, asthma, hypertension, aging in place, behavioral health, maternal health, and substance use disorder at the individual and household levels.
Centene, one of the nation’s largest Medicaid managed care organizations, serves more than 14.5 million managed care members across 32 states. The organization has committed itself to providing “access to high-quality health care, innovative programs, and a wide range of health solutions that help families and individuals get well, stay well, and be well” (Centene, 2019). Centene is in the process of developing new strategies to address the social determinants of health broadly, which could include social isolation and loneliness, through efforts to address factors known to be at the core of the health and well-being of individuals.
Centene envisions these long-term efforts as a way to create sustainable funding for programs that will address issues such as linguistic and cultural differences between the social sector (e.g., community benefit organizations) and the health sector (e.g., hospitals and payers organizations). Centene envisions a scalable program with broad impact that is guided by a standard set of protocols, procedures, and analytics that can be individualized to different markets. There has not yet been a formal evaluation of this program.
Interventions That Target Social Isolation and Loneliness in the Health Care System
A handful of trial interventions specifically targeting social isolation or loneliness within the health care system have been developed, though few of these have been empirically proven to work. Care More Health is an integrated health plan and care delivery system for Medicare and Medicaid patients. In 2017 it created the Togetherness Program, which is composed of three inter-related approaches for helping people found to be isolated: Phone Pal, a phone-based interaction; a home-based visiting program; and leveraging existing care centers as social hubs with a community health worker embedded in the space.
Individuals can opt into the Togetherness Program during their initial Healthy Start visit or can be referred to the program by physicians in the Care More system. Early results suggest that the Togetherness Program has decreased emergency room use among enrolled patients by 3.3 percent compared to baseline; additionally, hospital admissions per thousand members are 20.8 percent lower among program participants than in the control group). Care More appointed a chief togetherness officer who manages the program and fosters internal and external partnerships related to the topic.
UnitedHealthcare, a large health insurance company, launched the Navigate4Me program in fall 2017 for individuals enrolled in its Medicare Advantage plans who live with complex health issues such as diabetes, congestive heart failure, or multiple chronic conditions. The program offers health navigators who support and guide individuals through the complicated health care system, providing both clinical and administrative assistance (such as answering health questions and resolving billing issues) in addition to addressing the social determinants of health (e.g., by connecting individuals with reliable transportation or housing assistance). UnitedHealth Group reports early positive results, with a 14 percent reduction in hospitalizations and a 9 percent reduction in emergency room visits for people with congestive heart failure. In 2018, eligibility for the program was expanded and specifically made available to individuals at risk for social isolation.
Kaiser Permanente, an integrated managed care consortium, launched Thrive Local in 2019. This program created a new social health network in Oregon and southwest Washington State with the aim of creating connections between health care providers and social services agencies. To best address the social needs of its members, Thrive Local will be built locally in partnership with nonprofit and
government agencies, with the goal of including other health systems and health centers. Thrive Local will be integrated into Kaiser’s electronic health record as a way of tracking social needs and referrals to social providers .
Other health insurance companies are beginning to identify social isolation and loneliness as problems that need to be addressed in their broader health campaigns. Humana’s Bold Goals a population health strategy that specifically addresses the social determinants of health, including loneliness and social isolation, in order to improve health status. As part of this, Humana created a Loneliness Toolkit for consumers that addresses such issues as health care needs, staying engaged, and supporting loved ones who may be isolated or lonely.
Humana also developed a one-page guide for physicians, which focuses on defining social isolation and loneliness, highlighting their major health impacts, presenting the three-item UCLA Loneliness Scale, and advising physicians on potential referrals and resources. Other health insurance companies are leveraging existing health promotion programs to combat isolation and loneliness.
In May 2018, Cigna released the results from a survey assessing the impact of loneliness in the United States; the president and chief executive officer, David Cordani, said of the data: “[W]e’re seeing a lack of human connection, which ultimately leads to a lack of vitality” (Cigna, 2018). Cigna is using existing programs, such as its Health Advisor Program, Health Information Line, and Employee Assistance Program, in order to address loneliness in the company’s employee and patient populations.
Interventions That Target Specific Risk Factors
Another approach to addressing social isolation and loneliness in the health care system is to identify specific underlying risk factors (particularly health-related risk factors) and to address those issues as appropriate within the health care system. Interventions that fail to target the underlying causes of isolation and loneliness are likely to be less successful.
For example, untreated hearing loss is associated with social isolation and loneliness. Several studies suggest that treating hearing loss with hearing aids or cochlear implants may mitigate the effects of hearing loss on loneliness .
Other interventions that target specific risk factors focus on enhancing cognition; enhancing physical mobility or exercise ); and dealing with bereavement or widowhood.
Summary of Social Isolation Nursing Interventions
|Assess the patient’s feelings and perceptions about the situation.
The patient’s point of view provides a baseline for establishing the plan of care. It gives an insight into whether the patient thinks that he or she has control over the situation and wants to be alone or if the situation is not within the client’s control.
|Assess for cognitive and physical deficits that interfere with socializing.
Determining these factors that cause patients to isolate provides a starting point. Some reasons, such as age, disease, or other conditions, are out of the patient’s control. Nurses have to address these medical conditions in the care plan. This ensures the best possible treatment.
|Form a trusting relationship with the patient.
People are more likely to open up and be honest if they feel accepted.
|Have the patient participate in the goal setting and care plan development.
The more involved the patient is in establishing the care plan, the more compliant he or she will be. This also allows for personalizing the care plan as much as possible.
|Identify circumstances in the patient’s life causing or enabling isolation.
Being caught up in everyday life, the patient might not see the problem causing his or her loneliness. Sometimes it takes help from outside to determine the problem.
|Assist the patient in recognizing issues that cause isolation.
The patient has to be able to recognize situations that cause social isolation. To be able to improve upon the problem, the patient needs to identify the issue first.
|Assist the patient to practice social skills.
Providing the client with the necessary skills will increase self-esteem and prepare for social situations.
|Help the patient choose activities that require social involvement.
To get increasingly comfortable in social situations, the patient needs to expose himself or herself to these types of circumstances.
|Praise the client for making progress.
Showing appreciation keeps the patient motivated and increases self-esteem.
|Allow for many visitors to encourage social contact.
It can be therapeutic for the patient to discuss matters with other people.
|Encourage social interaction with people of the same interests.
It might make it easier for the patient to start and keep a conversation when there is an interest in the topic.
|Consider involving the patient in support groups as necessary.
Depending on the circumstance, the patient might benefit from regular group meetings or other activities consistently.