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Isolation: A Concept Analysis Heather M. Gilmartin, MSN, RN, FNP, Patti G. Grota, PhD, RN, CNS-M-S, and Karen Sousa, PhD, RN, FAAN

Heather M. Gilmartin, MSN, RN, FNP, is Adjunct Clinical Faculty, College of Nursing, University of Colorado, Aurora, CO; Patti G. Grota, PhD, RN, CNS-M-S, is Assistant Professor of Nursing, Schreiner University, Kerrville, TX; and Karen Sousa, PhD, RN, FAAN, is Professor and Associate Dean for Research and Extramural Affairs, College of Nursing, University of Colorado, Aurora, CO.

Keywords Communicable disease, concept analysis, nursing theory

Correspondence Heather M. Gilmartin, MSN, RN, FNP, College of Nursing, University of Colorado, Aurora, CO E-mail: heather.gilmartin@ ucdenver.edu

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.Conflict of Interest Statement: No conflicts of interest have been declared by the authors.

TOPIC. Concept analysis of isolation. PURPOSE. This article uses Walker and Avant’s methodological approach in distinguishing the concept of isolation between the normal, ordinary language usage and the scientific usage of the concept. BACKGROUND. The importance of social contact has long been recog- nized as a fundamental need for humans. The concept of isolation is used throughout the lay and scientific literature and has a primarily negative connotation for humans. The experience is sometimes severe enough to result in serious reductions in adaptation and performance. DATA SOURCES. The Medline, CINAHL, and Google Scholar databases were searched using the key terms of concept analysis, human, and isolation with no restriction on the year of publication. English language reports were used exclusively. CONCLUSION. Three attributes were identified: sensory deprivation, social isolation, and confinement. Antecedents included individual per- ception and situational dimensions. Consequences included anxiety, depression, mood disturbances, anger, loneliness, and adverse health events. Through this concept analysis, isolation has been theoretically defined as a state in which an individual experiences a reduction in the level of normal sensory and social input with possible involuntary limi- tations on physical space or movement. Systematic studies of isolation using this concept can ultimately enhance nurses’ knowledge base and contribute to the quality of life for isolated persons.

Introduction

It is generally recognized that humans are social animals whose behavior is significantly determined by their needs and reactions to other people. This social aspect of human existence is nowhere more evident than when he or she is isolated from others (Haythorn, 2008). People have been subjected to isolation for centuries, as evidenced through accounts of solitary confinement in the penal system, Arctic explorers, and ocean sailors (Haney, 2003; Laing & Crouch, 2009; Zubek, 2008). Isolation has also been used as a tool to prevent the spread of infectious disease through the physical separation of those infected from the popula- tion (Abad, Fearday, & Safdar, 2010; Gensini, Yacoub, & Conti, 2004). Isolation is now being recognized as an

outcome for those with mental, physical, infectious, and age-related issues that limit a person’s ability to connect with their social network (Abad et al., 2010; Furr et al., 2007; Hagedoorn & Molleman, 2006; Maunder, 2004; Nicholson, 2009; Trout, 1980; Victor, Scambler, Bond, & Bowling, 2000).

The anecdotal literature, field, and laboratory studies indicate that isolation is stressful to many indi- viduals and that the stress is sometimes severe enough to result in serious reductions in adaptation and per- formance (Catalano et al., 2003; Haythorn, 2008). This article attempts to distinguish the normal, ordi- nary language usage of the concept of isolation and the scientific usage, and develop an operational defi- nition of isolation using the methods of Walker and Avant (2011) because of its ease and straightforward

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approach. The key procedures in the concept analysis include identifying definitions, defining attributes, related cases, model, borderline and contrary cases, and empirical referents.

Uses of the Concept

Ordinary

The Merriam-Webster Dictionary defines isolation as the condition of being alone (Isolation, 2011c). WordNet.com (Isolation, 2011d), a word-defining Web site, adds, “A state of separation between persons or groups and a feeling of being disliked or alone,” and etymology.com (Isolation, 2011b), an online etymol- ogy dictionary, identifies the origin of isolation as the Latin insulatus, or “made into an island.” The popular literature has described isolation in song, such as Iso- lation by John Lennon (1970), literary essays, such as Papillion (Charriere, 2006), The Scarlet Letter (Haw- thorne, 1999), and The Colony: The Harrowing True Story of the Exiles of Molokai (Tayman, 2007). These works tell the stories of persons forced into isolation because of their social situation, as a penalty or because of fear of contagion. A consistent theme among the ordinary use of isolation is a physical or emotional separation that is negatively experienced by the individual or group.

Scientific

The term isolation is defined in the field of chemistry as the separation of a pure chemical substance from a compound or mixture; in computer science, it is defined as the ability of a logic circuit having more than one input to ensure that each input signal is not affected by any of the others; in evolution, it is defined as the restriction or limitation of gene flow between distinct populations because of barriers to interbreed- ing; in health care, it is defined as the separation of an individual with a communicable disease from other, healthy individuals; in microbiology, it is defined as the separation of an individual strain from a natural, mixed population; in physiology, it is defined as the separation of a tissue, organ, system, or other part of the body for purposes of study; and in psychology, it is defined as the dissociation of a memory or thought from the emotions or feelings associated with it (Iso- lation, 2011a). Science uses the concept of isolation as a separation of one object or individual from another.

Defining Attributes

To distinguish isolation from other related concepts, it is essential to identify its defining characteristics (Walker & Avant, 2011). Three major attributes of human isolation have been identified in the scientific literature: sensory deprivation, social isolation, and confinement (Rasmussen, 2008; Sells, 2008; Zucker- man, Persky, & Link, 1968). Studies have indicated that these attributes, when experienced in combina- tion, are stressful to many individuals and that the stress is sometimes severe enough to result in serious decrements in adaptation and performance (Haythorn, 2008).

Sensory Deprivation

Sensory deprivation, or the removal of reception and/or perception of human stimuli (Chodil & Will- iams, 1970), is noted to be disturbing to many indi- viduals. The importance of continued, varied sensory input is a noted necessity for the maintenance of normal, intelligent, and adaptive behavior in humans (Bexton, Heron, & Scott, 1954). The experience of sensory deprivation has been tested in lab studies by the complete restriction of communication, sights, and sounds from the external world (Bexton et al., 1954; Zubek, 2008). In the field, sensory deprivation has been described through the practice of solitary con- finement in the penal system (Haney, 2003), for hos- pitalized patients in isolated environments (Abad et al., 2010; Barratt, Shaban, & Moyle, 2010; Gammon, 1999), and for persons with restriction on one or many of their senses because of injury or treat- ment (Chodil & Williams, 1970).

In laboratory studies, the outcomes of sensory and stimulus deprivation were summarized by researchers into three themes: tedium stress, reflecting concern with the boredom and monotony of isolation; unreal- ity stress, concerned with the novel and frightening reactions to stimulus reduction; and positive contem- plation, reflecting the positive reactions of some indi- viduals to the opportunity that isolation provides for thinking about one’s life and the meaning of things (Haythorn, 2008). These themes have been validated in observational and qualitative studies in the health- care literature with patients in source isolation for infectious disease and protective isolation for cystic fibrosis and cancer reporting boredom, stress, fear, and positive reactions to the experience (Abad et al., 2010; Barratt et al., 2010; Bolin, 1974; Campbell, 1999;

H. M. Gilmartin et al. Isolation: A Concept Analysis

Gammon, 1999; Knowles, 1993; Madeo, 2001; Russo, Donnelly, & Reid, 2006; Skyman, Sjostrom, & Hell- strom, 2010; Ward, 2000; Wassenberg, Severs, & Bonten, 2010).

In addition, Wexler, Mendelson, Leiderman, and Solomon (1958) summarized the outcomes of previ- ous studies on experimental sensory deprivation, stating that subjects in these studies demonstrated an inability to tolerate or adapt to the stress of sensory isolation; subjects attempted to obtain extrinsic physi- cal and social stimuli during the experience; and the progressive failure, in certain subjects, of reality contact led to the emergence of pathological thought processes and behaviors. In essence, sensory depriva- tion acts as a stressor for humans for it jeopardizes a subject’s hold on external reality because of the chal- lenges to the person’s reality orientation. Negative outcomes, such as anxiety, depression, and hallucina- tions, have been reported by subjects (Abad et al., 2010; Bexton et al., 1954; Gammon, 1999; Vernon & McGill, 1957; Wexler et al., 1958; Zuckerman et al., 1968).

Social Isolation

Social isolation emphasizes the separation of persons from significant others, groups, activities, and social situations that subsequently impairs a person’s social processes (Biordi & Nicholson, 1995; Sells, 2008). There have been no direct laboratory studies testing the separate effects of social isolation from those of confinement and sensory deprivation, but Haythorn (2008) supports the hypothesis that social isolation by itself is a significantly stressful condition for at least a substantial number of people and that the reactions to it are distinguishable from those of confinement and sensory deprivation. Observational studies in the healthcare literature have described social isolation as an alienating, lonely experience with negative health consequences for all ages (Nicholson, 2009; Skipper, Leonard, & Rhymes, 1968; Trowbridge, 2008). Social isolation ranges from the voluntary isolate who seeks disengagement from social intercourse to those whose isolation is involun- tary or imposed by others (Biordi & Nicholson, 1995).

Isolation can occur at four layers of the social concept. The first social layer is the larger community, such as peer groups, next is organizations, such as school and work, followed by confidantes, such as friends and family, and last is the inner person’s ability to apprehend and interpret relationships (Lin, 1986).

In a concept analysis of social isolation in older adults, Nicholson (2009) identified five attributes that define social isolation in this population: number of contacts, feeling of belonging, fulfilling relationships, engagement with others, and quality of network members. In addition, Biordi and Nicholson (1995) have described social isolation to have three additional attributes: the experience of alienation, loneliness, and aloneness. In summary, the experience of social isolation has been well defined in the literature and is noted to lead to negative health consequences for all ages.

Confinement

Confinement connotes a forced, or involuntary, limitation in the amount of physical space and/or restraint on actual physical movement for a person. Confined subjects report emotional overreactions and physical discomfort because of the experience (Haythorn, 2008). Researchers have attempted to isolate the experience of confinement, but they have reported challenges due to the overlapping experi- ences of social isolation and sensory deprivation that occur during confinement (Haythorn, 2008; Zubek, 2008). Because of these challenges, confinement has been broadly defined as a physical concept that then can lead to the psychological concept of isolation, through a combination of social isolation and/or sensory deprivation (Rasmussen, 2008).

Confinement is practiced in the penal system through solitary confinement, where a prisoner is physically segregated from the rest of the prison popu- lation and is excluded from normal programming and collective activities (Haney, 2003). Confinement through geography is seen with travel to distant or isolated locations (Laing & Crouch, 2009) and in geo- graphically isolated populations (Haggard, 2008). Confinement is seen in health care through the use of source and protected isolation, where patients are not permitted to leave their rooms (Abad et al., 2010; Campbell, 1999; Catalano et al., 2003; Gammon, 1998, 1999; O’Connell, 1984; Russo et al., 2006) and in persons who are bedridden because of pregnancy (Schroeder, 1996) or illness (Ishizaki et al., 1994).

Definition of Isolation

Taking into account the attributes, the following definition of isolation is suggested: a state in which an

Isolation: A Concept Analysis H. M. Gilmartin et al.

individual experiences a reduction in the level of normal sensory and social input with possible invol- untary limitations on physical space or movement. It is not possible to state which of the attributes must be present for a person to be defined as isolated because the balance of each attribute varies on the individual’s perception or segment of society the person is func- tioning at.

Related Concepts

Related cases are instances of concepts that are related to the concept being studied but that do not contain all of the defining attributes (Walker and Avant, 2011). However, the concept of isolation is often interchanged with the concept of solitude. Soli- tude, historically, has had a more purposeful, positive, and healthful definition (Phelps, 1966). Solitude is defined as a state of being alone without being lonely and can lead to self-awareness through a positive and constructive state of engagement with oneself (Marano, 2003). Solitude, at times, is desirable and can replenish the soul (Marano, 2003). Throughout history, many philosophers, spiritual leaders, and artists have attested to the benefits of solitude (Long & Averill, 2003).

In addition, seclusion and privacy are related to isolation. The Merriam-Webster Dictionary (2011) defines seclusion as being screened or hidden from view and privacy as the quality or state of being apart from company or observation. These three concepts have similar descriptions, but in opposition to the proposed definition of isolation, they are acts of willing sensory and social reduction with voluntary limitations on space or movement.

Antecedents and Consequences

Walker and Avant (2011) describe antecedents as those events or incidents that must occur or be in place prior to the occurrence of the concept and con- sequences as the events or incidents that are an outcome of the concept (see Table 1). An understand- ing of the individual and the group or segment of society in which the person is functioning is necessary to shed light on the social contexts of isolation (Ras- mussen, 2008). In addition, the situational dimensions that have significant implications on isolation can help define the experience. Situational dimensions include the voluntary versus involuntary nature of the event; the purpose, or instrumental reason; the planning and preparation permitted prior to; the duration of isolation; whether isolation occurs to an individual or as a group; if confinement is severe; if there is a sub- jectively viewed threat from isolation; current social and support conditions; and lastly the environmental variability during isolation (Sells, 2008). The conse- quences, or outcomes, of isolation have been reported in the ordinary and scientific literature as anxiety, depression, mood disturbances, anger, loneliness, and adverse health effects (Abad et al., 2010; Bekhet, Zauszniewski, & Nakhla, 2008; Catalano et al., 2003; Gammon, 1998; Kennedy & Hamilton, 1997; Kuni- tomi et al., 2010; Tarzi, Kennedy, Stone, & Evans, 2001).

Model Case of Isolation

Walker and Avant (2011) define a model case as an example of the use of the concept that demonstrates all of the defining attributes of the concept. An

Table 1. Isolation: A Concept Analysis

Concept Attributes Antecedents Situational dimensions Consequences

Isolation Sensory deprivation Individual perception Voluntary versus involuntary Anxiety Social isolation Situational dimension Instrumental versus obstructive Depression Confinement Planned versus unplanned Mood disturbances

Duration Anger Individual versus group Loneliness Space restriction Adverse health events Threat Social conditions Support conditions Environmental variability

H. M. Gilmartin et al. Isolation: A Concept Analysis

example of isolation would be a person with multi- drug resistant tuberculosis that requires strict airborne isolation. This young man lives in a single 8-square meter space with no windows to view the outdoors. The room has a thick metal door with a 1 ¥ 1 meter window that faces the hallway. The young man is required to be in this room at all times, except for periodic examinations. His activity is limited to actions within his room. He is permitted a television for stimu- lus and has control over the lights in the room, but he is deprived of natural sounds, such as activities in the building or outdoors. Visitation is permitted but strictly limited. His mandated time in isolation will be 6 months.

Borderline Case of the Concept

Borderline cases are those examples or instances that contain most of the defining attributes of the concept being examined, but not all of them (Walker and Avant, 2011). Sarah is undergoing a bone marrow transplant and will be placed in protective isolation for 2 weeks during the treatment and recovery phase. She will be alone in a special room with the door closed at all times. She is not permitted to leave the room, except for special circumstances. She is permitted to have visitors, but they will be required to wear gloves, gowns, and masks during their time in the room. She and her parents have met with a recreation counselor to plan for activities and schoolwork to keep her mind active and entertained during her isolation. She is scared, but she and her parents are ready for the isolation because they know that it will help her heal, and it will protect her from illness when she is most susceptible.

Contrary Case of the Concept

Contrary cases are clear examples of what is not the concept (Walker and Avant, 2011). An example is a mystic who electively separates herself from others and confines herself to small spaces with the goal of inducing a mode of consciousness that permits clarity, relaxation, and internal assessment. She limits her movements to those essential for existence. She is emotionally, physically, and socially isolated from the world. She is not isolated though because she elec- tively enters into isolation to achieve her goals, and she is free to return to her normal life at any time.

Empirical Referents

Empirical referents are classes or categories of actual phenomena that by their existence or presence dem- onstrate the occurrence of the concept itself (Walker and Avant, 2011). After an extensive review of the literature, no empirical referents of the concept of isolation were found, but tools to assess the outcomes of isolation have been reported. Anxiety, depression, mood disturbances, anger, and loneliness have been assessed using instruments, such as the University of California, Los Angeles Loneliness Scale; the Hospital Anxiety and Depression Scale; the Hamilton Anxiety Rating Scale; the Hamilton Depression Rating Scale; the Health Illness Questionnaire; the Self-Esteem Scale; the Consumer Assessment of Healthcare Provid- ers and Systems; the Beck Depression Inventory; the State Anxiety Inventory; the Profile of Mood States; the Abbreviated Mental Test Score; the Barthel Index; the Geriatric Depression Scale; and the Crown-Crisp Experiential Index (Abad et al., 2010; Catalano et al., 2003; Gammon, 1998; Kennedy & Hamilton, 1997; Stelfox, Bates, & Redelmeier, 2003; Tarzi et al., 2001; Wassenberg et al., 2010)

Discussion

The limitations of this concept analysis include the interpretation of the research and potential for not locating source references. Although the literature was used to guide the process, any interpretation is subjective in nature. An extensive search was under- taken, but it is unlikely that this was all-inclusive.

This concept analysis presents an opportunity to develop nursing theory through the adoption of a theoretical model that supports the concept of isola- tion. Nicholson (2009) proposed Roy’s adaptation model as a nursing conceptual model that fits well with social isolation. This will require further study to determine if the model will encompass all the attributes of isolation.

According to Walker and Avant (2011), after con- structing an operational definition of a concept, the location of a research instrument is necessary to con- struct and test theoretical relationships between isola- tion and outcome variables. There is a need for more research to explore implications of the suggested defi- nition. Further clarification is needed to revise and test the attributes of isolation in clinical situations. System- atic studies of isolation can ultimately enhance nurses’

Isolation: A Concept Analysis H. M. Gilmartin et al.

knowledge base and contribute to the quality of life for isolated persons.

Conclusion

Being alone does not make a person isolated. The state of isolation that can lead to negative experiences and outcomes requires a combination of psychological and physical factors to experience the deleterious effects. The research presented here has identified and examined important characteristics of isolation. Isola- tion is defined as a state in which an individual expe- riences a reduction in the level of normal sensory and social input with possible involuntary limitations on physical space or movement. Nursing has an impor- tant role to play in recognizing isolation and in acting to minimize the event on their patient’s behalf.

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