Center Conducting Review
Indiana Center for Evidence Based Practice
Purdue University Calumet, Indiana
United States of America
Beth Vottero PhD, RN, CNE
Indiana Center for Evidence-Based Practice
Leslie Rittenmeyer Psy.D, RN
Indiana Center for Evidence-Based Practice
Many articles are written about guidelines and processes for placing patients in isolation, but less is known about the hospitalized patient's perceived experiences of being in isolation. The Centers for Disease Control (CDC) defines the use of isolation as separating ill persons with a communicable disease from those who are healthy to prevent cross-contamination between or among individuals (1). Hospital isolation procedures include the use of personal protective equipment (PPE), although consideration for the use of such equipment and the type of isolation (negative pressure and/or precaution type) are beyond the scope of this review. This review focuses specifically on the experience of the patient in isolation rather than the reason for isolation.
The placement of hospitalized patients in isolation is either done to protect the immunocompromised patient from others (reverse or protective isolation) or to protect others from the patient's infectious process (isolation). Both situations require limiting the contact between the patient and others in order to prevent the spread of pathogens or protect the patient who is immunocompromised. Gammon (2) describes source isolation as segregating the person with an infection or infectious disease to prevent cross-infection and protective isolation as protecting susceptible patients from contracting an infection from staff, other patients, or visitors. Regardless of the type of isolation, patient experiences resulting from being in isolation are important to form the basis for nursing care delivery that meets the patient's psychosocial and physical health care needs.
The duration of isolation is difficult to quantify and can last days, weeks, or months. The CDC describes the duration of isolation as dependent upon the reason for isolation (1). For source isolation, the duration lasts until the environment is decontaminated, until time specified after treatment is initiated, or in some cases, the duration remains unknown (1).
For the immunocompromised patient with temporary periods of neutropenia (reverse or protective isolation) the duration of isolation is dependent upon the duration of neutropenia, which is determined by individual lab tests. In either scenario, the duration of isolation initiates from detection of pathogen or neutropenia and can last through resolution of the initial problem, regardless of the number of days or months involved.
Apart from the reason for isolation, the patient in isolation is vulnerable to unique stressors that emerge from the experience. No systematic review exists to discover the meaning of being in isolation from the hospitalized patient's perspective. Rather than focusing on the reason for isolation, this proposal considers the effects of being in isolation from the patient's perspective.
For the purpose of this review, isolation will include any form of removing the patient from direct contact with others due to an infectious process or reverse isolation (3).
While the literature describes a detrimental psychological impact on the patient in isolation, it is not feasible to eliminate isolation procedures in the hospital setting. The nature of communicable diseases combined with the need to place immunocompromised patients in protective isolation supports isolation protocols and policies. Consideration for the holistic care of the patient in isolation necessitates concern not only for the body, but also the mind and spirit. For that reason, nurses require knowledge of not only procedures for placing patients in isolation, but also on the meaning of isolation by the hospitalized patient to plan and provide appropriate nursing care.
Researchers have identified psychological effects of isolation as producing anxiety, depression, hallucinations, fear, frustration, loneliness, and anger (3-6). Research by Catalano et al. (5) identified “…significant negative alterations in mood and anxiety level occur after only 1 week of isolation” (p. 144). Findings suggest that patients in isolation, regardless of the criticality of their illness demonstrated increased symptoms of anxiety and depression. Gaskill (1) found that patient perceptions of being in isolation included a lack of motivation and disinterest in activities of daily living. The feeling of facing another day elicited responses of lasting lethargy and depression, negatively impacting recovery. Results from the study indicated that patients perceived a distinct lack of ‘true presence’ or ‘being with’ the patient during nursing care. The ability of the nurse to understand and connect with the patient's meaning and experience on a level that is significant for the patient substantially impacted patient's perceptions. Additionally, a need for nurses to acknowledge how patients interpret their environment, including the behaviors of staff within the environment, was an important aspect of the patient's perceived experience. Consequently, nurse awareness, knowledge, and assimilation of actions or interventions associated with ‘being with’ the patient can strongly influence psychological effects of isolation.
Coping with isolation was found to contribute to the psychological effects with varying results. Gammon (4) found that the lack of control over being in isolation directly impacted coping abilities and psychological stressors. Placing the patient in isolation separated the person from their normal habits and routines, disrupting their ability to control their life. Findings suggested that isolated patients experienced the lack of control differently resulting in varied coping mechanisms. When the lack of control was not acknowledged by health care workers, the patient manifested coping mechanisms as psychological indicators of stress (anxiety, depression, etc.).
Collins (7) identified that a positive attitude towards isolation emerged when the patient's unique style of coping was recognized and respected by health care providers. In order to prevent or diminish psychological stressors related to isolation, nurses must be aware of factors that influence the perspective of the isolated hospitalized patient.
Isolating patients with an infectious disease or to protect immunocompromised patients remains a primary treatment in the hospital setting. Isolation procedures consider the person in terms of the disease, but do not respect the holistic mind-body-spirit of the total patient. A need exists to develop a knowledge-base of how the person perceives the meaning of being in isolation to inform the development of proper nursing care for the isolation patient. A systematic review of the evidence is proposed to clarify the meaning of isolation by the hospitalized patient. Findings will inform identification of appropriate interventions to minimize harmful effects from placing patients in isolation.
The overall objective of this systematic review is to synthesize the best available evidence on the meaning of being in isolation from the hospitalized patient's perspective for both protection and as a barrier for hospitalized patients.
Criteria for considering studies for this review
Types of Studies
This review will consider qualitative research studies about the patient's perspective of being in isolation, research consisting of, but not limited to, designs such as interpretive, descriptive-exploratory, observational, phenomenology, ethnography, grounded theory, hermeneutics, participatory action research, and critical theory. In the absence of research studies, text and opinion papers and reports will be considered and reported in a narrative summary.
Types of Participants
This review will consider hospitalized adult patients in isolation for protection from others or as a barrier to prevent the transmission of infection.
Phenomena of Interest
The phenomenon of interest consists of patients' experience, perceptions and meanings from being in isolation.
The setting will be limited to hospital environments.
The context will be patients in isolation as both a protective measure and as a barrier for cross-infection.
The comprehensive search strategy aims to find both published and unpublished studies. The search will be limited to English language reports from 1971 to May 2010. A three-step search strategy will be used in each component of the review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract and the index terms used to describe the article.
A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of identified reports and articles will be hand searched for additional studies.
The databases to be searched include:
EBSCOHost Health Source: nursing/Academic Edition
Elsevier Science Direct
ISI Web of Science
Psychology and Behavioral Sciences Collection
TRIP (Turning Research into Practice)
The search for unpublished studies or grey literature will include:
Theses Canada Portal
Proquest Dissertations and Theses [http://proquest.umi.com/login]
Grey Literature Bulletin (North West Health Library & Information Service, UK)
Index to Theses
Networked Digital Library of Theses and Dissertations (NDLTD)
DiVA [dissertations and other publications in full text from Nordic universities]
Institute for Health & Social Care Research (IHSCR)
OPHL (Ontario Public Health Libraries Association)
Policy Hub [http://www.policyhub.gov.uk/about/]
Public Health Agency of Canada
New York Academy of Medicine's Grey Literature Report
Initial Keywords to be used will include a combination of the following: isolation, protective, barrier, patient perception, patient meaning, feeling, hospital, isolation experience, source isolation, psychological effects, psychological consequences.
Assessment of Methodological Quality
Methodological quality will be independently established by two reviewers, using standardized appraisal tools from the Joanna Briggs Institute (JBI) System for the Unified Management, Assessment and Review of Information (SUMARI) package (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or, if needed, with a third party reviewer.
Data will be extracted from papers included in the review using standardized JBI data extraction tools (Appendix II).
Data from qualitative research papers will be synthesized using the JBI Qualitative Assessment and Review Instrument (QARI). In the absence of research studies, data from text and opinion papers and reports will be synthesized using the JBI Narrative Opinion, and Text Assessment and Review Instrument (NOTARI).
Potential Conflict(s) of Interest
No potential conflict of interest is anticipated.