Psychological aspects of patients in germ-free isolation: a review of child, adult, and patient management literature

Construction and Validation of a Scale to Measure Loneliness and Isolation During Social Distancing and Its Effect on Mental Health

A variety of factors contribute to the degree to which a person feels lonely and socially isolated. These factors may be particularly relevant in contexts requiring social distancing, e.g., during the COVID-19 pandemic or in states of immunodeficiency. We present the Loneliness and Isolation during Social Distancing (LISD) Scale. Extending existing measures, the LISD scale measures both state and trait aspects of loneliness and isolation, including indicators of social connectedness and support. In addition, it reliably predicts individual differences in anxiety and depression. Data were collected online from two independent samples in a social distancing context (the COVID-19 pandemic). Factorial validation was based on exploratory factor analysis (EFA; Sample 1, N = 244) and confirmatory factor analysis (CFA; Sample 2, N = 304). Multiple regression analyses were used to assess how the LISD scale predicts state anxiety and depression. The LISD scale showed satisfactory fit in both samples. Its two state factors indicate being lonely and isolated as well as connected and supported, while its three trait factors reflect general loneliness and isolation, sociability and sense of belonging, and social closeness and support. Our results imply strong predictive power of the LISD scale for state anxiety and depression, explaining 33 and 51% of variance, respectively. Anxiety and depression scores were particularly predicted by low dispositional sociability and sense of belonging and by currently being more lonely and isolated. In turn, being lonely and isolated was related to being less connected and supported (state) as well as having lower social closeness and support in general (trait). We provide a novel scale which distinguishes between acute and general dimensions of loneliness and social isolation while also predicting mental health. The LISD scale could be a valuable and economic addition to the assessment of mental health factors impacted by social distancing.

The experiences of protective isolation in patients undergoing bone marrow or haematopoietic stem cell transplantation: systematic review and metasynthesis

Protective isolation is aimed at preventing infection in neutropenic patients, but it is implemented inconsistently across centres and is supported by recommendations with poor evidence. This review and metasynthesis explored the experiences and the psychological implications of protective isolation in patients with haematological malignancies undergoing bone marrow (BMT) or haematopoietic stem cell transplantation (HSCT). A systematic search of multiple databases for qualitative studies exploring BMT or HSCT patients' experiences of protective isolation was completed. The metasynthesis followed the meta-aggregative method from the Joanna Briggs Institute, with four procedural steps: (1) comprehensive search, (2) quality appraisal, (3) extraction of relevant findings and (4) synthesis of the identified findings. Twenty-six findings were extracted from 11 articles included in the review. The synthesising process yielded seven categories, aggregated into three synthesised findings: (1) isolation is a source of suffering, (2) isolation can lead to relating with oneself and (3) the person does not close the door to the outside world. This metasynthesis sheds light on patients' suffering from being isolated, and the possibility of overcoming this suffering thanks to relationships that patients have with themselves and with the external world. Healthcare providers should reconsider this practise in order to avoid unnecessary patient suffering.

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events

Contact isolation of infected or colonised hospitalised patients is instrumental to interrupting multidrug-resistant organism (MDRO) cross-transmission. Many studies suggest an increased rate of adverse events associated with isolation. We aimed to compare isolated to non-isolated patients in intensive care units (ICUs) for the occurrence of adverse events and medical errors.

METHODS

We used the large database of the Iatroref III study that included consecutive patients from three ICUs to compare the occurrence of pre-defined medical errors and adverse events among isolated vs. non-isolated patients. A subdistribution hazard regression model with careful adjustment on confounding factors was used to assess the effect of patient isolation on the occurrence of medical errors and adverse events.

RESULTS

Two centres of the Iatroref III study were eligible, an 18-bed and a 10-bed ICU (nurse-to-bed ratio 2.8 and 2.5, respectively), with a total of 1,221 patients. After exclusion of the neutropenic and graft transplant patients, a total of 170 isolated patients were compared to 980 non-isolated patients. Errors in insulin administration and anticoagulant prescription were more frequent in isolated patients. Adverse events such as hypo- or hyperglycaemia, thromboembolic events, haemorrhage, and MDRO ventilator-associated pneumonia (VAP) were also more frequent with isolation. After careful adjustment of confounders, errors in anticoagulant prescription [subdistribution hazard ratio (sHR) = 1.7, p = 0.04], hypoglycaemia (sHR = 1.5, p = 0.01), hyperglycaemia (sHR = 1.5, p = 0.004), and MDRO VAP (sHR = 2.1, p = 0.001) remain more frequent in isolated patients.

CONCLUSION

Contact isolation of ICU patients is associated with an increased rate of some medical errors and adverse events, including non-infectious ones.

Psychosocial predictors of immune response following bone marrow transplantation

This study analyzed the relationship between some psychosocial variables (depression, anxiety, stress, coping strategies, social support, optimism, rationality, and need for harmony) and clinical parameters indicative of immunological response after bone marrow transplantation (BMT; day of engraftment, number of infections and hemoglobin level) while controlling for demographic variables (age, educative level, civil state, and time from cancer diagnosis). Thirty-one post BMT hematological cancer patients were evaluated. Results show that higher educative levels are associated to lower number of infections, while age is associated with a delay in the time of engraftment; coping strategies, specially redefinition of the situation, relaxation, stoicism and passivity, are positively associated with the three clinical indices; depression is positively associated to number of infections during the hospitalization period; and rationality is associated with lower hemoglobin levels. These results suggest that psychosocial variables, especially coping strategies, play an important role in determining the immunological response after BMT.

The experience of being a neutropenic cancer patient in an acute care isolation room: a systematic review of qualitative evidence

BACKGROUND

Protective isolation is one of the precautionary measures put in place for neutropenic cancer patients, where patients will be placed in an isolation room during their medical treatment in the hospital. The purpose of this practice is to minimise neutropenic patients from contracting nosocomial infection and the length of stay in the isolation room varies depending on their medical condition. It has been reported in some literature that this group of patients experience social isolation, a wide range of emotions and psychological burdens such as depression and anxiety as a result of staying in the isolation room. Therefore, a systematic review on neutropenic cancer patients' experience in isolation room will add knowledge to the nursing science of providing high quality care for this particular group of patients.

OBJECTIVES

The objectives of this review are to understand neutropenic cancer patients' experiences in the isolation room and their coping mechanisms.

INCLUSION CRITERIA

The participants of interest were adults neutropenic cancer patients aged 18 years old and above.The phenomenon of interest i was the experience of neutropenic cancer patients who were nursed in an isolation room due to chemotherapy induced neutropenia or during the period of haematopoietic stem cell transplant.The studies of interests were are qualitative studies which focus on adult neutropenic cancer patients' experiences in an isolation room.The outcome of interest wai s patients' self reported experiences.

SEARCH STRATEGY

An initial search to identify keywords was undertaken in MEDLINE and CINAHL. A second search using all identified keywords and index terms across the databases was performed subsequently. The final search included reference lists from included papers for additional studies.

METHODOLOGICAL QUALITY

Six qualitative papers were included in this review. The papers were qualitative descriptive, phenomenological, qualitative exploratory and grounded theory. All the papers used interview as primary method to collect data except one study which had an additional art making directive method.

DATA COLLECTION

Data were extracted using standardised data extraction tools from JBI-QARI.

DATA SYNTHESIS

Categories were formed based on aggregation from the similar findings with like meaning. The categories were then read and reread to develop two synthesised findings that were presented as declamatory and generalisable statements to guide and inform clinical practice.

RESULTS

Two syntheses were generated based on the meta-aggregation. The first synthesis was that health care workers need to be aware physical isolation could result in social isolation in patients that made them feel powerless. The second synthesis was that health care workers should encourage patients to use cognitive mechanisms to cope with isolation experiences. Family, friends and nurses should step in to provide help in any form whenever patients need it.

CONCLUSIONS

Isolation room has a negative impact on the neutropenic cancer patients while they are hospitalised. However, they are coping effectively using cognitive mechanisms and receive adequate support externally.Offering patients more options especially having flexibility in their daily routine such as meal times could be a useful intervention to allow them to take some control. Notifying the patient in advance of their time of treatment and involving patients in their treatment care will promote their autonomy. Tracking the patients' coping mechanisms and offering support when necessary will ease the patients' isolation experience.The psychological effects of being cared for in isolation room may undermine the clinical benefits of infection control. Therefore, future research is needed to evaluate the effectiveness of isolation room in preventing neutropenic cancer patients from infection.

Adverse effects of isolation in hospitalised patients: a systematic review

The use of transmission precautions such as contact isolation in patients known to be colonised or infected with multidrug-resistant organisms is recommended in healthcare institutions. Although essential for infection control, contact isolation has recently been associated with adverse effects in patients. We undertook a systematic review to determine whether contact isolation leads to psychological or physical problems for patients. Studies were included if (1) hospitalised patients were placed under isolation precautions for an underlying medical indication, and (2) any adverse events related to the isolation were evaluated. We found 16 studies that reported data regarding the impact of isolation on patient mental well-being, patient satisfaction, patient safety or time spent by healthcare workers in direct patient care. The majority showed a negative impact on patient mental well-being and behaviour, including higher scores for depression, anxiety and anger among isolated patients. A few studies also found that healthcare workers spent less time with patients in isolation. Patient satisfaction was adversely affected by isolation if patients were kept uninformed of their healthcare. Patient safety was also negatively affected, leading to an eight-fold increase in adverse events related to supportive care failures. We found that contact isolation may negatively impact several dimensions of patient care. Well-validated tools are necessary to investigate these results further. Large studies examining a number of safety indicators to assess the adverse effects of isolation are needed. Patient education may be an important step to mitigate the adverse psychological effects of isolation and is recommended.

Risk perception and compliance with quarantine during the SARS outbreak

PURPOSE

To explore the experience of being on quarantine for severe acute respiratory syndrome (SARS) with a focus on the relationship between perceived risk of contracting SARS and reported compliance with the quarantine order and protocols.

DESIGN

Descriptive, qualitative.

METHODS

Semi-structured interviews were conducted with people who had been quarantined during the SARS outbreak in Toronto in 2003. Data analysis was completed using an iterative and collaborative approach of reading and re-reading the transcribed interviews, identifying common themes, and comparing and contrasting the data.

FINDINGS

To varying extents, participants wavered between fear and denial about their risk of contracting or spreading SARS. Reported compliance with the actual quarantine order was high. However, within households quarantine protocols were followed unevenly.

CONCLUSIONS

This research indicates the need for greater credibility in public health communications to increase compliance with quarantine protocols and to contain outbreaks of new and deadly infectious diseases.

The experience of quarantine for individuals affected by SARS in Toronto

OBJECTIVE

The purpose of this study was to explore the experience of home quarantine during the severe acute respiratory syndrome (SARS) outbreak in Toronto in 2003.

DESIGN

Qualitative descriptive design.

SAMPLE

Stratified random sampling techniques were used to generate a list of potential participants, who varied in terms of gender and closeness of exposure to someone with suspected SARS (contact level). Twenty-one individuals participated in the study.

MEASUREMENTS

All interviews were audiotaped and followed a semistructured interview guide. Participants were invited to describe their experience of quarantine in detail including their advice for Public Health.

RESULTS

The experience followed a trajectory of stages beginning before quarantine and ending after quarantine. Despite individual differences, common themes of uncertainty, isolation, and coping intersected the data.

CONCLUSIONS

Public Health has a dual role of monitoring compliance and providing support to people in quarantine. This study has implications for public health policy and practice in planning for future public health emergencies in terms of the information and the resources required to mount an effective response.

Songwriting and digital video production interventions for pediatric patients undergoing bone marrow transplantation, part I: an analysis of depression and anxiety levels according to phase of treatment

Purposes of this exploratory case study were: (1) to examine how anxiety and depression levels vary with phase of bone marrow transplantation (BMT) and (2) to examine the effect of the proposed music therapy treatment protocol on anxiety and depression levels. Six pediatric BMT patients participated in the study. Three participants experienced the music condition and three participants experienced the no-music contact condition. Both conditions consisted of six, one-hour sessions that occurred over a three week period. The Children's Depression Inventory (CDI) was administered at the conclusion of each session to examine changes in depression levels across each phase of treatment. The State Trait Anxiety Inventory for Children (STAIC) served as a pre-/post-session measure of state anxiety. Graphic analysis of scores from the CDI and STAIC indicated a consistent trend in depression and anxiety levels according to phase of treatment for all participants. Four participants (3 music; 1 no-music) experienced decreased anxiety following a majority of sessions.

Songwriting and digital video production interventions for pediatric patients undergoing bone marrow transplantation, part II: an analysis of patient-generated songs and patient perceptions regarding intervention efficacy

Part I of this exploratory case study examined patient anxiety levels and depressive symptoms according to phase of bone marrow transplantation (BMT). The second part of this study examines more qualitative outcomes of the music therapy intervention. Purposes of this part of the study included: (1) to examine the lyrical content of patient-generated songs and (2) to compare patient perceptions regarding the effectiveness of a 6-week music condition with a no-music contact condition. Six pediatric BMT patients participated in the study. Three participants experienced the music condition and three participants experienced the no-music contact condition. Both conditions consisted of six, 1-hour sessions that occurred over a 3-week period. Content analysis of patient-generated songs revealed expression of issues related to the following themes: hope, positive coping, appreciation, mental status, control, time, bewilderment, treatment, and diagnosis. Examination of patient-generated songs provided insight into each patient's experience with transplantation and the coping strategies used during treatment. Outcomes from a poststudy questionnaire are summarized.

Infection control: reducing the psychological effects of isolation

Although previous studies have shown that some patients, when nursed in isolation for infection control purposes, experience negative emotional effects, little research has been published which suggests what healthcare professionals can do to prevent or reduce these effects. A study was therefore carried out involving 21 patients being nursed in isolation who completed questionnaires. Five patients with negative experiences of isolation were then interviewed about the reasons for feeling the way they did and what they felt could be done to reduce or prevent negative emotions. Recommendations made from the research include the provision of written and individualized information, improved communication from medical staff, provision of a common room and better facilities to relieve boredom. Further large scale research is needed to investigate strategies to improve the isolation experience.

The psychological consequences of source isolation: a review of the literature

Source isolation can be an extremely frightening and anxiety provoking experience. With the many epidemiological changes that are prevalent in the UK today the need to care for individuals in source isolation is becoming increasingly important to prevent the spread of infection in hospitals. However, the psychological effects of source isolation are not well understood or researched. This review defines and examines the historical developments of source isolation and then discusses related research which suggests possible effects of source isolation on an individual's psychological well-being. Research which has determined the effects of sensory deprivation and social isolation are discussed, together with literature on the intensive care syndrome. This review highlights the lack of research on the psychological effects of source isolation. Furthermore, literature and research on related aspects of isolation suggests very serious effects are noted on the psychological well-being of individuals. Whilst a cessation of source isolation is not an option, urgent research is required to examine what nurse interventions can be implemented to ameliorate these negative effects.

Therapeutic play and bone marrow transplantation

Constructive, therapeutic play is an essential part of the care of children with long-term hospitalizations. The O'Connor theoretical framework supports the importance of play in ensuring the emotional, developmental, and physical health of children. The negative effects of long-term hospitalization are particularly evident for children who have undergone bone marrow transplants and must be kept in germ-free environment and isolation for extended periods of time. This article describes a successful play therapy program in a Bone Marrow Transplant Unit, using a play cabinet designed to provide readily available, sterilized toys that are appropriate for each of four age groups. Two cases are presented that show the efficacy of the use of the play cabinet in play therapy programs.

Measurement of behavioral, affective, and somatic responses to pediatric bone marrow transplantation: development of the BASES scale

A new measure to assess behavioral, affective and somatic outcomes in the acute phase of bone marrow transplant is described. The Behavioral Affective and Somatic Experiences Scale (BASES) is a 38 item nurse-report instrument, with five subscales labeled Somatic distress, Compliance, Mood/Behavior, Interactions, and Activity. A series of pilot studies were conducted to refine the content of the BASES scale and to establish its psychometric properties in terms of internal consistency, inter-rater reliability, and validity. Internal consistency (Chronbach's alpha) for the subscales ranged from .742 to .902. Inter-rater reliability was good, with a median correlation between paired nurse observations of .866. A parent report version of the BASES scale has also been developed, and the finding of significant parent-nurse correlations provides preliminary evidence of the validity of the measure. Potential uses of the BASES scale in the pediatric BMT setting are discussed.

Psychiatric and psychosocial aspects of bone marrow transplantation

Bone marrow transplantation (BMT) is being increasingly used to treat children and adults with a variety of life-threatening diseases. Although BMT is a life-saving intervention in many instances, it is a high-technology procedure--both aggressive and life-threatening--associated with an array of physical and psychological stressors. Therefore, psychiatric and psychosocial research and intervention can greatly contribute to the understanding and management of BMT recipients, donors, and their families. Seven major areas of psychiatric and psychosocial concern in BMT are identified and the literature relevant to each area is reviewed.

Bone marrow transplantation: support of the patient and his/her family

Bone marrow transplantation (BMT) has evolved over the last decade from a controversial research procedure to a standard therapeutic modality, becoming an important innovative treatment for hematological malignancies, solid tumors, immunodeficiency diseases and metabolic disorders. Historically in research and clinical literature, the BMT procedure is divided into several stages, each accompanied by particular emotional tones and psychological issues. In providing care for transplant recipients, donors, and families, caregivers must be familiar with the psychological stages of the procedure, the psychological themes such as body image, and the patient's mechanisms of coping with the stress of such protocols. BMT's complex regimens of high-dose chemotherapy and total-body irradiation, germ-free environments, graft-versus-host disease, and total parenteral nutrition can precipitate significant psychological sequelae in some patients with acute and long-term consequences. In response to their illness, transplant patients may also develop emotional disturbances of anxiety, depression, agitation, and non-compliance. This paper will address the psychological care of the patient, donor and family from pre-BMT consultation, through informed consent, hospitalization and convalescence. Various psychotherapeutic, pharmacological and behavioral interventions will be briefly described. Finally, areas of research in quality of life after BMT and factors that may predict BMT adjustment and outcome will be explored. We hope this brief paper will familiarize the reader with this psychologically intriguing field and will provide a departure point for future reading, study, research, and patient/family care.

Pegademase bovine: replacement therapy for severe combined immunodeficiency disease

Severe combined immunodeficiency (SCID) represents a syndrome characterized by abnormal function of cellular and humoral immunity. Of the various types of SCID, approximately one-fourth are associated with adenosine deaminase (ADA) deficiency. Treatment consists of bone marrow transplantation, red blood cell transfusions, enzyme replacement, and, more recently, gene therapy. Pegademase bovine is the sole agent available for enzyme replacement therapy of SCID associated with ADA deficiency. The drug is administered intramuscularly to infants from birth and to children of any age at time of diagnosis. At present, few adverse effects or drug interactions have been documented. Although it is expensive (approximately $60,000 annually), pegademase bovine offers an alternative to standard means of therapy.