Isolation

The recognition of the medical benefits of isolating patients to prevent the spread of infection has led to the development of specific guidelines aiming to clarify principles of isolation (Gould and Chamberlaine 1995). Source isolation is the main guiding principle whereby the patient, as the source of infection, is nursed in isolation from other patients. Until recently, the emphasis on prevention of hospital epidemics has overshadowed consideration of the consequences for the isolated patient. In particular, interest in the psychological consequences is relatively new. Lesko et al (1984) and Collins et al (1989) conducted research on the experiences of patients in protective isolation – those who are in isolation because they are at high risk of cross-infection from other patients. Lesko et al (1984) found in particular, that only eight hours of isolation in a cubicle resulted in higher generalized stress levels. Knowles (1993) highlights, however, that despite the similarities between protective isolation and source isolation, there are important differences. Protective isolation involves awareness of benefits to oneself, choice, and a period of preparation by the patient for the experience. Source isolation confers no benefit to the patient, deprives him or her of choice, and often leaves no time to prepare. There is currently an increasing prevalence of infection with antibiotic-resistant bacteria in hospitals in the developed world, the most frequently identified bacterium being methicillin-resistant Staphylococcus aureus (MRSA) (Gould and Chamberlaine1995). Research has identified many variables that can positively influence mood. For example, Kennedy and Hamilton (1997) highlighted factors which might have mitigated mood disturbance in their population of isolated spinal cord injury patients, such as younger age, and the high levels of concurrent supportive interventions available in that rehabilitation setting. Patients also commented that additional privacy was advantageous, allowing more time to think, and feeling more relaxed. Nichols (1993), among others, has identified one of the core principles of appropriate psychological care to be good emotional care. Three elements are involved in addressing the emotional needs of medical patients: Acknowledging patients’ emotional responses (and identifying abnormally high levels of mood disturbance). Providing a supportive environment and relationship, this allows the patient to express distress safely. Providing basic supportive counseling. The last of these involves a range of skills in which nurses are increasingly seeking training. Mood disturbance is a significant consequence of source isolation in a proportion of patients. Anecdotal evidence suggests that the deprivation of social contact when in isolation can be an extremely distressing factor to patients (Knowles1993). Gammon (1998) observed loss of self-esteem and sense of control among isolated patients, with an associated higher rate of anxiety and depression. The current management of patients infected with one of the increasingly prevalent antibiotic resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) involves nursing in source isolation. Hospital staff are now recognizing that patients experience feelings of being shunned by staff (Bennett 1983), a deprivation of personal contact (Ketcham 1981) and loss of control and choice (Denton 1986). There are clinical situations in the general hospital in which contact isolation is necessary. The most common types of infectious disease isolation are source isolation and reverse barrier isolation. (MacKellaig JM.1987). Source isolation refers to a patient who is colonized or infected by an organism and requires isolation to protect other patients from possible infection. (MacKellaig JM.1987). Protective (i.e., reverse barrier) isolation protects the patient from infections potentially carried by others. (MacKellaig JM.1987). Both types of isolation may adversely affect the delivery of medical care. For example, physical rehabilitation can be hampered by isolation protocols because of the patient’s restricted access to the physical therapy areas. (Peel et al 1997). Many community facilities are reluctant to accept patients who require that isolation precautions be taken. Peel et al 1997). Another consideration is that patients dislike being placed in isolation. Patients in isolation often perceive that they are treated differently from other patients. These concerns about different levels of care may not be far off the mark; in their study, Kirkland and Weinstein (1999) found that health care workers were half as likely to enter the room of a patient in contact isolation as they were to enter the room of a non isolated patient. There is concern that isolation may negatively affect a patient’s mental health. Peel et al stated that the psychological impact of spending weeks in isolation is “considerable.” MacKellaig reported that “extreme changes in human behavior” can occur in people who have been isolated, including delusions, hallucinations, and memory disturbances. Holland et al noted that these patients felt isolated and that they thought that their “most significant” psychological deprivation was the loss of human touch.