For most people, occasionally spending time alone bolsters their defences against life’s trials and tribulations. But few of us want to become modern-day hermits: loneliness and social isolation (LSI) harm our mental and physical health.
‘The World Health Organisation and Department of Health recognise LSI as a serious risk factor for poor health outcomes,’ says Robin Hewings, Programme Director at the Campaign to End Loneliness, a UK-based charity. And LSI is common. Mr Hewing notes that the Office for National Statistics (ONS) estimates that 3.3 million people – about three times the population of the City of Birmingham – in the UK feel ‘chronically lonely’.
It’s not just patients who live with the consequences of LSI. A recent review suggests that LSI promotes emotional exhaustion and burn-out among community and hospital nurses.1 ‘Early in my career as a nurse, I relied heavily on my peers for support,’ says Dr Rachel Wood, Assistant Professor, Virginia Commonwealth University School of Nursing, in Richmond, USA and the review’s lead author. ‘We helped each other not only with the physical duties, but we also leaned on one another to help process and cope with the emotional burdens of our work.’
But soon after moving into professional development and education, Professor Wood was struck by how many nurses seemed to be struggling with their wellbeing. ‘The strong social support I had experienced didn’t seem to be as common anymore,’ she says. ‘It’s become a passion of mine to learn more about how clinicians experience loneliness and how it detracts from their overall wellbeing.’
A common problem
LSI is inherently subjective: a gregarious person’s view of sociability may be a wallflower’s idea of purgatory. So, defining LSI is difficult. Professor Wood draws a distinction between loneliness and social connectedness.1 Lonely people feel distress because the quality or quantity of their social connections does not meet their emotional needs.2 Social connectedness reflects a person’s perception that the frequency of social contacts meets their emotional needs and desired relationships.3 ‘Loneliness and social connectedness are very closely related, if not directly inverse concepts - almost like two sides of the same coin,’ Professor Wood explains.
‘Loneliness acknowledges that social connections are inadequate. Social connectedness looks for evidence that connections are adequate.’
‘Essentially, LSI arises from a mismatch between the social relationships that the person wants or needs and those they have,’ Mr Hewings says. ‘LSI can arise from poor quality relationships as well as too few social relations. LSI in bullied schoolchildren reflects poor quality relationships rather than isolation. The problems with the definition mean that it is difficult to be accurate about epidemiology, but there is no doubt that LSI is very common.’
The Campaign to End Loneliness notes that the ONS estimates that 6.3% of adults in the UK, some 3.3 million people, felt lonely often or always between September and November 2021. Perhaps surprisingly, loneliness did not rise at the start of the COVID-19 pandemic. But during the second lockdown, the number of adults reporting feeling lonely ‘often’ or ‘always’ rose from 5.0% in April and May 2020 to 7.2% between October 2020 and February 2021. ‘That may not seem a large absolute increase, but it translates into about another million people,’ Mr Hewings points out. The number of people feeling lonely often or always rose from 2.6 million adults to 3.7 million, an increase equivalent to twice the population of the City of Manchester.
‘People coped well during the initial lock down,’ Mr Hewings says. But the further rounds of lock down took their toll. ‘Certain people, such as students, were especially vulnerable, partly because the pandemic disrupted our ability to build and sustain relationships,’ he notes. ‘The data suggests that levels of social isolation seem to remain elevated.’
While common, certain people seem especially prone to LSI, such as those who experienced physical, social and emotional abuse, and people with mental health issues. Lonely children often grow into socially isolated adults. Women also seem especially vulnerable. The Campaign to End Loneliness found that 56% of women and 43% of men ‘experienced some feelings of loneliness’ between September and November 2021.
The Campaign to End Loneliness suggests that the cost-of-living crisis and the looming recession will mean LSI becomes even more widespread. ‘Having less disposable income can reduce a person’s ability to maintain social relationships. Social isolation is a particular problem for people on low incomes,’ Mr Hewings notes. ‘Lack of money can push vulnerable people into crisis.’
Age also influences the likelihood of LSI, although the results seem to depend on how you ask the question. The Campaign to End Loneliness says, based on ONS data, that 9% of those aged 16-29 years reported chronic loneliness between September and November 2021 compared to 4% of those people older than 70 years. But other estimates suggest that LSI among seniors is more common than these figures suggest. For instance, a UK survey of people aged 80 years or older found that 16% felt slightly lonely and 25% felt lonely.4
In addition, being a loner carries considerable stigma. So, traditionally, people may have been reluctant to admit to LSI, skewing the epidemiological estimates. ‘Perhaps the pandemic has made it more accepted to acknowledge LSI, removing past stigma around admitting distress,’ Professor Wood suggests. ‘Further research needs to clarify the epidemiology of LSI in different populations,’ Mr Hewings adds.
Managing LSI
Each socially isolated person is lonely in their own way. ‘Efforts to tackle LSI need to be targeted and individualised,’ says Mr Hewings. ‘Some people are quite happy by themselves.’ Nevertheless, nurses need to be wary of stoicism. ‘Some people may say they are happy by themselves when they are profoundly lonely and isolated,’ he says. ‘They may even be unaware that LSI is undermining their physical and mental health.’
Mr Hewings stresses the importance of listening to patients and suggesting that they take the time to reflect on factors that influence their social relationships, which may help them find solutions. ‘In some people, a physical issue, such as mobility problems, may lead to isolation,’ he says. ‘In other people, the cause may be predominately social, such as poor access to public transport. LSI can also become entrenched and chronic. Over time, some lonely people become fearful of interacting with others. They brood about social interactions or become apathetic; so they further restrict their social contact. In such people, loneliness may not be as obvious as in people facing acute isolation, such as following bereavement or children leaving home.’
Nurses and other clinicians have numerous opportunities to engage with these patients: LSI people tend to use more social and health services than those who are better connected. For instance, a UK survey of 665 people aged 80 years or older found that lonely people were three times more likely to be in contact with community nurses (incidence rate ratio [IRR] 3.4) and meals on wheels (IRR 2.5) than those who were not lonely.4 In 2013, the Campaign to End Loneliness surveyed 1007 GPs. Of these, 76% reported that between one and five patients a day attended their surgery primarily because they are lonely. The poll also found that 11% and 4% of GPs reported that six to ten, and more than 10 patients a day respectively attended primarily because they are lonely.5
‘Finding time to ask about loneliness can be difficult in a pressurised clinic,’ Mr Hewings remarks. ‘But if people keep attending with a variety of complaints, nurses and other clinicians should try to build a relationship and offer people the opportunity to discuss their social isolation. Sometimes even recognising there is a problem offers some relief.’
Social prescribing
LSI increases the risk of diverse mental and physical conditions, including anxiety, depression, cardiovascular disease, obesity, cognitive decline, Alzheimer’s disease and premature death.6-8 In a recent scientific statement, the American Heart Association (AHA) concluded that LSI appear ‘to be independent risk factors for worse cardiovascular and brain health.’7 A meta-analysis reported that social isolation, loneliness and living alone increased the likelihood of mortality by, on average, 29%, 26% and 32% respectively. The link between LSI and death seemed to be particularly strong in people younger than 65 years.8
But the best way to manage these LSI-related problems isn’t only on pharmacists’ shelves. Rather Mr Hewings advocates referral to social prescribing link worker. These link workers can, as part of a holistic approach to health and wellbeing, connect people to community groups and statutory services offering practical and emotional support for numerous health and wellbeing issues including LSI.
Every primary care network should now have at least two social prescribing link workers, who accept referrals from various agencies including general practice, pharmacists, police and social care services. Mr Hewings notes, however, that implementation ‘varies somewhat’ across the UK. ‘Many social prescribing link workers started work at the beginning of the pandemic,’ he says. ‘They did not have time to establish themselves before the NHS entered crisis mode.’
In addition, nurses should encourage lonely people to take steps to address LSI. ‘Counselling and cognitive behavioural therapy may help some people overcome barriers to social participation,’ says Mr Hewings. ‘Volunteering is an excellent way to overcome LSI. Pick up the phone and speak to a friend or family member. Small positive interactions soon add up.’
Nurse burn out
Nurses can face LSI in the midst of a busy clinic, which increases the risk of emotional exhaustion and burn out. Professor Wood and colleagues recently published a review of 24 studies showing that social support is critical to coping with the stresses nurses face daily. Indeed, social support explains about a third of the variability in risk of burnout.1
Professor Wood advises nurses to be alert for signs of burnout for themselves and among their colleagues. Warning signs include emotional exhaustion, depersonalisation and a reduced sense of personal accomplishment. ‘In nurses and other clinicians, emotional exhaustion and depersonalisation are typically the first or most strongly experienced,’ she says. ‘Clinicians may report feeling pervasive exhaustion. They may feel tired even when they wake, feel unable to do even routine tasks or feel exhausted in all aspects of life. Depersonalisation may be a sense of not feeling able to connect emotionally with others, a sense of feeling numb or detached, or a sense of not feeling like a whole human or feeling empty.’
So, nurses need to remember that they are not alone. ‘I would suggest finding someone with a shared experience and try to make a connection. Be open and honest about your struggles with someone who can relate or who will also share their issues,’ Professor Wood comments. ‘Reach out to peers who seem to be struggling and see if they are willing to connect. Perhaps get coffee together to have a chat, take a walk together once a week to talk, or set an appointment on your calendars to phone one another.’
‘All workplaces need to invest in support that avoids LSI among their staff,’ Mr Hewings adds. ‘Over the years, I have seen examples of excellent support from NHS providers. But I have also seem some very poor practices. There’s usually no good reason for this variability. Jobs in the NHS and elsewhere should be designed in ways that foster social interactions and good relationships.’
Professor Wood also stresses the importance of a health system approach to improving social connections in clinicians, from workflow design, to removing barriers to peer support, to offering opportunities for interaction and more meaningful connections. ‘We are a resilient group, we can heal from within, our strength will flourish in our unity,’ she says.
Unanswered questions
‘Nurses and other clinicians need more education about LSI,’ Mr Hewings comments. The Campaign to End Loneliness found that just 13% of GPs felt confident about helping people attending the surgery primarily because of LSI. Half (49%) were not confident they could help LSI patients.5 So, the Campaign produced an e-learning module in collaboration with Health Education England and the now dissolved Public Health England (see further information). The Campaign, Age UK, the Red Cross and the Co-Op offer advice, education and support for nurses and other clinicians, and people living with LSI.
Mr Hewings called for more research into the links between LSI and ill-health, focusing on three pathways: behavioural, psychological and physiological. ‘We have a reasonable understanding of the possible behavioural and psychological links. Poor sleep, for example, can have a knock on effect on social connectivity,’ he says. ‘The physiological links, such as why LSI leads to heart disease, are much less well understood. We also need a better understanding of which intervention works in which patients.’ Meanwhile, the AHA highlighted the ‘need to develop, implement, and test interventions to improve cardiovascular and brain health for individuals who are socially isolated or lonely.’7
Meanwhile, Professor Wood plans to publish an analysis suggesting that COVID-19 exacerbated the risk of isolation and burnout by increasing demands on nurses, while reducing opportunities for social interactions. ‘I think it is important to bring more understanding and awareness to the issue of clinician loneliness and to implement strategies to reduce loneliness in our healthcare workforce,’ she adds. ‘I plan to continue to build knowledge around the experience of loneliness among nurses and other healthcare professionals and how this experience detracts from wellbeing. I also hope to refine ways of measuring clinician loneliness that address the nuances in how LSI may be uniquely experienced in caregiving professions and to identify strategies for promoting deeper connections within the workforce.’
In the longer term, Mr Hewings suggested changes to the built environment to counter LSI. ‘Planners should help create environments where people feel safe and are likely to ‘bump’ into people as they go about their daily lives. This means increasing opportunities to walk, which is, of course, good for our physical health,’ he comments. ‘Social interactions are important in the way we feel. We need to do more to tackle LSI.’
In the end, no nurse is an island. Nursing attracts empathic, sociable, friendly people. So, nurses may be especially prone to the ill effects of LSI. ‘You can be surrounded by people and still experience loneliness,’ Professor Wood concludes. ‘Truly feeling seen and having meaningful, deeper relationships is powerful in improving wellbeing. Make a connection with someone who has a shared experience. You will both benefit.’
Mark Greener is a freelance medical writer
References
1. Wood RE, Brown RE, Kinser PA. The connection between loneliness and burnout in nurses: An integrative review. Applied Nursing Research. 2022. 66:151609. https://doi.org.https://doi.org/10.1016/j.apnr.202...
2. Hawkley LC, Cacioppo JT. Loneliness matters: A theoretical and empirical review of consequences and mechanisms. Annals of Behavioral Medicine. 2010. 40 (2):218-27. https://doi.org.10.1007/s12160-010-9210-8
3. Emerson E, Fortune N, Llewellyn G, Stancliffe R. Loneliness, social support, social isolation and wellbeing among working age adults with and without disability: Cross-sectional study. Disability and Health Journal. 2021. 14 (1):100965. https://doi.org.https://doi.org/10.1016/j.dhjo.202...
4. Wang H, Zhao E, Fleming J, Dening T, Khaw K-T, Brayne C. Is loneliness associated with increased health and social care utilisation in the oldest old? Findings from a population-based longitudinal study. BMJ Open. 2019. 9 (5):e024645. https://doi.org.10.1136/bmjopen-2018-024645
5. Campaign to End Loneliness. Family doctors ill-equipped for loneliness epidemic. Available at https://www.campaigntoendloneliness.org/wp-content/uploads/downloads/2013/11/FINAL-GP-Polling-PR-15.11.13.pdf. Accessed August 2022.
6. National Institute on Aging. Social isolation, loneliness in older people pose health risks. 2019. Available at www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks. Accessed August 2022.
7. Cené CW, Beckie TM, Sims M, et al. Effects of objective and perceived social isolation on cardiovascular and brain health: a scientific statement from the American Heart Association. Journal of the American Heart Association. 2022 e026493. https://doi.org.10.1161/jaha.122.026493
8. Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspectives on Psychological Science. 2015. 10 (2):227-37.