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The loneliness of the hospitalized patient Brennan, Audrey Diane 1975

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THE LONELINESS OF THE HOSPITALIZED PATIENT by AUDREY DIANE BRENNAN B . S c . N . , Univers i ty of B r i t i s h Columbia, 1971 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of Nursing We accept th is thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1975 In presenting th is thesis in p a r t i a l f u l f i l l m e n t of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the Library shal l make i t f ree ly avai lable for reference and study. I further agree that permission for extensive copying of th i s thesis for scholar ly purposes may be granted by the Head of my Depart-ment or by his representative. I t i s understood that copying or publ icat ion of th is thesis for f i n a n c i a l gain shal l not be allowed without my wri t ten permission. Department of The Univers i ty of B r i t i s h Columbia Vancouver, Canada V6T 1W5 Abstract This study is an enquiry into the lonel iness of the hospi ta l ized patient . The l i t e r a t u r e review i s extensive and provides a conceptual framework for the development of lonel iness . Loneliness i s defined in re la t ion to the need for relatedness and described in terms of i t s be-havioural and cognitive dimensions. The tool used in the study i s a two-part questionnaire developed by the invest igator from the l i t e r a t u r e . The f i r s t part i d e n t i f i e s v a r i -ables s p e c i f i c to the hospi ta l ized pat ient . The second part l i s t s s tate-ments of behavioural indicators of lonel iness . The purpose of the analysis i s to determine the degree of association between the variables of the f i r s t part and the behavioural indicators of the second part . The questionnaire was d i s t r i b u t e d and col lec ted by the inves t igator . There are l i m i t a t i o n s in the use of the questionnaire method of data c o l l e c t i o n for th i s study. The l i t e r a t u r e indicates that a high degree of lonel iness associated change i s accompanied by a low degree of freedom to communicate. However, the data analysis did not uphold th i s association in a l l i n -stances. The pretest and test population samples are patients resident in three s p e c i f i c hospitals on the day selected for the study. Two of these hospitals were general acute treatment hospi ta l s , each with a separate but associated Extended Care U n i t , and one spec ia l ized r e h a b i l i t a t i o n h o s p i t a l . The l a t t e r supplemented an otherwise d e f i c i e n t c l i n i c a l ser-vice population within the two acute treatment centres. Four hundred and forty- three patients was the population tested. i i i i i Analysis of the data indicates that s p e c i f i c variables within the hospital are s i g n i f i c a n t l y associated with the behavioural indicators of lonel iness . One of the hospital variables studied was c l i n i c a l service . The variat ions within each c l i n i c a l service , i d e n t i f i e d some primary areas of concern. Medicine and Extended Care respondents perceived lone-l iness associated changes in themselves but did not perceive the freedom to communicate these perceptions. While s i m i l a r in t h e i r response to lonel iness behaviours, respondents from Psychiatry expressed a strong sense of relatedness with the nurse and a d e f i n i t e freedom to communicate with her. Surgery and Maternity respondents indicated no p a r t i c u l a r areas of concern. Rehabi l i ta t ion respondents, while low in loneliness expression, provided a c o n f l i c t i n g pattern to t h e i r perceived freedom to communicate and relatedness with the nurse. Rehabi l i ta t ion respondents were very pos i t ive in t h e i r sense of freedom to communicate with the nurse, yet very negative i n t h e i r sense of relatedness to her. The variable of number of v i s i t o r s received per week s i g n i f i c a n t l y affected patient response. To a l e s s e r , though s t i l l s i g n i f i c a n t degree, patient response i s influenced by the length of h o s p i t a l i z a t i o n and the number of v i s i t o r s received per v i s i t . The pattern of response for each of the variables i s a function of the other. Research implicat ions and recommendations for further study are indicated. This study provides i n i t i a l information and a focus for f u r -ther research. i v Table of Contents Page LIST OF TABLES . . v i i LIST OF FIGURES ix Chapter 1. INTRODUCTION 1 INTRODUCTION TO LONELINESS . 2 THE PURPOSE OF THE STUDY 4 2. REVIEW OF THE LITERATURE 6 LONELINESS A CONCEPTUAL FRAMEWORK 6 Loneliness and the Need for Relatedness 6 Loneliness: Behavioral Manifestations and Cognitive Dimensions 10 LONELINESS vs. DEPRESSION, ALIENATION 15 Loneliness vs. Depression 15 Loneliness vs. Al ienat ion 17 LONELINESS AND HOSPITALIZATION 19 SUMMARY 23 3. RESEARCH DESIGN 25 THE PURPOSE OF THE STUDY 25 DEFINITION OF TERMS 25 ASSUMPTIONS 27 LIMITATIONS 27 V Chapter Page HYPOTHESES 28 THE QUESTIONNAIRE 29 The Development and Construction of the Questionnaire 29 The Pretest of the Questionnaire 33 The Administration of the Questionnaire 35 THE POPULATION SAMPLE 35 SUMMARY 39 4. ANALYSIS OF THE DATA 40 ANALYSIS IN RELATION TO THE POPULATION SAMPLE . . . 40 The Character is t ics of the Population Sample 40 ANALYSIS IN RELATION TO THE BEHAVIORAL RESPONSE CATEGORIES 44 ANALYSIS IN RELATION TO THE HYPOTHESES OF THE STUDY 46 Analysis of the Data i n Relation to Hypothesis 1 48 Analysis of the Data i n Relation to Hypothesis 2 52 Analysis of the Data i n Relation to Hypothesis 3 . 57 Analysis of the Data in Relation to Hypothesis 4 67 Analysis of the Data i n Relation to Hypothesis 5 73 SUMMARY 78 v i Chapter Page 5. SUMMARY, CONCLUSION, RESEARCH IMPLICATIONS AND SUGGESTED RECOMMENDATIONS 81 SUMMARY 81 CONCLUSIONS 84 RESEARCH IMPLICATIONS 89 SUGGESTED RECOMMENDATIONS 92 BIBLIOGRAPHY 93 APPENDIXES 103 A. VERBAL REQUEST TO PARTICIPATE IN THE STUDY 104 B. WRITTEN PATIENT CONSENT FORM 106 C. WRITTEN INSTRUCTIONS FOR PARTICIPANTS 108 D. THE QUESTIONNAIRE 110 v i i L i s t of Tables Table Page 1. The Name and Location of Hospitals Used in th is Study and the Patient Populations on the Day of the Investigation Exclusive of Pediatr ics or Day Care Patients 37 2. The Number and Percent of the Non-Participants in th is Study 38 3. Frequency of Respondents According to the Sex of the Respondent 40 4. Frequency of Male/Female Respondents According to C l i n i c a l Service 41 5. Frequency of Respondents According to Length of H o s p i t a l i z a t i o n 42 6. Frequency of Respondents According to C l i n i c a l Service 42 7. Frequency of Respondents According to the Number of Visits/Week 43 8. Frequency of Respondents According to the Number of Visitors/Week 43 9. Associat ion Between Categories of the Question-n a i r e . Degrees of Freedom and Chi-Square Values Lis ted per Associat ion 45 10. Comparison of Responses Indicating Perceived Behavioral Change and Sex of the Patient 49 T l . Comparison of Responses Indicating Perceived Freedom to Communicate and Sex of the Patient . . 50 12. Comparison of Responses Indicat ing Perceived Relatedness to the Nurse and the Sex of the Patient 51 13. Comparison of Responses Indicating Perceived Freedom to Communicate and Length of Hospi-t a l i z a t i o n 55 vi i i Table Page 14. Comparison of Responses Indicating Perceived Relatedness and Length of H o s p i t a l i z a t i o n 56 15. Comparison of Responses Indicating Perceived Freedom to Communicate and Number of V i s i t s Received 70 16. Comparison of Responses Indicating Perceived Freedom to Communicate and Number of V i s i t o r s Received per V i s i t 76 17. Comparison of Responses Indicating Perceived Relatedness and Number of V i s i t o r s Received per V i s i t 77 ix L i s t of Figures Figure Page 1. The Conceptual Framework for the Development of Loneliness as Used i n this Study 14 2. Comparison of Responses Indicating Perceived Behavioral Change and Length of Hospi-t a l i z a t i o n 53 3. Comparison of Responses Indicating Perceived Behavioral Change and C l i n i c a l Service 58 4. Comparison of Responses Indicating Perceived Freedom to Communicate and C l i n i c a l Service . . . . 60 5. Comparison of Responses Indicating Perceived Relatedness and C l i n i c a l Service 62 6. Comparison of Responses Indicating Perceived Behavioral Change and Number of V i s i t s Received 68 7. Comparison of Responses Indicating Perceived Relatedness and Number of V i s i t s Received 71 8. Comparison of Responses Indicating Perceived Freedom to Communicate and Number of V i s i t o r s Received per V i s i t 74 Acknowledgment My deepest thanks and appreciation to Helen E l f e r t , Committee Chairman, and El izabeth McCann, Committee Member, for t h e i r sincere interes t and capable guidance. My thanks to the s t a f f and patients who per-mitted me to carry out th i s study. x THE LONELINESS OF THE HOSPITALIZED PATIENT xi Chapter One INTRODUCTION I have often wondered what made me aware of the fee l ing of lone-l iness that day. I t was a day s i m i l a r to many other days I had spent as a nurse on a psychia t r i c ward. I was l i s t e n i n g to a gentleman patient explain to me in his very reasonable, well-argued way, the genesis of his alcoholism. I had heard what he was saying before. I t was a repe-t i t i o n of items I had heard from other pat ients , even from himself , the day p r i o r . However, on th is occasion as I was l i s t e n i n g to th i s man, I became aware of emotions I had never noticed before. I f e l t myself w i t h -drawing in a reaction of fear . Later , as time and occasions passed, the fear lessened and accep-tance grew. I look back on that day now as my f i r s t recognition of lone-l i n e s s . I t was not an immediate recognit ion. I t was merely the f i r s t step in a long journey of enquiry. I t r i e d to i d e n t i f y the spec i f i c s of that experience and of the many others which fol lowed. I shared thoughts with others and found that the more I shared, the more I became aware that lonel iness i s hidden beneath many of the behaviours which give r i s e to c l i n i c a l diagnoses. While loneliness i s an interes t ing philosophical hobby, i t proved to be a d i f f i c u l t topic to f i t into a format for research. Much i s wri t ten on loneliness as a subjective experience, l i t t l e i s wri t ten on loneliness as an experience for objective ana lys i s . However, there i s one convict ion which encouraged me to t r y . I t i s that lonel iness l i e s 1 2 within the realm of nursing judgment and nursing ac t ion . If detected and accepted, loneliness can be dealt wi th . INTRODUCTION TO LONELINESS Loneliness i s most c l e a r l y related to the capacity for love. I t i s a sense of being i s o l a t e d , excluded, denied--a pervading sense of 2 contrast between what i s and what might have been. Not that I am alone but that I am desolate. Not that I am without you but that I am abandoned by you. Not that I do not love you _ but the love I remember was once ours i s no longer. There i s something about being human that condemns us to lonel iness . We l i v e in a society in which loneliness i s a common problem for 5 a l l . Formerly, we were control led by soc ia l c l a s s , the family the i n d i s s o l u b i l i t y of marital bonds and f i l i a l respect imposed by Eloise Clark , "Aspects of Lonel iness , " Developing Behavioral  Concepts in Nursing, eds. L. Zerod and H. Belcher (Southern Regional Education Board, 1968), p. 33; see a l s o , Wil l iam Duensbury, The Theme of  Loneliness in Modern American Drama ( G a i n s v i l l e : Univers i ty of F lor ida Press, 1960J7 p. 212; see a l so , C l a i r e Francel , "Lonl iness , " Some  C l i n i c a l Approaches to Psychiatr ic Nursing, eds. S. Burd and S. Marshall (Toronto: MacMillan C o . , 1963), p. 178. 2 Opinion expressed by Abraham Kaplan in an address, "Lonel iness , " at the Univers i ty of B r i t i s h Columbia, May 25, 1972. 3 Ib id . Claude Bowman, "Loneliness and Social Change," American Journal of Psychiatry , 112 (1955), 194; see a l so , El isabeth Mannin, Loneliness "[London: Hutchison C o . , 1966), p. 9; see a l so , Margaret Wood, Paths of  Loneliness (New York: Columbia Univers i ty Press, 1953), p. 78. 3 t r a d i t i o n . 6 Today's soc ie ty , however, i s not a community, but a c o l l e c -t i v i t y . The neighbourhood has given way to the z ip code.^ We l i v e in a society in which lonel iness i s a common problem for a l l . Several reasons are postulated for the increase in comtemporary lone l iness : the rapid urban growth and the enormity of bureaucracy; the decline in the cohesiveness of family l i f e ; the increase in the number of o divorces; and the decline of the act ive r e l i g i o u s l i f e . g Loneliness i s the most exclusive form of human s u f f e r i n g . I t makes the courageous t i m i d , the confident u n s u r e . ^ Gregariousness has nothing to do with i t ; sol i tude does not spel l i t ; companionship does not protect against i t . ^ Loneliness i s so productive of psychic pain 12 that suicide i s a preferred s o l u t i o n . More unbearable than anxiety, 13 i t s experience baff les c lear r e c a l l . Yet despite i t s in tens i ty and Peter Tournier, Escape From Loneliness (Phi ladelphia : West-minster Press, 1948), p. 20. ^ Kaplan. 8 Bowman; see a l so , Peter S l a t e r , The Pursuit of Loneliness (Boston: Beacon Press, 1970), p. 5. 9 Duensbury. 1 0 E d i t o r i a l , Nursing Outlook, 16, No. 1 (January 1968), 21. 1 1 Wood, p. 9. 12 Freida Fromm-Reichmann, "One Lonel iness , " Psychoanalysis and  Psychotherapy, ed. D. N. Bui lard (Chicago: Univers i ty of Chicago Press, 1959), p. 324." 13 Harry Stack S u l l i v a n , The Interpersonal Theory of Psychiatry (New York: W.-W. Norton C o . , 1963T7~p. 161. 4 u n i v e r s a l i t y , loneliness belongs to the least s a t i s f a c t o r i l y conceptual -14 ized psychological phenomena. PURPOSE OF THE STUDY Fromm-Reichman believed the s p e c i f i c problem in dealing with lone-l iness i s for the therapist to recognize his/her own ex is t ing l o n e l i n e s s . 1 Nurses as therapists are less than fearless i n t h e i r acceptance of lone-l i n e s s . Pretending or ignoring are two patterns used by nurses to escape the r e s p o n s i b i l i t y of response to the pat ients ' manifestations of l o n e l i -n e s s . ^ I f the nurse refuses to l e t the patient r e a l l y express his f e e l -ings or implies that the patient has no r ight to these f e e l i n g s , the resul t i s withdrawal by the p a t i e n t . 1 7 Kubler-Ross stresses the need for perceptive, understanding people in dealing with the lonel iness of the I o dying pat ient . Often, because of our own feel ings of fear we allow the patient to die a very lonely death. The s igni f icance of th is study for nursing i s two- fo ld . The f i r s t point of s igni f icance i s in i t s attempt to provide resource information for nurses so that each nurse can discover for herself the expressions of Fromm-Reichmann, p. 325. 1 5 I b i d . , p. 329. 1 6 Francel , p. 180. 1 7 C lark , p. 35. 1 8 El isabeth Kubler-Ross, On Death and Dying (New York: MacMillan C o . , 1969), p. 228. 5 lonel iness . In her e f f o r t s to ass i s t the pat ient , i t i s essential that 19 the nurse not deny her own fee l ings . I f she denies her own lone l iness , the nurse may be unable to accept the pat ient ' s expression of these f e e l -ings , or she may ignore obvious clues to lonel iness in the pat ient ' s behaviour. The nurse may seek to avoid any feel ings expressed by the 20 patient which might arouse s i m i l a r feel ings within herse l f . As a c l i n i c a l problem, lonel iness requires nursing intervent ion. The second point of s igni f icance for th is study i s to give some notion of the occurrence of lonel iness within the hospital se t t ing and of the pat ient ' s perception of lonel iness . The question of whether the patient perceives elements of his lonel iness and whether he perceives the freedom to communicate to the nurse w i l l influence the planning of nursing i n t e r -vention. Along with t h i s , the s igni f icance of the hospital induced v a r i -ables on the expression of lonel iness provides d i rec t ion for the determi-nation of the nursing p r i o r i t i e s . The purpose of the study i s to determine the s igni f icance of selected variables in the response of patients to loneliness-associated, statements. Clark , p. 35. 2 0 Ib id . Chapter Two REVIEW OF THE LITERATURE Thinkers in philosophy, r e l i g i o n , sociology and psychology have concerned themselves with the concept of loneliness throughout the ages. Authors in the arts portray loneliness often as a central theme in drama and poetry. The l i t e r a t u r e avai lable i s extensive and i t s review reveals a var ie ty of perceptions about lone l iness . The research for th is paper focuses pr imar i ly on two major concerns. The f i r s t i s to develop a conceptual framework for loneliness to be used i n th is study; the second is to investigate the associat ion between lonel iness and h o s p i t a l i z a t i o n . LONELINESS A CONCEPTUAL FRAMEWORK Loneliness and the Need for Relatedness Some claim i t i s an i n s t i n c t u a l need for man to be dependent on others . 1 Loneliness i s the f r u s t r a t i o n of th is i n s t i n c t u a l need to p be dependent. S u l l i v a n and Sutt ie refer to the need for interpersonal 3 relatedness as being one of man's basic needs. This soc ia l need of 1 Paul Halmos, Solitude and Privacy (London: Routledge and Kegan Paul L t d . , 1952), p. 1; see a l s o , Wil l iam T r o t t e r , Inst incts of the Herd i n Peace and War (Houston: T. Fisher Unwin L t d . , 1921 )•, p. 113. 2 Halmos, i b i d . 3 Harry Stack S u l l i v a n , The Interpersonal Theory of Psychiatry (New York: W. W. Norton C o . , 195377 p. 161; see a l s o , Ivan S u t t i e , The  Origins of Love and Hate (New York: Matrix House L t d . , 1952), p. 20. 6 7 man i s an adaptation to the soc iocul tura l environment. Mother love i s primal not so much as i t i s the f i r s t formed but i t i s the f i r s t outer-4 directed emotional r e l a t i o n s h i p . Loneliness i s most acute during pre-adolescence, although ear-5 l i e r developmental stages lay important groundwork. As early as infancy, the need for contact along with the many other dependencies i s charac ter i s t i c of the i n f a n t ' s primary need for tenderness. During childhood and l a t e r , th is primary need i s characterized by the need for peer acceptance. D i s s a t i s f a c t i o n or maladaptation or f r u s t r a t i o n of th is need at any stage is f e r t i l e ground for lone l iness . Loneliness i s associated with the d i s s a t i s f a c t i o n , maladaptation, f r u s t r a t i o n of the need for interpersonal re latedness . 7 Loneliness i s described as the lack of understanding wi th in a re la t ionship or the f ee l ing that no o one ever r e a l l y cared. Loneliness i s the f ee l ing that once someone g did care but that no one cares anymore. 4 S u t t i e , p. 20. 5 Freida Fromm-Reichmann, "On Lonel iness , " Psychoanalysis, Psy-chotherapy, ed. D. M. Bul lard (Chicago: Univers i ty of Chicago Press, 1959), p. 328. 6 S u l l i v a n , pp. 160-62. 7 Fromm-Reichmann, p. 326; see a l s o , Hildegard Peplau, " L o n e l i -ness," American Journal of Nursing, 55, No. 12 (December 1955), 1477. Q Eloise C l a r k , "Aspects of Loneliness: Toward a Framework of Nursing Intervent ion, " Developing Behavioral Concepts in Nursing, eds. L . Zerod and H. Belcher (Georgia: Southern Regional Education Board, 1969), p. 29. g Irene Burnside, "Loneliness in Old Age, Mental Hygiene, 55, No. 3 (July 1971), 392. 8 I t i s a very new strange f e e l i n g - - o f touching many people s u p e r f i c i -a l l y and no one i s touching me. . . . a kind of physical loneliness that I never experienced before I never understood before that mad wish of some people j u s t to have humans--any humans--near them.10 Fromm-Reichmann was for years fascinated with the problem of lone l iness . In her l a s t unfinished chapter she describes lonel iness as a state of mind in which . . . the fact that there were people in one's past l i f e i s . . . forgotten and the hope [of] interpersonal re lat ionships in one's future l i f e i s out of the realm of expectation or imaginat ionJ1 12 Loneliness i s the experience of being denied an i d e n t i t y . The most fundamental of needs i s to be recognized as the person we are. I am neither a c l i e n t , a customer, a const i tuent , or a c i t i z e n . I am the p a r t i c u l a r person I am.13 The indiv idual experiences loneliness when he i s denied his i d e n t i t y as a unique person by others. Thoreau claims that th i s lack 14 of i d e n t i t y from others i s the basis for his loneliness i n the c i t y . At Walden, where he i s t o t a l l y alone, there i s no other person there to negate his being. 1 0 Anne Morrow Lindberg, Bring Me a Unicorn (New York: Harcourt House, 1973), p. 49. ^ Fromm-Reichmann, p. 327. 1 2 Opinion expressed by Abraham Kaplan i n an address, " L o n e l i -ness," at the Univers i ty of B r i t i s h Columbia, May 25, 1972. 13 . . . . I b i d . 1 4 Henry David Thoreau, " S o l i t u d e , " Walden and Other Writings (New York: Random House I n c . , 1937), p. 142. 9 Loneliness i s said to e x i s t when an indiv idua l i s unable to meet his basic need for relatedness. The degree to which th i s need i s s a t i s f i e d bears a re la t ionship to the degree to which loneliness i s experienced. Loneliness can occur at any age, given the interrupted s a t i s f a c -t ion of the need for relatedness. I t can be sa id that the stage of development at which this interrupt ion occurs has bearing on the degree 15 of loneliness experienced. 16 Loneliness can be e i ther temporary or l a s t i n g . I t can be primary or secondary, contingent or essent ial J ' 7 The d i f f e r e n t i a t i o n referred to i s the degree of interpersonal deprivation and the severi ty of the behavioral maneuvers mobilized i n defense against lone l iness . For example, one patient i n childhood retreated from loneliness by s i t -18 t ing i n a darkened room, i n adulthood by delusional t h i n k i n g . This lonel iness i s an example of the l a s t i n g or essent ial lone l iness . This loneliness renders people who suffer i t emotionally paralyzed and help-19 l e s s . Temporary or contingent loneliness i s that which i s transient 20 or correctable . For example, the loneliness associated with t r a v e l , 15 C l a r k , p. 38; see a l s o , Fr mm-R ichmann, p. 326. 16 Fromm-Reichmann, p. 326. Henry D. von Witzleben, "On Lonel iness , " Psychiatry , 21 (1958), 17 37; see a l s o , Kaplan. 18 r n „ , „ Fromm-Reichmann, p. 330. 19 I b i d . , p. 329. 20 Kaplan, 10 death, i l l n e s s are correctable e i ther i n time or when the s i t u a t i o n cor-rects i t s e l f . 2 1 Loneliness: Behavioral Manifestations and Cognitive Dimensions ' The cognit ive dimension of loneliness i s described as the exper-22 ience of non-being, or the loss of r e a l i t y . Project ive t h i n k i n g , s u i c i d a l i d e a t i o n , a l cohol i c apathy are defenses used i n withdrawal from severe lone l iness . Escape through unreal i ty i s the schizophrenic 's main 23 defense against lone l iness . Overly subjective and unreal thinking i s 24 observed i n those attempting to cope with lone l iness . Some patients t ry to ward of f the evolving pathology of loneliness by subst i tut ing 25 non-personalized transactions with knowledge and things . For some, 26 suic ide i s a preferred a l ternat ive i n the struggle with lone l iness . . 27 Others escape through alcohol or drugs. 2 1 Kaplan. 22 C l a r k , p. 38; see a l s o , Fromm-Reichmann, p. 330; see a l s o , Peplau, p. 1476; see a l s o , Edith Wiegert, "Loneliness and T r u s t , " Psychiatry , 2 (1960), 124. 23 Antonio F e r r i e r a , "Loneliness and Psychopathology," The  American Journal of Psychoanalysis, 22, No. 2 (1962), p. 205. C H Peplau, p. 1480. I b i d . o r Anne Bancroft , "Now She's a Disposi t ion Problem," Perspec- t ives in Psychia t r i c Care, 9, No. 3 (1971), p. 102; see a l s o , C l a i r e Francel , "Lonel iness , " Some C l i n i c a l Approaches to Psychia t r i c Nursing, eds. S. Burrard, S. Marshall (Toronto: MacMillan C o . , 1963), p. 178; see a l s o , National Council of Social Service , Loneliness (England: Latimer Co. L t d . , 1964), p. 10. 27 C l a r k , p. 33; see a l s o , Peplau, p. 1476. 11 28 Loneliness invades a l l three time dimensions. At times, i t 29 exhibi ts i t s e l f i n the fusion of past experience and present events. 30 The anxiety of lonel iness reduces c lear r e c a l l of i t s experience. The person i s unable to remember how he f e l t or what he did when he was 31 lone ly . Because feel ings l i k e these are d i f f i c u l t to communicate, the lonely person i s even more i so la ted from others. The question of whether loneliness can be d i r e c t l y communicated i s not e a s i l y answered. Some people in severe lonel iness are unable to 32 ta lk about i t . They keep t h e i r loneliness hidden from others , many times, even from themselves. However, one of the great d i f f i c u l t i e s i n dealing with lonel iness i s for the therapist to recognize traces of his 33 own ex is t ing lone l iness . The question may not be one of the lonely person's a b i l i t y to communicate but rather the therapis t ' s a b i l i t y to create a climate in which the person fee ls free to communicate th is lone l iness . The lonely person w i l l respond i f the therapist assumes the 34 i n i t i a t i v e to open the discussion about lone l iness . The therapist can convey acceptance by his mere presence without any therapeutic Helena Lopta, "Loneliness , Forms and Components," Social  Problems, 17 (1969), 248. 2 9 Peplau, p. 1477. 3 0 S u l l i v a n , p. 261. 31 Fromm-Reichmann, p. 328. I b i d . 3 3 I b i d . , p. 335. 34 T h . . I b i d . 12 pressure. The therapist can of fer his presence to the lonely patient f i r s t in a s p i r i t of expecting nothing but to be to lera ted , then, to be 35 accepted simply as some person who i s there. The lonely person i s b a s i c a l l y embarrassed to express feel ings and emotions to another person. People must have t rus t in each other before a re la t ionship 37 i s establ ished. Patients when ready to t a l k , open up and share the i r oo lone l iness . The therapist must provide a re la t ionship in which there 39 i s an openness to involvement, a climate for s e l f - d i s c l o s u r e . The l i t e r a t u r e proposes that the nurse should s t r i v e to estab-l i s h a re la t ionship of t rus t in which the patient feels free to communi-cate f e e l i n g s . Unfortunately e f for ts to es tabl i sh such a climate for 40 communication are not often made. Were the nurse able to provide such a c l imate , she would function in a preventative as well as thera-peutic capacity. She could prevent loneliness from reaching a painful degree and she could re l ieve feel ings of loneliness that reach such a 41 degree. 35 Fromm-Reichmann, p. 335. 3 6 Rosalee Bradley, "Measuring Loneliness" (unpublished Doctor's d i s s e r t a t i o n , Univers i ty of Washington, 1969), p. 4. 3 7 Weigert, p. 124. 3 8 El isabeth Kiibler-Ross, On Death and Dying (New York: MacMillan C o . , 1969), p. 45. 3 9 C lark , p. 40. 4 0 E loise Brown, "Meeting the Pat ient ' s Psychosocial Needs in the General H o s p i t a l , " Social Interaction and Patient Care, eds. J . Skipper and R. Leonard (Montreal: J . B . Lippencott C o . , 1965), p. 10; see also Francel , p. 180; see a l s o , Kiibler-Ross, pp. 154, 261. 4 1 C l a r k , p. 40. 13 S u l l i v a n believes that the lonely person moves outward toward others.. Although anxious and a f r a i d , he directs himself toward estab-42 l i s h i n g a re la t ionship with another. Several other authors hold an opposing view. They believe that the lonely person withdraws from others. Withdrawal into fantasy, s u i c i d e , or addict ion are chosen a l t e r -43 natives for the lone ly . I t may be postulated that a continuum exis ts wi thin these divergent opinions. I n i t i a l l y the lonely person ac t ive ly seeks the companionship of others but resorts to destruct ive withdrawal should his need for relatedness remain u n f u l f i l l e d . Figure 1, which f o l l o w s , i s presented i n an attempt to sum-marize the concepts of loneliness presented thus far i n th i s chapter. Loneliness i s said to e x i s t when an indiv idual i s unable to s a t i s f y his need for relatedness. Loneliness can occur at any age, given the i n t e r -rupt ion , , f r u s t r a t i o n or d i s s a t i s f a c t i o n of th i s basic need. Loneliness can be of two types, essent ial or temporary. This depends on the degree to which the need for relatedness i s u n s a t i s f i e d . Essential refers to deep-rooted loneliness manifesting i t s e l f in psy-chotic withdrawal, addict ion or s u i c i d e . Temporary lonel iness i s of a more transient nature, correctable e i ther i n time or when the s i t u a t i o n corrects i t s e l f . The lonely person, though anxious and a f r a i d seeks the compan-ionship of others. Often the i r seeking behavior causes further re jec-t ion leaving them even more lonely than before. 42 S u l l i v a n , p. 262. 43 Bancroft , p. 102; C l a r k , p. 33; F e r r i e r a , p. 205; Francel , p. 178; Fromm-Reichmann, p. 330; Peplau, p. 1476. S o c i a l _ Stresses 'Lone!iness' Developmental Stresses Sat i s fac t ion Need For Relatedness -> SEEK OTHERS Interruption D i s s a t i s f a c t i o n Frustrat ion / \ w D i s s a t i s f a c t i o n - — ? W i thdrawal ^Demanding Behavior —^Physical Complaints - ^ A d d i c t i o n Depression/Suicide -> UnReality/Fantasy Infancy Childhood Adolescence Adulthood Old Age Figure 1 Conceptual Framework for the Development of Loneliness as Used i n this Study 15 LONELINESS vs . DEPRESSION, ALIENATION Aloneness, i s o l a t i o n , lonesomeness, self-imposed i s o l a t i o n , com-pulsory sol i tude and real loneliness are a l l thrown into the one termi-nological basket of ' l o n e l i n e s s . ' Very l i t t l e i s known about the v a r i -ous experiences which are d e s c r i p t i v e l y and dynamically d i f f e r e n t from 44 lone l iness . With th is in mind then, an attempt i s made to super f i c -i a l l y d i f f e r e n t i a t e loneliness from two of these l i k e s ta tes , depression and a l i e n a t i o n . The rat ionale for th is i s that wi thin the l i t e r a t u r e , a l i e n a t i o n , depression and loneliness are frequently used interchangeably. Loneliness vs . Depression Zilboorg wrote of loneliness i n terms of the process of depres-45 s i o n . Pathological loneliness i s the loss of the n a r c i s s i s t i c image and normal loneliness i s a transient state wi th in the process of mour-ning. The psychodynamics of loneliness are s i m i l a r , i f not i d e n t i c a l 46 with the psychodynamics of depression. A low corre la t ion i s observed between Bradley's scale for loneliness and the M . M . P . I . scale for 47 depression. Freeman's study shows that people seeking general p r a c t i t i o n e r s ' 48 help , often did so because of pain or sadness, sorrow or lone l iness . 44 Fromm-Reichmann, p. 325. Gregory Z i l b o o r g , "Lonel iness , " A t l a n t i c Monthly, 61 (1938), 45 53. 46 I b i d . 47 Bradley, p. 18. Lucy Freeman, Cry for Love (New York: MacMillan C o . , 1969), 48 p. 36 16 49 There is a l i nk between lonel iness, shame and depression. Shame caused by g u i l t results in an evaluation of s e l f as less good than others. As a resu l t the person experiencing shame and depression w i th -50 draws into lonel iness. Buhler c i tes two patient examples of unex-51 pressed lonel iness. One woman manifests a c l a s s i ca l character disorder; the other develops nausea, pains and depression. Both are l o n e l y . 5 2 Loneliness i s ranked as the f i r s t of nine common causes of 53 depression and suicide among the e lde r l y . In a study of suicide in London, the highest rate of suicide i s found with those who l i v e a 54 lonely l i f e . The theoret ical d i f f e ren t i a t i on between loneliness and depres-sion i s i l l - d e f i n e d and the c l i n i c a l p icture i s unclear. I t i s observed, however, that in depression and loneliness there i s a s imi la r d i f f i c u l t y in meeting the need for relatedness. The d i f -ference between these two states i s in the i r attempts to establ i sh relatedness. The d i rect ion of the depressed person i s inward, toward the s e l f , away from others. The d i rect ion of the lonely person is out-ward, in an attempt to reestabl ish his relatedness to others. 49 M. Barry, "Depression, Shame and Loneliness," American Jour-nal of Psychotherapy, 16, No. 4 (1962), 589. 5 0 Ib id. 51 Charlotte Buhler, "Loneliness in Matur i ty, " Journal of Human- i s t i c Psychology, 9, No. 2 (1969), 168. 52 T k . , Ib id. 5 3 Bancroft, p. 102. 54 National Council of Social Science, p. 10. 17 Loneliness vs . Al ienat ion Among the f i r s t to concern themselves with a l ienat ion were 55 Nietzche and Kirkegaard. Kirkegaard's 'sickness unto death 1 i s des-pair at the loss of s e l f , a s e l f which he believes can only be main-56 tained through a re la t ionship with God. Nietzche declares that the indiv idual not subject himself to any d e i s t i c purpose, rather l e t him 57 seek the growth of s e l f and happiness throughout l i f e . Marx i s con-cerned pr imar i ly with the l imi ta t ions i n which the working class suf fer . He i d e n t i f i e s a gap which exis ts between the worker, his work and i t s product. Marx attacks the powerless condition of the lower classes and 58 the lack of personal commitment allowed them i n t h e i r work. Sociologis ts c a l l th i s separateness a l i e n a t i o n . Hendin c a l l s 59 i t 'anomie' and Reisman suggests the term 'outerd i rec ted . 1 Moustakas points out that although a l ienat ion i s c losely associated with l o n e l i -ness, not a l l lonely people are a l i e n a t e d . ^ May claims that 55 Fredrick Nietzche, Beyond Good and E v i l (Edinburgh: The David Press, 1914); see a l s o , Soren Kirkegaard, Thoughts on Crucial Si tuat ions  i n Human L i f e (Minneapolis: Augsburg Press, 1944). 56 Kirkegaard, p. 248. 57 Karl Marx, "Alienated Labor," Man Alone, eds. E. Josephson and N. Josephson (New York: Del l Publishing C o . , 1971), pp. 93-99. 5 8 I b i d . 5 9 H. Hendin, "Suicide in Denmark," Who Am I? (New York: Dell Publishing C o . , 1969), p. 285; see a l s o , David Reisman, The Lonely Crowd (New York: Yale Univers i ty Press , 1950), p. 14. Clark Moustakas, Loneliness (Michigan: Prent ice -Hal l I n c . , 1961), p. 34. 18 loneliness i s due to the emphasis society places on soc ia l accepta-fii b i l i t y . The indiv idua l can temporarily lose his lonel iness through soc ia l acceptance. The price i s high however. He gives up his e x i s -tence as an indiv idua l for that of the group. As an example of th is May c i tes the German people during World War II who gave up the i r iden-t i t y of s e l f i n exchange for the i d e n t i t y of s ta te . Fromm's concept of the 'marketing o r i e n t a t i o n 1 encompasses this same notion of soc ia l 63 acceptance. Personal q u a l i t i e s are not valuable i n themselves, rather only to the extent that they are valuable to others. This leaves man alienated not only from his fe l low man. but al ienated from himself and his own f e e l i n g s . ^ 4 65 Ours i s an age not of commitment but of a l i e n a t i o n . Schaectal writes that when th is lack of i d e n t i t y or a l ienat ion becomes conscious 66 i t i s experienced as being not f u l l y a person. The al ienated feel fi7 powerless, estranged, and i s o l a t e d . Further, t h e i r behavior indicates a normlessness and meaninglessness in t h e i r l i v e s . c i R. May, Man's Search for Meaning (New York: W. W. Norton C o . , 1953), p. 34, 6 2 I b i d . 63 E r i c Fromm, Man for Himself (New York: H o l t , Rinehart , and Winston, 1947), p. 80. 64 T h . , I b i d . 65 Kenneth Kenniston, The Uncommitted (New York: Del l Publishing C o . , 1965), p. 4. 6 6 K. Schaectal , "On Alienated Concepts of I d e n t i t y , " Who Am I? (New York: Dell Publishing C o . , 1969), p. 13. Melvin Seeman, "The Meaning of A l i e n a t i o n , " American Socio- log ica l Review, 24 (December, 1959), 783-91. 19 The alienated and the lonely both share the perception that a margin of difference exists between themselves and the society of others. The difference between loneliness and a l ienat ion i s found i n the sense of unrelatedness. Loneliness i s associated with the re la ted-ness of the indiv idual to others. Al ienat ion i s associated with the relatedness of the indiv idual to soc ie ty , in i t s i n s t i t u t i o n s , mores, or expectations. In summary the depressed and the lonely persons both exhib i t d i f f i c u l t y i n meeting the need for relatedness. The difference i s observed i n t h e i r attempt to meet this need. The e f for ts of the depres-sed person are inward, toward the s e l f , whereas the e f for t s of the lonely person are outward, towards a re la t ionship with others. The alienated and the lonely persons both exh ib i t a difference between themselves and the society of others. In a l i e n a t i o n , the d i f -ference is between oneself and soc ie ty ' s i n s t i t u t i o n s , mores, or expec-t a t i o n s ; i n lone l iness , the difference i s between oneself and the sense of relatedness with others. LONELINESS AND HOSPITALIZATION Moustakas was introduced to loneliness when he experienced his 68 daughter's h o s p i t a l i z a t i o n for heart surgery. His pioneering text relates other examples of the loneliness which s i ck people endure during the course of accepting treatment. Not yet acquainted with other 6 8 Moustakas, p. 17. 20 69 pat ients , the newly admitted patient i s p a r t i c u l a r l y alone. The admission procedure would be more aptly ca l led "trimming" or "program-ming" in which the newly admitted patient i s shaped and coded into the administrative machinery .^ The experience of unrelatedness i s raised within the l i t e r a t u r e in connection with three p a r t i c u l a r patient groups. One group, as mentioned above, i s the newly admitted pat ient . Another group i s the patient whose i l l n e s s requires extended hospi ta l ized care. The chroni-c a l l y i l l and the e lder ly are both affected by the disengagement process. 7 ^ Disengagement i s an adjustive response to the withdrawal or 72 detachment of meaningful r e l a t i o n s h i p s . I t i s a response to pro-longed separation from home or loved ones which motivates the disengaged 73 into a c t i v i t i e s which minimize interpersonal r e s p o n s i b i l i t y . F i r s t the v i s i t o r s come r e g u l a r l y , then they stop coming at a l l . The few avai lable fr iends and family lose i n t e r e s t , and soon the v i s i t i n g hours 74 blend into the general monotony of the day. 69 Brown, p. 8. 7 0 Erving Goffman, Asylums (Garden C i t y , N . Y . : Doubleday Anchor, 1961), p. 44. 7 1 Rhoda L . Levine, "Disengagement in the E l d e r l y , " Nursing  Outlook, 17, No. 10 (November 1969), 28-30. 72 F. B. A r j e , "Disengagement," Nursing C l i n i c s of North America, 1 (June, 1966), 235. 7 3 I b i d . 7 4 Statement made by a resident of one of the Extended Care Units used for th is study, February 1972. 21 The t h i r d patient group for whom relatedness i s of p a r t i c u l a r concern are those admitted to the psychia t r i c c l i n i c a l serv ice . Often a patient f inds his loneliness increased rather than re l ieved upon 75 admission. Many maladaptive patterns encountered on a psychia t r i c unit mask a basic lone l iness . Severe anxiety, s u i c i d e , a d d i c t i o n , psychoses, neuroses, and character disorders can represent attempts to 7 ft deal with a fundamental lone l iness . D i f f i c u l t i e s in interpersonal re lat ionships are concomitant with d i f f i c u l t i e s of adjustment to l i f e . One of the more important themes within psychia t r i c care focuses on the establishment and maintenance of interpersonal r e l a t i o n s h i p s . One-to-one rapport , group encounter, or people communication through c r a f t , . r o l e - p l a y , meetings, focus the exper ient ia l use of interpersonal s k i l l s to regain interpersonal relatedness. For the sensi t ive observer, the lonely person non-verbally com-municates his loneliness i n s i g n i f i c a n t behavioral expressions. Time-oriented complaints are often observed. The patient complains about the endlessness of each day, days which are endured but without any e f f o r t to change. Some patients speak as though past events and present experiences are i d e n t i c a l or fused t o g e t h e r . 7 7 V a c i l l a t i o n or hes i ta -t ion in making plans or the lack of any interes t in any goal are 7 5 Francel , p. 180. Barry, p. 589; see a l s o , F e r r i a , p. 205; see a l s o , Fromm-Reichmann, p. 326; see a l s o , Peplau, p. 1476; see a l s o , N. Ross, "Death at an Early Age," Canada's Mental Health, XVI I I , No. 6 (1970), 16; see a l s o , Jack Rubins, "On the Psychopathology of Lonel iness , " American  Journal of Psychoanalysis, 24, No. 2 (1964), 157; see a l s o , von W i t z l e -ben, p. 38. 7 7 Peplau, p. 1477. 22 78 observed. The p a t i e n t may over-plan or demonstrate a f a m i l i a r i t y with things rather than people, or he may show a tendency to d i s l i k e 79 everyone or to view people as anonymous beings. The l o n e l y person moves toward e s t a b l i s h i n g a r e l a t i o n s h i p with others. In t h e i r e f f o r t s to make contact with others, l o n e l y people often show an i n c l i n a t i o n to worship other people, to i n v e s t i n someone e l s e h i s so-far-unmet needs and wishes. R o l e - r e v e r s a l i s seen as an attempt to e s t a b l i s h contact with another; i n a d d i t i o n , i t a s c r i b e s to 81 the l o n e l y person f e e l i n g s of worth and s t r e n g t h . Other e f f o r t s to e s t a b l i s h contact with the nurse include complaints about p a i n , n o i s e , s t u f f i n e s s , concern over strength or frequent requests f o r a t t e n t i o n . Minor i l l n e s s e s seem to occur i n an e f f o r t to bring contact and protec-t i o n . Vomiting and belching occur i f the p a t i e n t perceives r e j e c t i o n 82 from the nurse. Loneliness i s described as a change in behavior: grabbing of food to avoid t h i n k i n g or the demand f o r immediate a t t e n t i o n from the 83 nursing s t a f f . Obesity, p h y s i c a l complaints, alcohol and drug con-84 sumption are seen as attempts to deal with a fundamental l o n e l i n e s s . 7 8 Fromm-Reichmann, p. 330; Peplau, p. 1477. 7 9 Peplau, i b i d . 8 0 S u l l i v a n , p. 262. 8 1 Peplau, p. 1478. 8 2 I b i d . , p. 1479. 8 3 A l i c e Goldman, "Learning Abortion Care," Nursing Out____k, 19, No. 5 (May 1971), 351 OA Buhler, p. 32; C l a r k , p. 53; Fromm-Reichmann, p. 330. 23 There are numerous incidents of the loneliness of the terminal ly i l l pat ient : the surgical patient who knows that his surgery i s only a temporary measure; the medical patient who comes to the hospital for his l a s t admission. ' Their loneliness would be endurable i f only . . . someone would ac tual ly p u l l up a chair and s i t down . . . ac tua l ly l i s tens and does not hurry by . . . someone who breaks the monotony of the loneliness . . . the agonizing w a i t i n g . . . .85 I t can be said then that lonel iness and h o s p i t a l i z a t i o n are not mutually exc lus ive . H o s p i t a l i z a t i o n interrupts the s a t i s f y i n g r e l a t i o n -ships through which a person endeavors to meet his need for relatedness. The patient attempts to es tabl ish contact and meet his need for re la ted-ness i n s i g n i f i c a n t patterns of behavior. Three patient groups are i d e n t i f i e d as p a r t i c u l a r l y sens i t ive to a sense of unrelatedness wi thin the h o s p i t a l : the newly admitted, the psychia t r i c patient and the patient whose h o s p i t a l i z a t i o n i s extensive. Kiibler-Ross i d e n t i f i e s a fourth group, the terminal ly i l l pat ients . She,as t h e i r advocate, admonishes us for not providing in f u l l , the quiet l i s t e n i n g time of which they are i n such desperate need. SUMMARY The purpose of th is chapter i s to out l ine the conceptual frame-work for loneliness and to provide some background to the loneliness of the hospi ta l ized pat ient . Loneliness i s said to e x i s t when an indiv idual i s unable to 8 5 Kiibler-Ross, p. 259. 24 s a t i s f y his need for relatedness with others. The need for relatedness i s basic to man and thus the threat of loneliness i s present at a l l stages of l i f e . The behavioral manifestations and cognit ive dimensions are described and the differences between depression and a l ienat ion are i d e n t i f i e d . Loneliness i s most often described in terms of i t s behavioral manifestations which frequently bring the lonely person into contact with the nurse in the c l i n i c a l s e t t i n g . Within the c l i n i c a l se t t ing of the h o s p i t a l , the dimensions of loneliness were further s tudied. Exploration of the l i t e r a t u r e r e l a t i v e to loneliness raises several questions: Does the patient perceive loneliness associated changes in his behavior? Does the patient feel free to communicate his f ee l ing to the nurse? Does the patient perceive a sense of relatedness with the nurse? In the h o s p i t a l , several variables e f fect the experience of lone-l i n e s s . Ident i f ied from the l i t e r a t u r e these are: the patient care category, or the c l i n i c a l se rv ice , the length of time the patient i s in the h o s p i t a l , and the contact the patient has with s i g n i f i c a n t others. Before guidelines for nursing intervention are attempted, some d i rec t ion to these questions needs to be es tabl ished. Chapter Three RESEARCH DESIGN The study's purpose and hypothesis, l i m i t a t i o n s and assumptions are o u t l i n e d , along with the d e f i n i t i o n of terms used in the study. The descr ipt ive method of research is used for th is study, the data gathered by means of a self -administered questionnaire. The question-naire used i s one developed by the researcher i n an attempt to systemati-c a l l y answer the questions raised from the l i t e r a t u r e reviewed. THE PURPOSE OF THE STUDY The purpose of the study i s to determine the s igni f i cance of selected variables i n the response of patients to lonel iness-associated statements. DEFINITION OF TERMS The hospi ta l ized patients are a l l patients resident in three s p e c i f i c hospitals on the day selected for the study. The lonel iness-associated statements are derived from the l i t e r -ature and they seek to i d e n t i f y the patient's perception of h is /her behavioral changes, freedom to communicate and sense of relatedness to the nurse. These lonel iness-associated statements w i l l be referred to as behavioral response categories and refer to : a) perceived behavioral changes; 25 26 b) perceived freedom to communicate; and c) perceived relatedness to the nurse. The selected variables are: a) the patient care category; b) the sex of the pat ient ; c) the length of h o s p i t a l i z a t i o n ; and d) the frequency of v i s i t o r s received. Questionnaire refers to a two part questionnaire developed by the invest igator for use in th is study. I t represents the combination of the above two d e f i n i t i o n s . The f i r s t part of the questionnaire seeks patient information to the selected var iab les . The second part of the questionnaire seeks a pos i t ive or negative reply to statements within the three behavioral response categories. (See Appendix D.) S i g n i f i c a n t i s considered the .05 level of s i g n i f i c a n c e . Patient care category refers to the c l i n i c a l services wi thin the general h o s p i t a l . These are the services of Extended Care, Mater-n i t y , Medicine, Psychiatry , Surgery, R e h a b i l i t a t i o n . Extended Care refers to that level of care for persons of a l l ages who do not require acute hospital care and treatment nor an in ten-sive or comprehensive program of mental and physical r e h a b i l i t a t i o n . 1 Rehabi l i ta t ion refers to that level of care for patients with a d i s a b i l i t y not requir ing acute treatment but who could benefit from 1 B r i t i s h Columbia Department of Health, The B r i t i s h Columbia  C l a s s i f i c a t i o n of Types of Health Care (September, 1973), p. 11. 27 a planned intensive and comprehensive program of mental and physical 2 r e h a b i l i t a t i o n . Loneliness refers to a state which exis ts when an indiv idual i s unable to s a t i s f y his need for relatedness with others. Relatedness refers to a fee l ing of emotional bonding an i n d i -vidual perceives between himself and another person. ASSUMPTIONS This study i s based on the fol lowing assumptions: 1. loneliness i s a state experienced to some degree by h o s p i t a l -ized pat ients ; 2. a lonely patient responds to the questionnaire in a d i f f e r e n t pattern than a non-lonely pat ient ; 3. the assurance to protect the pat ient ' s anonymity predisposes the patient to be candid i n his response; and 4. the patients requested to par t i c ipate in the study have a level of understanding or cognit ive a b i l i t y to comprehend the ques-tionnai re . LIMITATIONS This study i s subject to the fol lowing l i m i t a t i o n s : 1. the hospitals selected for the study service a demographically varied population. No attempt i s made to relate any demographic variable to lone l iness ; 2 The B r i t i s h Columbia C l a s s i f i c a t i o n of Types of Health Care, p. 9. 28 2. the time for the data c o l l e c t i o n is selected for the i n v e s t i -gator 's convenience and may have introduced some unforeseen variable not accounted for i n the study; 3. the questionnaire developed from relevant l i t e r a t u r e by the invest igator i s constrained by subjective biases; 4. the questionnaire as a paper and pencil method of data c o l l e c -t ion i s intended pr imar i ly for wide d i s t r i b u t i o n . I t i s l imi ted i n that i t seeks to achieve a surface level of i n f o r -mation only ; 5. several authors state that the lonely person i s not aware of his lone l iness . This study i s l imi ted by the questionnaire method of data c o l l e c t i o n in that i t i s based on the pat ient ' s a b i l i t y to respond to lonel iness-associated statements; and 6. the invest igator as a stranger to the pat ient , d i s t r ibutes the questionnaire and may introduce some unforeseen variable not accounted for in the study. HYPOTHESES This study seeks to prove the fo l lowing hypotheses: 1. there i s no s i g n i f i c a n t difference in the response of male and female pat ients ; 2. there i s no s i g n i f i c a n t difference i n the response of patients when length of h o s p i t a l i z a t i o n i s compared; 3. there i s no s i g n i f i c a n t difference i n the response of patients when c l i n i c a l service i s compared; 29 4. there is no s i g n i f i c a n t difference i n the response of patients when number of v i s i t s per week i s compared; and 5. there i s no s i g n i f i c a n t difference in the response of patients when number of v i s i t o r s per v i s i t i s compared. THE QUESTIONNAIRE The Development and Construction of the Questionnaire  At the outset , the design of th i s study involved the use of 3 Bradley's tool to measure lone l iness . Further examination of the t o o l , however, presented some methodological questions which inter fered with i t s u t i l i z a t i o n . Since no other tool to measure lonel iness could be located from the l i t e r a t u r e , i t then became the task to develop one for use in this study. To es tabl i sh the v a l i d i t y and r e l i a b i l i t y of the tool i s not considered wi th in the scope of th is study. The main pur-pose of the tool i s i t s attempt to es tabl i sh the degree of associat ion between the selected variables and the loneliness associated statements. The l i t e r a t u r e reviewed regarding the lonel iness of the hospi-t a l i z e d patient relates a disproportionate degree of lonel iness with certain var iab les . The length of h o s p i t a l i z a t i o n i s one variable thought to be s i g n i f i c a n t to the development of lone l iness . Espec ia l ly susceptible i s the newly admitted patient because of the unfamil iar 3 Rosalee Bradley, "Measuring Loneliness" (unpublished Doctor's d i s s e r t a t i o n , Univers i ty of Washington, 1969). 4 The invest igator acknowledges the assistance of Dr. Donald Anderson, Professor and Direc tor , Div i s ion of Health Sciences Research Development, Univers i ty of B r i t i s h Columbia. 30 environment and somewhat impersonal admission procedure and the extended care patient because of the reduced contact, over t ime, with s i g n i f i c a n t others. To be determined within the questionnaire then, i s the length of h o s p i t a l i z a t i o n the patient reports when he answers the questionnaire. The time categories selected were between "less than one week" through to "three months or more." Selection of the l a t t e r category is on the basis that the majority of extended care patients are hospi ta l ized for 5 a minimum of three months. The v i s i t s or contact with s i g n i f i c a n t others i s thought to be c r u c i a l to the development of lone l iness . For the patient whose care is extended, the contact with s i g n i f i c a n t others i s often reduced and thus t h e i r tendency to experience loneliness i s p a r t i c u l a r l y acute. In order to determine contact with s i g n i f i c a n t others, two questions are asked: the number of v i s i t s the patient received within a week and the approximate number of people who came each time. Analysis of the data from these two questions w i l l provide some indica t ion as to the degree of contact the patient maintained with others. The degree of the i r re la t ionship with the patient was not determined. The patients using the c l i n i c a l services of Psychiatry and Extended Care are most frequently c i ted as prone to manifest loneliness f e e l i n g s . Comparison of the patients i n these two services with the patients i n the other c l i n i c a l services wi th in the hospital w i l l give some credence to this observation. On the questionnaire, the c l i n i c a l Statement made by the Head Nurses of each Extended Care Unit used i n th is study. 31 services are l i s t e d i n alphabetical order. The respondent i s asked to i d e n t i f y his p a r t i c u l a r serv ice . An addit ional category of "Don't know" is included for those respondents uncertain of t h e i r answer. The ap-propriate service w i l l be i d e n t i f i e d by the invest igator upon the pat ient ' s completion of the questionnaire. Nowhere in the l i t e r a t u r e does i t state whether males or females show a greater tendency to express loneliness f e e l i n g s . To see whether such a tendency e x i s t s , a response to i d e n t i f y one's gender i s requested i n i t i a l l y i n the questionnaire. The f i r s t part of the questionnaire then, i s developed to e l i c i t responses to the variables of: a) the sex of the pat ient ; b) the length of h o s p i t a l i z a t i o n ; c) the c l i n i c a l serv ice ; d) the number of v i s i t s received per week; and e) the number of v i s i t o r s per v i s i t . The second part of the questionnaire i s an attempt to corrob-orate empirical data with patient response. The patient i s asked to respond to a series of twenty-two lonel iness-associated statements derived d i r e c t l y from the l i t e r a t u r e . The statements are al tered only to the extent that they f i t the questionnaire format. The l i t e r a t u r e reviewed indicates several behavioral changes which manifest an underlying lone l iness . Whether the patient i s aware that these behaviors are manifestations of loneliness i s unknown; 32 however, the patient i s reportedly able to acknowledge the behavioral change, i f not the loneliness i t represents. Most authors are of the opinion that the lonely person cannot communicate his lonel iness d i r e c t l y because he does not feel a sense of relatedness i n which to make this communication. Were the nurse able to create a climate of relatedness between herself and the pat ient , th is communication of lone-l iness might take place. This second part of the questionnaire then, i s divided into three categories of : a) perceived behavioral change; b) perceived freedom to communicate; and c) perceived sense of relatedness to the nurse. Perceived behavioral change (statements 1 to 10 inc lus ive) refers to an a l t e r a t i o n in e i ther the behavioral or emotional responses expressed by the patient since h o s p i t a l i z a t i o n . The s p e c i f i c causative factors are not determined. Perceived freedom to communicate (statements 11 to 17 inc lus ive) refers to the pat ient ' s fee l ing of being able to share feel ings or emo-tions with the nurse. The s p e c i f i c causative factors were not i d e n t i f i e d . Perceived sense of relatedness to the nurse (statements 18 to 22 inc lus ive) refers to the pat ient ' s perception of being known or accepted by the nurse. These questions attempt to determine the expres-sed feel ings by the patient of recogni t ion , approval or understanding as demonstrated by the nurse. 33 The patient i s requested to select whether he/she agrees or disagrees with the statements i n the above three categories. Alternate responses are not offered as th is design appears to be the best to e l i c i t the desired information for ana lys i s . In summary, the questionnaire can thus be described as divided into two sect ions . The f i r s t i s designed to test the variables i d e n t i -f i e d as s i g n i f i c a n t to the development of loneliness wi thin the h o s p i t a l . These variables are: a) the sex of the pat ient ; b) the length of h o s p i t a l i z a t i o n ; c) the c l i n i c a l serv ice ; d) the number of v i s i t s received per week; and e) the number of v i s i t o r s received per v i s i t . The second section requests [yes] or [no] responses to twenty-two lone-l iness associated statements. The statements are divided into the behavioral categories of : a) perceived behavioral change; b) perceived freedom to communicate; and c) perceived relatedness to the nurse. The Pretest of the Questionnaire A pretest questionnaire of f i f t y - f o u r items was drawn up from a pool of 110 statements derived from the l i t e r a t u r e . This question-naire was tested in one of the three hospitals included i n the study. 34 The time period between the pretest and the l a t e r test administration was two months. The patient population selected for the pretest were those r e s i -dent in a short-stay surgical ward, a ward considered to have a complete change of i t s patient population within th is two month period. The population sample for the pretest was t h i r t y - e i g h t , including twenty-three female and f i f t e e n male pat ients . The purpose of the pretest was to examine the construction of the questionnaire in terms of r e a d a b i l i t y and comprehension, to gather patient comment and to f a m i l i a r i z e the invest igator with the use of the questionnaire. The resul ts of the pretest strongly indicated that a questionnaire of f i f t y - f o u r items was too lengthy. It i s not reasonable to expect an unwell person to complete such a questionnaire with any degree of accuracy. The questionnaire was then revised. El imination of those statements which ostensibly test for the same response, reduced the questionnaire to twenty-two items. This twenty-two itemed questionnaire was pretested in one of the hospitals included in th i s study. This pretest was conducted with twenty pat ients , including eleven female and nine male pat ients . No changes in the questionnaire were indicated. The pretest group was excluded from the population studied. The invest igator acknowledges the assistance of Mrs. Janet Gormick, Assis tant Professor, School of Nursing, Univers i ty of B r i t i s h Columbia. 35 The Administration of the Questionnaire The questionnaire was d i s t r i b u t e d and col lected by the i n v e s t i -gator. The day selected for administration of the questionnaire was at the convenience of the invest igator and the nursing administrator for each h o s p i t a l . Attention was paid to ward schedules and patient care requirements. The time period for the to ta l invest igat ion was f i v e consecutive days. Privacy to answer the questionnaire was provided to the extent that the s i t u a t i o n permitted. The invest igator asked each patient to par t i c ipate in the study. The invest igator stated that t h e i r p a r t i c i p a -t ion was voluntary, t h e i r answers would remain anonymous, and that the purpose of the study was to help nurses to better understand pat ients . The invest igator requested that i f the patient did p a r t i c i p a t e , would he please read and sign the consent form for th is study. This was c o l -lected separately so that the questionnaire would not be associated with any i n d i v i d u a l ' s name. Any inquir ies that arose from the question-naire were answered when the invest igator returned to c o l l e c t the com-pleted questionnaires. (See Appendixes A, B, and C.) THE POPULATION SAMPLE The hospitals selected for th i s study were two general acute treatment h o s p i t a l s , each with a separate but associated extended care uni t and one spec ia l ized r e h a b i l i t a t i o n h o s p i t a l . These hospitals were selected because the i r c l i n i c a l services included a l l those to be studied and t h e i r combined patient population provided s u f f i c i e n t 36 numbers for data collection. The rehabilitation hospital supplemented an otherwise deficient c l i n i c a l service population within the other two general hospitals. The population sample consisted of a l l patients resident in these three hospitals on the day selected for the study. The pediatric wards were excluded from the population sample because of the d i f f i -culty in obtaining parental consent. The emergency and day care patients were also excluded from the population sample. The routine of their treatment measures would have rendered the answering of the ques-tionnaires very inconvenient. Table 1 represents the types of hospitals sampled and their patient population. The patient population quoted is for the day selected for the study and is exclusive of pediatric, day care or emer-gency ward patients. Four hundred patients was the projected population sample, a number considered to be s t a t i s t i c a l l y significant for this descriptive method of research. 7 Patients who required help with simple reading or mechanical s k i l l s to answer the questionnaire were assisted by the investigator. Patients who were receiving treatment or who were physically or mentally incapable of answering the questionnaire were not asked to participate. The Head Nurse or her deputy on each ward assisted in this selection. Table 2 illustrates the number and relative percentage by reason of those patients excluded from the study. The largest percentage of 7 Dr. Donald 0. Anderson. Table 1 The Type of Hospitals Used in th is Study, t h e i r Patient Populations on the Day of the Investigation Exclusive of Pedia t r i c and Day Care Patients Type Patient of Hospital Population A r e h a b i l i t a t i v e 4 8 hospital A general acute treatment 509* hospital A general acute treatment 305 hospital Total 852 The pretest-population (20 patients) i s excluded. 38 Table 2 The Number and Percent by Reason of Non-Participants in the Study Reason for Exclusion from the Study Number Percent Receiving Treatment - on ward admission 8 2.0 - on ward pre-operative 9 2.2 - on ward general 8 2.0 - of f ward del ivery room 9 2.2 - of f ward diagnostic 19 4.3 - of f ward operating room 54 13.2 - of f ward recovery room 35 8.6 Cognit ively Unresponsive - aphasic 4 1.0 - pain/discomfort 13 3.2 - s e n i l i t y 110 26.9 - unconscious 76 18.6 D i f f i c u l t y in Feeding Newborn 4 1.0 D i f f i c u l t y in Language Comprehension 19 4.7 Unwil l ing to Par t i c ipate - preparing for discharge 18 4.0 - receiving v i s i t o r s 14 3.5 - refused, no reason stated 9 2.2 Total 409 100.0 39 non-participants were excluded for reasons of cognit ive d i s a b i l i t y . A comparison of non-participants by c l i n i c a l service was not made at the time of the study. However, i t i s the inves t iga tor ' s opinion that the major proportion of those cogni t ive ly unresponsive patients were from the c l i n i c a l services of Extended Care and the s p e c i a l i t i e s wi th in Medicine and Surgery, s p e c i f i c a l l y cardiology, neurology, and neuro-surgery. This lack of cognitive response i s not e n t i r e l y foreign to the patients cared for i n these p a r t i c u l a r services . I t i s to be noted that in the category of non-part ic ipants , those receiving treatment or feeding a newborn were v i s i t e d twice to ascertain t h e i r a v a i l a b i l i t y before exclusion from the study. SUMMARY The s p e c i f i c s of the research design, i t s purpose, assumptions, l i m i t a t i o n s , and hypotheses were l i s t e d and the terms def ined. The tool used in the study i s a two-part questionnaire developed by the invest igator from the l i t e r a t u r e . The f i r s t part i d e n t i f i e s variables s p e c i f i c to the loneliness of the hospi ta l ized pat ient . The second part l i s t s statements of behavioral indicators of lone l iness . The main purpose of the study i s to determine the degree of associat ion between the variables of the f i r s t part and the behavioral indicators of the second part . The method of pretest and d i s t r i b u t i o n of the questionnaire i s described. The population sample i s described and the n o n - p a r t i c i -pating population sample i s l i s t e d and i d e n t i f i e d . Chapter Four ANALYSIS OF THE DATA Three separate sections of analysis are made on the data c o l -l ec ted . The f i r s t section i s the analysis of the population sample in terms of the selected var iab les . The second section determines the degree of associat ion between the three categories of behavioral response. The t h i r d section tests the hypotheses of the study. ANALYSIS IN RELATION TO THE POPULATION SAMPLE The Character is t ics of the Popu-l a t i o n Sample  Of the tota l 443 respondents, more than hal f were female. Table 3 represents the sample s ize and indicates the d i s t r i b u t i o n for female and male respondents. Table 3 Frequency of Respondents According to the Sex of the Respondents Patient Number of Respondents Percentage Male 141 31.8 Female 302 68.2 Total 443 100.0 Further inquiry into this disproportionate number of females reveals 40 41 that certain c l i n i c a l services are more prone to treat females as demon-strated i n Table 4. Table 4 Frequency of Male/Female Respondents According to C l i n i c a l Service C l i n i c a l Service Number of Respondents Male Percent of Respondents Number of Respondents Female Percent of Respondents Extended Care 15 3.4 72 16.3 Maternity - - 48 10.8 Medicine 42 9.5 42 9.5 Psychiatry - 18 4.1 49 11.1 Surgery 49 11.1 50 11.3 Rehabi l i ta t ion 17 3.8 41 9.3 Total 141 31.9 302 68.3 Medicine and Surgery c l i n i c a l services are evenly divided between the sexes. In Psychiatry , Rehabi l i ta t ion and Extended Care c l i n i c a l ser-v i c e s , the number of females i s dominant. The high percentage of female respondents i n Extended Care may be a t t r ibuted to the longer l i f e expec-tancy for females and the older age group which predominates i n th is serv ice . Table 5 represents the frequency d i s t r i b u t i o n for length of hos-p i t a l i z a t i o n . As demonstrated i n th is tab le , the length of h o s p i t a l i z a -t ion holds the greatest frequency for respondents at opposite ends of the sca le . More than hal f the respondents e i ther reported ' less than one week1 or 'more than three months' of h o s p i t a l i z a t i o n . 42 Table 5 Frequency of Respondents According to Length of H o s p i t a l i z a t i o n Length of H o s p i t a l i z a t i o n Number of Respondents Percentage Less than 1 Week 148 33.4 1 Week - Less than 2 Weeks 78 17.6 2 Weeks - Less than 3 Weeks 34 7.7 3 Weeks - Less than 1 Month 20 4.4 1 Month - Less than 2 Months 38 8.5 2 Months - Less than 3 Months 27 6.1 3 Months or More 98 22.3 Total , 443 100.0 This observation i s supported by the data i n Table 6 which pro-vides the frequency d i s t r i b u t i o n by c l i n i c a l serv ice . Table 6 Frequency of Respondents According to C l i n i c a l Service C l i n i c a l Service Number of Respondents Percentage Extended Care 87 19.6 Maternity 48 10.8 Medicine 84 18.9 Psychiatry 67 15.1 Surgery 99 22.3 Rehabi1i ta t ion 58 13.3 Total 443 100.0 43 The high percentage of surgical pat ients , 22.3 percent, might account for those patients who responded to the ' less than one week' category. S i m i l a r l y , since 19.6 percent of the respondents are from Extended Care, the 'three months or more' h o s p i t a l i z a t i o n would seemingly stem from t h e i r responses. Tables 7 and 8 provide information col lected on the frequency of v i s i t o r s per v i s i t . Table 7 Frequency of Respondents According to the Number of Visits/Week Number of Number of Percentaae Visits/Week Respondents percentage Dai ly 303 68.3 Twice a Week 85 19.1 Once a Week 31 6.9 Almost Never 24 5.7 Total 443 100.0 Table 8 Frequency of Respondents According to the Number of V i s i t o r s / V i s i t u.Number °f DNumbe^ °l Percentage V i s i t o r s / V i s i t Respondents One 178 40.1 2 - 3 243 54.8 4 or More 15 3.3 None 7 1.8 Total 443 100.0 44 These tables indicate that the majority of patients are well v i s i t e d . This i s both i n terms of the number of v i s i t s received and the number of v i s i t o r s per v i s i t . Dai ly v i s i t s of two or three v i s i t o r s per time are reported most frequently . In summary, the analysis r e l a t i v e to the population sample i s that the population sample i s 68.2 percent female. Comparison of the male/female d i s t r i b u t i o n by c l i n i c a l service indicates a d isproport ion-ate number of females i n Extended Care, Psychiatry , R e h a b i l i t a t i o n , Maternity . The frequency d i s t r i b u t i o n for length of h o s p i t a l i z a t i o n i s loaded i n two categories, 33.4 percent i n the ' less than one week' and 22.3 percent f o r 'three months or more.' The d i s t r i b u t i o n for c l i n i c a l service by to ta l population ranges from Surgery, 22.3 percent to Reha-b i l i t a t i o n , .13.3 percent. The majority of respondents, 68.0 percent, reported d a i l y v i s i t s , and 54.8 percent received two to three v i s i t o r s per v i s i t . The population sample can be described as disproport ionately female, with Surgery, 22.3 percent, the largest s ingle respondent group. The major proportion of respondents were hospi ta l ized for e i ther less than one week or more than three months. The major proportion of respondents were well v i s i t e d , reporting most frequently two to three v i s i t o r s d a i l y . ANALYSIS IN RELATION TO THE BEHAVIORAL RESPONSE CATEGORIES The degree of associat ion among the three behavioral response categories (that i s , perceived behavioral change, perceived freedom to 45 communicate and perceived relatedness to the nurse) i s determined by the chi-square method of ana lys i s . This analysis i s to determine i f there is any associat ion among these three categories, s p e c i f i c a l l y , whether these three categories e l i c i t separate and d i s t i n c t behavioral responses. Table 9 i l l u s t r a t e s the chi-square analysis for the behavioral response categories and the degree of freedom for these categories. Table 9 Associat ion Between Categories of the Questionnaire Degrees of Freedom and Chi-Square Values L is ted per Associat ion Questionnaire Patient Numbers Perceived . 1 i n / n 17 Behavioral Change/ ' Freedom to Communicate i i n / l a 9 9 Behavioral Change/ i - i u / i a - _ _ Relatedness to Nurse n 17/1 a 9 9 Freedom to Communicate/ M - I / / I _ - _ _ Relatedness to Nurse d f X2 Value P 12 33.12 0 .00098 9 41.86 0 .00000 12 110.72 0 .00000 The associat ion between a l l three categories i s highly s i g n i f i c a n t . However, the associat ion between the freedom to communicate and re la ted-ness with the nurse i s so highly s i g n i f i c a n t that these categories appear to test for the same behavioral response. Some conclusions can be drawn from the associat ion of behavioral change with the other two categories. A high response to those changes i n behavior reported to indicate lone l iness , i s associated with a low degree of freedom to communicate and perceived relatedness. The 46 impl icat ion i s that those respondents who reported a high degree of loneliness associated behavioral changes did not feel free to communi-cate these feel ings nor did they perceive a high degree of relatedness i n which to make this communication. The analysis of the associat ion between the behavioral response categories reveals two interes t ing observations. A high degree of perceived behavioral change i s associated with a low degree of perceived freedom to communicate and perceived re la ted-ness to the nurse. That i s , the more lonel iness-associated changes a patient perceives i n himself , the less l i k e l y he feels free to communi-cate these to the nurse. The second observation i s the high degree of associat ion between perceived freedom to communicate and perceived relatedness to the nurse. These two categories test for the same behavioral response. Freedom to communicate and perceived relatedness are one and the same perception. Since both these categories test for the same response, a .05 level of s igni f i cance for e i ther of the two categories i s considered s i g n i f i c a n t for the hypothesis. ANALYSIS IN RELATION TO THE HYPOTHESES OF THE STUDY The hypotheses are tested by means of the chi-square method of ana lys i s . Since there are no previous studies to use as a guide, the frequencies are based on the marginal to ta ls and groupings assigned by the i n v e s t i g a t o r . 1 These groupings provide a span from high to low 1 The invest igator acknowledges the assistance of Dr. Donald Ander-son, Professor and Direc tor , D i v i s i o n of Health Services Research Development, Univers i ty of B r i t i s h Columbia. 47 frequency d i s t r i b u t i o n f o r each of the behavioral response c a t e g o r i e s . The responses with small frequencies were grouped together to provide t h i s d i s t r i b u t i o n . The groupings a r r i v e d at f o r perceived change were: 0 p o s i t i v e responses; 1 to 2 p o s i t i v e responses; 3 to 4 p o s i t i v e responses; and 5 to 7 p o s i t i v e responses. The groupings a r r i v e d at f o r perceived freedom to communicate were: 0 to 2 p o s i t i v e responses; 3 p o s i t i v e responses; 4 p o s i t i v e responses; 5 p o s i t i v e responses; and 6 to 7 p o s i t i v e responses. The groupings a r r i v e d at f o r perceived relatedness were: 0 to 1 p o s i t i v e responses; 2 p o s i t i v e responses; 3 p o s i t i v e responses; and 4 to 5 p o s i t i v e responses. 48 Analysis of the Data in Relation to Hypothesis 1 Hypothesis 1: There i s no s i g n i f i c a n t difference in the response of male and female pat ients . Support for Hypothesis 1 i s achieved. There i s no s i g n i f i c a n t difference between male and female respondents in any of the behavioral categories. Tables 10, 11 and 12 v e r i f y th is conclusion. Table 10 Comparison of Responses indicat ing Perceived Behavioral Change and Sex of Patient Sex of Low Degree High Degree Respondent of Change of Change 1 2 3 4 Percent Freq. Percent Freq. Percent Freq. Percent Freq. Male 30.50 43 32.62 46 19.15 27 17.73 25 Female 25.17 76 28.15 85 24.83 75 21.85 66 Total 26.86 119 29.57 131 23.02 102 20.54 91 100.00 443 3.81 3 0.28201 Table 11 Comparison of Responses Indicating Perceived Freedom to Communicate and Sex of the Patient Sex of Patient Low Degree of Freedom High Degree of Freedom Percent Freq. Percent Freq. Percent Freq. Percent Freq. Percent Freq, Male 17.73 25 21.99 31 20.57 29 22.70 32 17.02 24 Female 24.83 75 17.55 53 17.55 53 16.23 49 23.84 72 Total 22.57 100 18.96 84 18.51 82 18.28 81 21.67 96 100.00 443 7.88 d f = 4 P = 0.09483 cn o Table 12 Comparison of Responses Indicating Perceived Relatedness to the Nurse and Sex of the Patient Sex of Patient Low Degree of Relatedness 1 High Degree of Relatedness 3 4 Percent Freq. Percent Freq. Percent Freq. Percent Freq. Male Female 20.57 29 23.40 33 33.33 47 22.70 32 16.23 49 24.17 73 28.48 86 31.13 94 Total 71.61 78 23.93 106 30.02 133 28.44 126 100.00 443 4.21 d f = 3 P = 0.23838 52 Analysis of the Data in Relation to Hypothesis 2 Hypothesis 2: There i s no s i g n i f i c a n t difference in the response of patients when length of h o s p i t a l i z a -t ion i s compared. Support for th is hypothesis i s achieved. There i s no s i g n i f i -cant difference in the response of patients when length of h o s p i t a l i z a -t ion i s compared. The category of perceived behavioral change achieves a 34.34 (P = 0.00063) level of s i g n i f i c a n c e . The categories of perceived free-dom to communicate and perceived relatedness do not achieve s i g n i f i c a n c e . The associat ion between length of h o s p i t a l i z a t i o n and behavioral change i s i l l u s t r a t e d i n Figure 2. C l e a r l y , patients hospi ta l ized for '3 months or more1 perceived themselves as the most changed of any group. Those in the hospital for ' less than one week' perceived the least changes. Almost consis-t e n t l y , the number of changes perceived increased as the length of h o s p i t a l i z a t i o n increased. LO OO Low High Degree of Change LESS THAN 1 WEEK o _ oo _ o UJ c_> _ LU CL. 40 35 30 25 20 15 10 5 ov •-JCTi CSJ _> OO CM Low High Degree of Change LESS THAN 2 WEEKS oo o _ oo LU _ LU _> _ 40 35 30 25 20 15 10 5 C\J _> C\J • • — " CM Low High Degree of Change LESS THAN 1 MONTH CO o OO o oo 0 0 40 {_ 35 I 30 _ oo 20 15 10 5 _ _ LU _ Low High Degree of Change LESS THAN 3 MONTHS LO oo CM Low High Degree of Change 3 MONTHS OR MORE = 34.34 d f = 12 P = 0.00063 Figure 2 Comparison of Responses Indicating Perceived Behavioral Change and Length of H o s p i t a l i z a t i o n 54 Tables 13 and 14 indicate the frequency d i s t r i b u t i o n s for per-ceived freedom to communicate and perceived relatedness with length of h o s p i t a l i z a t i o n . The associat ion between both these variables and length of h o s p i t a l i z a t i o n is not s i g n i f i c a n t . Summarizing the data in re la t ion to Hypothesis 2 shows support for th is hypothesis i s achieved. There i s no s i g n i f i c a n t dif ference i n patient response when length of h o s p i t a l i z a t i o n i s compared. However, in the category of perceived behavioral changes, a s i g n i f i c a n t trend i s noted. The longer the h o s p i t a l i z a t i o n , the more changes are perceived. Almost cons i s tent ly , the number of changes perceived increased as the length of h o s p i t a l i z a t i o n increased. Table 13 Comparison of Responses Indicating Perceived Freedom to Communicate and Length of Hospi ta l iza t ion Length of Stay Low Degree of Freedom High Degree of Freedom Percent Freq. Percent Freq. Percent Freq. Percent Freq. Percent Freq, Less than 1 week Less than 2 weeks Less than 1 month Less than 3 months 3 Months or more 22.30 15.38 31.48 23.08 23.47 33 12 17 15 23 19.59 20.51 20.37 15.38 18.37 29 12.16 16 19.23 11 10 18 16.67 27.69 22.45 18 15 9 22 23.65 23.08 12.96 18 15.38 11 .22 35 22.30 18 21.79 7 18.52 10 18.46 11 24.49 33 17 10 12 24 Total 22.57 100 18.96 84 18.51 82 18.28 81 21.67 96 100.00 443 = 19.56 d f = 16 P = 0.24024 en cn Table 14 Comparison of Responses Indicating Perceived Relatedness and Length of Hospi ta l iza t ion Length of Stay Low Degree of Freedom High Degree of Freedom Percent Freq. Percent Freq. Percent Freq. Percent Freq. Less than 1 week Less than 2 weeks Less than 1 month Less than 3 months 3 Months or more 14.54 17.95 12.96 20.00 21.43 23 14 7 13 21 21.62 21.79 22.22 21.54 31.63 32 17 12 14 31 27.03 37.18 42.59 27.69 23.47 40 29 23 18 23 35.81 23.08 22.22 30.77 23.47 53 18 12 20 23 Total 117.61 78 23.93 106 30.02 133 28.44 126 100.00 443 16.44 12 0.16303 57 A n a l y s i s o f the Data in R e l a t i o n to Hypothesis 3 Hypothesis 3: There i s no s i g n i f i c a n t d i f f e r e n c e i n the response of p a t i e n t s when c l i n i c a l s e r v i c e i s compared. This hypothesis i s r e j e c t e d on the basis of the data a n a l y s i s . A l l behavioral response c a t e g o r i e s are s i g n i f i c a n t f o r each of the c l i n i c a l s e r v i c e s compared. Figure 3 demonstrates the a s s o c i a t i o n between perceived behavioral change and c l i n i c a l s e r v i c e . Extended Care and P s y c h i a t r y groups both reported a high degree of perceived change. This p o s i t i v e a s s o c i a t i o n toward more change perceived i s a d i r e c t c o n t r a s t to the negative a s s o c i a t i o n demonstrated by a l l other c l i n i c a l s e r v i c e s . P s y c h i a t r y i s the only c l i n i c a l s e r -v i c e to show so few responses w i t h i n the category of 'no change per-ceived. 1 There e x i s t s w i t h i n P s y c h i a t r y and Extended Care a common element which predisposes t h e i r respondents to perceive more changes i n themselves. Maternity, Medicine, Surgery, and R e h a b i l i t a t i o n respondents a l l demonstrated a trend toward p e r c e i v i n g few changes i n themselves. Maternity respondents perceived themselves as the l e a s t changed of these four c l i n i c a l s e r v i c e s . No Maternity respondents answered i n the l a s t category of ' f i v e or more changes perceived.' Surgery respondents reported only 'one or two changes' most o f t e n . The trend f o r Medicine and R e h a b i l i t a t i o n respondents was to perceive few changes i n themselves, yet not as few as t h e i r Maternity and Surgery counterparts. 58 o Q. OO LU CC u. o c_> cc 50 45 40 35 30 25 20 15 10 5 EN Q ~2Z O D_ oo UJ cc o ' CT> OS co NT OJ i — LU • • • • C_> ro LO co cc i — CM CM oo LU CL. 1 2 3 4 Low High Degree of Change EXTENDED CARE 50 45 40 35 30 25 20 15 10 5 oo co o CM o o 1 2 3 4 Low High Degree of Change MATERNITY 50 45 40 oo 35 i— S 30 25 20 15 10 5 o D-OO LU CC LL O LU C_> cc LU Q_ O ("CO I 1 2 3 4 Low High Degree of Change MEDICINE oo o CL OO LU cc o cc 50 45 40 35 30 25 20 15 10 5 Low p CO as CO CO CO s* • • • CM LO I  CM CO CO 1 2 3 4 High Degree of Change PSYCHIATRY 50 45 40 c_ 35 S 30 o CL. OO LU CC LL_ O O CC LU 25 20 15 10 5 o CO o CO CM LO| CM LOl OJ 1 2 3 4 Low High Degree of Change SURGERY 50 45 40 £ 35 y 30 o CL OO LU CC LU CC 25 20 15 10 5 CO as co o CM 78.83 15 0.00000 as CO 1 2 3 . 4 Low High Degree of Change REHABILITATION Figure 3 Comparison of Responses Indicating Perceived-Behavioral Change and C l i n i c a l Service 59 In the previous analysis of the data regarding the length of h o s p i t a l i z a t i o n , i t i s noted that increased change i n behavior coincided with increased length of h o s p i t a l i z a t i o n . Maternity and Surgery patients are usually hospi ta l ized for shorter periods of time than are Medicine or Rehabi l i ta t ion pat ients . This then, might account for the more obvious downward trend toward fewer changes perceived within the Maternity and Surgery respondent groups. Hospita l ized for shorter per iods , Maternity and Surgery respondents would then perceive them-selves as less changed than would the Medicine or Rehabi l i ta t ion respon-dents. In r e l a t i o n to perceived behavioral change then, Psychiatry and Extended Care patients perceived many changes in themselves; Medicine and Rehabi l i ta t ion patients perceived a few changes; and Maternity and Surgery patients perceived the least changes of any respondent group. Figure 4 demonstrates the association between perceived freedom to communicate and c l i n i c a l serv ice . Rehabi l i ta t ion respondents very d e f i n i t e l y did not perceive the freedom to communicate. A high degree of difference exis ts between those who reported a low degree and those who reported a high degree of freedom to communicate. The contrast i s espec ia l ly apparent when the other c l i n i c a l services are compared. Extended Care, Surgery and Medicine respondents appear almost evenly divided between a low degree and a high degree of freedom to communicate. This minimal difference leads one to believe that freedom 60 oo o Q_ OO LU _ O CC 35 30 25 20 15 10 5 CO CTI OO CO CTl CM LO CM VO CM Low High Degree of Freedom EXTENDED CARE oo o _ oo LU _ o CC 35 30 25 20 15 10 5 • -• vo LO LO o o oo oo ' vo co CO LO CM o CM f_ 35 _ 30 25 _ 20 o Q-OO LU _ _ 15 _ io LU ° 5 Low High Degree of Freedom MATERNITY CM CM CM CTl _> CM CT) CM 1 ^ "=3" CM O CM Low High Degree of Freedom MEDICINE o Q-00 LU CC c_> cc 35 30 25 20 15 10 5 LO OO CTl Low High Degree of Freedom PSYCHIATRY o CL. OO LU CC LU cc 35 30 25 20 15 10 5 O C L -ES _ Ll_ O I— _> OO VO LO CTl CM r— r— CM — — LU <_) VO OO VO LO CTl _ CM i — i — CM i LU D-Low High Degree of Freedom SURGERY Low High Degree of Freedom REHABILITATION 33.66 20 0.02851 Figure 4 Comparison of Responses Indicating Perceived Freedom to Communicate and C l i n i c a l Service 61 to communicate i s of no p a r t i c u l a r s igni f i cance for e i ther of these three groups. • The most s i g n i f i c a n t associat ion within the category of freedom to communicate i s found within Psychiatry . A large proportion of the respondents from Psychiatry perceived a high degree of freedom to com-municate. A s i m i l a r pos i t ive association i s also found within the Maternity respondent group, but not to the degree that i s perceived by the Psychiatry respondents. In r e l a t i o n to freedom to communicate then, Maternity and Psychiatry respondents perceived a high degree of freedom; Extended Care, Medicine and Surgery respondents were i n d i f f e r e n t ; and R e h a b i l i -tat ion respondents perceived l i t t l e freedom i n which to communicate. Figure 5 i l l u s t r a t e s the associat ion between perceived re la ted-ness to the nurse with the c l i n i c a l serv ice . Maternity and Psychiatry respondent groups both exhibited a high degree of relatedness to the nurse. S ix ty - four percent of Psy-chiatry respondents reported wi th in the t h i r d and fourth highest cate-gory for relatedness. The most obvious expression of relatedness, however, comes from the Maternity respondents, 60 percent of whom answer to the highest category of relatedness. There i s an even d i s t r i b u t i o n across a l l categories of response for Extended Care respondents. This d i s t r i b u t i o n pattern seems to indicate an indif ference to the question of relatedness by the Extended Care pat ients . The three c l i n i c a l services of Medicine, Surgery, and 62 60 55 50 45 40 £ 35 " 30 25 20 15 10 5 LU cn __ o Cu oo LU CC Ll_ O C_> _ LU S f -3 CM CM 2 3 4 Low High Relatedness EXTENDED CARE 60 55 50 45 40 £ 3 5 | 30 I 25 oo £ 20 15 10 ° 5 c_ 3 LU D. 1 2 3 4 Low High Relatedness PSYCHIATRY 60 55 50 45 40 «_ 35 | 30 ^ 25 20 15 _ 1 0 o 5 oCu OO LU c_ LL-C-CM (Tl CM CM CM •=3-2 3 4 Low High Relatedness MATERNITY • Q zz: o CL oo 1 1 1 • cc 1 1 o 1— ' 1 — CM «!*• «* (Ti CO CO LU • • • • c_> CM CM cc i— r— CO CO LU CL 60 55 50 45 40 35 30 25 20 15 10 5 en LO CM LO CM CO 1 2 3 4 Low High Relatedness SURGERY Figure 5 o CL OO LU cc Ll_ o o cc 60 55 50 45 40 35 30 25 20 15 10 5 -s t -CM CM • • • • o cn (Ti O CM CM CM CM 1 2 3 4 Low High Relatedness 0 0 o o. oo LU cc Lu O O CC 60 55 50 45 40 35 30 25 20 15 10 5 MEDICINE X 2 = 43.73 d f = 15 0.00013 •=3-co CM 1 2 3 4 Low High Relatedness REHABILITATION Comparison of Responses Indicating Perceived Relatedness and C l i n i c a l Service 63 Rehabi l i ta t ion exh ib i t an average d i s t r i b u t i o n pattern i n response to the category of relatedness. The highest degree of relatedness wi th in these three c l i n i c a l services was reported by the Rehabi l i ta t ion respon-dents . In the section of analysis dealing with the associat ion between the behavioral response categories (pages 44 to 46) , perceived freedom to communicate and perceived relatedness were found to test for the same response. For the variable of c l i n i c a l s e r v i c e , however, these response patterns vary. Comparison reveals some in teres t ing contrasts as well as s i m i l a r i t i e s . The most remarkable contrast between freedom to communicate and perceived relatedness i s found within the Rehabi l i ta t ion respondent group. Rehabi l i ta t ion patients reported the lowest of a l l the c l i n i c a l services in the category of freedom to communicate. Curiously enough, while these respondents reacted negatively to the category of freedom to communicate they reacted p o s i t i v e l y to the category of relatedness. One speculation regarding th is divergent pattern may re late to the r e h a b i l i t a t i o n treatment goals . Emphasis of the relearning tasks may predispose the patient to de-emphasize free communication i n order to get on with the task at hand. However, these relearning tasks require the close involvement between patient and nurse, which predisposes the patient to perceive a sense of relatedness to the nurse. Differences i n the d i r e c t i o n of response for Medicine and Surgery c l i n i c a l services tends to be s l i g h t and unremarkable. Medi-cine respondents were s l i g h t l y more negative in the i r reaction to 64 freedom to communicate yet average i n the i r response to relatedness. Surgery respondents while i n d i f f e r e n t to the category of freedom to communicate, demonstrated a s l i g h t l y more pos i t ive response i n t h e i r perception of relatedness. S i m i l a r i t i e s are seen in the response patterns of patients wi thin Extended Care, Maternity and Psychiatry . Extended Care respon-dents showed an indif ference to both categories of response. Neither the freedom to communicate nor the sense of relatedness was of any p a r t i c u l a r s igni f i cance to the respondents from Extended Care. Psy-chiatry respondents consistent ly responded in a pos i t ive d i r e c t i o n in both categories. They reported a high degree of freedom to communicate as well as a high degree of relatedness to the nurse. Maternity respondents also showed a pos i t ive d i r e c t i o n i n t h e i r responses to both categories. However, t h e i r pos i t ive response to relatedness was remarkable. While a 4 percent difference exis ts between high and low on the freedom to communicate s c a l e , there i s a 58 percent difference between high and low on the relatedness sca le . Maternity respondents very d e f i n i t e l y perceived a sense of relatedness with the nurse even though they were not as d e f i n i t e i n t h e i r percep-t ion of t h e i r freedom to communicate with her. Summarizing the data i n r e l a t i o n to Hypothesis 3 shows th i s hypothesis i s re jected. There was a s i g n i f i c a n t difference i n the response of patients when c l i n i c a l service was compared. Extended Care respondents reported many behavioral changes i n themselves but were i n d i f f e r e n t to the categories of perceived freedom 65 to communicate and perceived relatedness. Psychiatry respondents also perceived many behavioral changes, y e t , they reported a pos i t ive reac-t ion to perceived freedom to communicate and perceived relatedness. Implications for these two c l i n i c a l services i s important. Patients in both perceive many loneliness associated changes in them-selves but Psychiatry respondents feel free to communicate and Extended Care patients do not. Maternity respondents repl ied to very few of the lonel iness associated changes in behavior. Their response was pos i t ive to the categories of freedom to communicate and perceived relatedness. The pos i t ive trend for relatedness, however, far exceeds that for freedom to communicate. This seems to indicate that Maternity respondents very d e f i n i t e l y perceived a sense of relatedness with the nurse even though they were not as d e f i n i t e i n t h e i r perception of the freedom to communicate with her. The data analysis for Surgery respondents indicates that few lonel iness-associated behavioral changes were perceived. Freedom to communicate was of no p a r t i c u l a r s igni f i cance although a pos i t ive sense of relatedness to the nurse was reported. Medicine respondents related more lonel iness-associated behav-i o r a l changes than did Surgery respondents. Medicine respondents per-ception of relatedness was average, but t h e i r perception of freedom to communicate was negative. The impl icat ion i s important. Medicine respondents often perceive lonel iness-associated changes in themselves but l i k e Extended Care respondents, they do not perceive the freedom to 66 communicate these changes. Patients in both these c l i n i c a l services perceived lonel iness-associated change in t h e i r behavior but from the data, i t seems u n l i k e l y that these changes would be communicated. Rehabi l i ta t ion respondents perceived few lonel iness-associated changes i n themselves. Their response to freedom to communicate was the most negative of any c l i n i c a l se rv ice , yet they were pos i t ive i n t h e i r response to relatedness. These respondents i t appears, perceived a sense of relatedness to the nurse yet did not or would not allow themselves the freedom to communicate with her. 67 Analysis of the Data in Relation to Hypothesis 4 Hypothesis 4: There i s no s i g n i f i c a n t difference in the response of patients when number of v i s i t s received i s compared. This hypothesis i s rejected on the basis of the data analys is . There i s a s i g n i f i c a n t difference for perceived behavioral change and perceived relatedness when number of v i s i t s i s compared. However, there i s no s i g n i f i c a n t difference when perceived freedom to communicate i s compared. As stated e a r l i e r (page 46), the hypothesis i s s i g n i f i c a n t when a level of s igni f icance i s achieved for two of the three categories of behavioral response. Figure 6 demonstrates the associat ion between perceived behav-i o r a l change and number of v i s i t s received. Respondents who received v i s i t s d a i l y perceived very few changes in themselves. Respondents who received v i s i t o r s twice a week were i n d i f f e r e n t in t h e i r response while those who received v i s i t s only once a week reported a high degree of change perceived. Very c l e a r l y the respondents who received v i s i t o r s once a week reported a high degree of change perceived. CO o o CO co cn co LO co L O co Low High Degree of Change DAILY VISITS 50 45 40 35 30 25 S 20 c5 15 £ 10 LU cc 5 o OO Csl CO CM O o o CM s f CM CO CM Low High Degree of Change 2 VISITS/WEEK 50 45 40 35 30 25 2 20 o oo o 15 £ 10 LU S 5 LU CM LO LO cn o CO CM Low High Degree of Change 1 VISIT/WEEK X 2 = 49.54 d f = 6 P = 0.00000 Figure 6 Comparison of Responses Indicating Perceived Behavioral Change and Number of Visits Received 69 Table 15 represents the associat ion between perceived freedom to communicate and number of v i s i t s received. The data does not achieve s i g n i f i c a n c e . The number of v i s i t s received bears no s i g n i f i -cant association to the respondents perception of his freedom to com-municate . Figure 7 demonstrates the associat ion between perceived re la ted-ness and the number of v i s i t s received. Clear ly there i s a s i g n i f i c a n t associat ion between perceived relatedness and number of v i s i t s received. There i s a pos i t ive associ -ation between perceived relatedness and d a i l y v i s i t s . Those who re-ceived d a i l y v i s i t s reported a high degree of relatedness. Conversely, those who received v i s i t s twice or once a week reported a low degree of relatedness. Table 15 Comparison of Responses Indicating Perceived Freedom to Communicate and Number of V i s i t s Received No. of V i s i t s Low Degree of Freedom High Degree of Freedom 1 2 3 4 5 Percent Freq. Percent Freq. Percent Freq. Percent Freq. Percent Freq. Daily 20.13 61 18.48 56 18.15 55 18.81 57 24.42 74 2/Week 25.88 22 20.00 17 20.00 17 18.82 16 15.29 13 1/Week 30.91 17 20.00 11 18.18 10 14.55 8 16.36 9 Total 22.57 100 18.96 84 18.51 82 18.28 81 21.67 96 100.00 443 X 2 = 7.00 d f = 8 P = 0.53765 o 35 . r O O 1 — _: DE _ o Q -O O RE o , C O C T l _> 1 — _ C \ J _> _> L U • • • • C_> C M C O o C O _ — — C M C O C O L U _ Low High Relatedness 35 30 25 20 15 10 5 _> o C M co co L O C M L O Low High Relatedness oo 35, g 301 | 251 _ 20| _ L L . 15 o _ 1 0 § 5 _ C O C M Low High Relatedness DAILY VISITS 2 VISITS/WEEK 1 VISIT/WEEK X 2 = 26.04 d f = 6 P = 0.00025 Figure 7 Comparison of Responses Indicating Perceived Relatedness and Number of Visits Received 72 Summarizing the data in relation to Hypothesis 4 shows this hypothesis is rejected. There is a significant difference in the response of patients when number of vis i t s received is compared. Those respondents who received visits daily reported very few loneliness-associated changes in themselves and indicated a high degree of relatedness to the nurse. Respondents who received vi s i t s twice a week were indifferent in their perception of loneliness-associated changes and negative in their perception of relatedness. Respondents whose vis i t s were only once a week perceived many of the loneliness-associated changes but did not perceive a sense of related-ness to the nurse. Clearly the area of concern is those respondents who receive less than daily v i s i t s . It seems that their reduced relatedness with significant others reduces their relatedness with the nurse and predisposes them to perceive many loneliness-associated changes in their behavior. 73 Analysis of the Data in Relation to Hypothesis 5 Hypothesis 5: There is no significant difference in the response of patients when number of visitors per v i s i t is compared. Support for this hypothesis is achieved. There is no s i g n i f i -cant difference in the response of patients when number of visitors per v i s i t is compared. The category of perceived behavioral change achieves a level of significance. The categories of perceived freedom to communicate and perceived relatedness do not. Figure 8 demonstrates the association between perceived behavioral change and the number of visitors per v i s i t received. Comparison of previous analysis for number of vis i t s reveals that a more notable difference exists between respondents who received vi s i t s daily and those, who received visits weekly. The more obvious degree of difference indicates that vi s i t s received is more significant than number of visitors per v i s i t . Low High Degree of Change 1 VISITOR/VISIT O _ 00 RE OF y— LO co O OO CTl C\J L U • • o i — _> LO _> _ CM CvJ CM CM L U Q_35] 3 25 20 15 10 5i o CO CM CO CTl CO Low High Degree of Change 2 OR MORE VISITORS/VISIT X 2 = 11.23 d f = 3 0.01064 Figure 8 Comparison of Responses Indicating Perceived Behavioral Changes and Number of Visitors per V i s i t 75 Tables 16 and 17 indicate the frequency d i s t r i b u t i o n for per-ceived freedom to communicate and perceived relatedness with number of v i s i t o r s per v i s i t . The associat ion between both these variables and number of v i s i t o r s i s not s i g n i f i c a n t i n e i ther category. Summarizing the data in r e l a t i o n to Hypothesis 5 shows support for th is hypothesis i s achieved. There i s no s i g n i f i c a n t difference in the response of patients when number of v i s i t o r s per week i s com-pared. Respondents who reported one v i s i t o r per v i s i t perceived more lonel iness-associated changes i n themselves than did those whose v i s i t o r s were more numerous. The d i f ference , however, i s not as apparent as when number of v i s i t s i s compared as in Hypothesis 4. Table 16 Comparison of Responses Indicating Perceived Freedom to Communicate and Number of V i s i t o r s Received per V i s i t No. of Low Degree High Degree V i s i t o r s of Freedom • of Freedom 1 2 3 4 ' 5 Percent Freq. Percent Freq. Percent Freq. Percent Freq. Percent Freq. One 34.16 43 21.19 39 17.98 32 15.73 28 20.22 36 T ! ! 0 o r 20.93 54 17.05 44 18.22 47 20.54 53 23.26 60 More Total 22.25 97 19.04 83 18.12 79 18.58 81 22.02 " 96 100.00 443 X 2 = 3.55 d f = 4 P = 0.47200 Table 17 Comparison of Responses Indicating Perceived Relatedness and and Number of V i s i t o r s Received per V i s i t No. of V i s i t o r s Low Degree of Relatedness High Degree of Relatedness 1 2 3 4 Percent Freq. Percent Freq. Percent Freq. Percent Freq. One 23.03 41 24.16 43 27.53 49 25.28 45 Two or More 13.95 36 23.64 61 31.40 81 31.01 80 Total 17.66 77 23.85 104 29.82 130 28.67 125 100.00 443 6.66 3 0.08210 78 SUMMARY The analysis of the data i s divided into three sect ions . The f i r s t section is the analysis of the population sample in terms of the selected var iab les . The population is found to be disproport ionately female, with Surgery 22.3 percent, the largest respondent group. The major proportion of respondents were hospi ta l ized for e i ther ' less than one week' or 'more than three months.' The major proportion of patients received two to three v i s i t o r s d a i l y . The second section i s the chi-square analysis for the degree of association among the three categories of behavioral response. A high degree of perceived behavioral change i s associated with a low degree of perceived freedom to communicate and a low degree of perceived relatedness to the nurse. The association between perceived freedom to communicate and perceived relatedness to the nurse indicates that these categories test for the same response. A s igni f i cance level in e i ther one of these categories is considered s i g n i f i c a n t for the hypothesis. The t h i r d section of analysis tests the hypotheses of the study. The behavioral response categories are tested against each of the var-iables by chi-square ana lys i s . Hypothesis 1 i s upheld. There was no s i g n i f i c a n t difference in the response of patients when sex of the patient i s compared. Hypothesis 2 i s upheld. There was no s i g n i f i c a n t difference in the response of patients when length of h o s p i t a l i z a t i o n i s compared. However, the data shows s igni f icance for the category of perceived behav-i o r a l change. The associat ion i s negative. The longer the 79 h o s p i t a l i z a t i o n , the more changes are reported. The converse i s also t rue . Hypothesis 3 i s re jected. There i s a s i g n i f i c a n t difference in the response of patients when c l i n i c a l service i s compared. Extended Care respondents reported a high degree of behavioral change, an i n d i f -ference to freedom to communicate, and, a lack of relatedness to the nurse. Maternity respondents reported very few behavioral changes, a high degree of freedom to communicate, and,' a high degree of re la ted-ness to the nurse. Medicine respondents reported a few behavioral changes, a low degree of freedom to communicate, and, an average response to re la ted-ness . Psychiatry respondents reported many behavioral changes, a high degree of freedom to communicate, and, a high degree of re la ted-ness to the nurse. Surgery respondents reported few behavioral changes, an i n d i f -ference to freedom to communicate, and, an average response to re la ted-ness . Rehabi l i ta t ion respondents reported few behavioral changes, a low degree of freedom to communicate, and, a pos i t ive response to relatedness. Hypothesis 4 i s re jected. There i s a s i g n i f i c a n t difference in the response of patients when number of v i s i t s i s compared. S i g n i f -icance i s achieved i n two of the three behavioral response categories: 80 perceived behavioral change and perceived relatedness. The associat ion for perceived behavioral change i s negative. The more frequent the v i s i t s , the fewer changes are reported. The converse i s also true . The association for perceived relatedness i s p o s i t i v e . The more f r e -quent the v i s i t s , the more relatedness perceived. The converse i s also true . Hypothesis 5 i s upheld. There i s no s i g n i f i c a n t difference in the response of patient when number of v i s i t o r s per v i s i t i s compared. However, the data i s s i g n i f i c a n t for the category of perceived behav-i o r a l change. The association was negative. The more v i s i t o r s per v i s i t , the fewer behavioral changes perceived. The converse was also true . Chapter Five SUMMARY, CONCLUSION, RESEARCH IMPLICATIONS AND SUGGESTED RECOMMENDATIONS SUMMARY The purpose of the study was to determine the s igni f i cance of selected variables on the response of patients to lonel iness -associated statements. The variables and statements are derived from the l i t e r a t u r e r e l a t i v e to the topic of the loneliness of the hospi-t a l i z e d pat ient . A greater degree of loneliness i s associated with certa in i n s i t u var iab les . The variables i d e n t i f i e d were: the length of the pat ient ' s h o s p i t a l i z a t i o n , the type of c l i n i c a l service and the contact the patient maintained with s i g n i f i c a n t others. In order to determine the contact of s i g n i f i c a n t others, two questions were asked: the number of v i s i t s the patient receives per week and the number of v i s i t o r s he receives per v i s i t . There i s no indica t ion i n the l i t e r -ature as to whether the sex of the patient i s s i g n i f i c a n t in the development of lone l iness . To determine whether such a s igni f i cance e x i s t s , the variable of sex was added to the questionnaire. The questionnaire, thus, i s divided into two sect ions . The f i r s t i s designed to e l i c i t information r e l a t i v e to the variables of the study. The variables as mentioned are: sex of the pat ient ; 81 82 length of h o s p i t a l i z a t i o n ; c l i n i c a l serv ice ; number of v i s i t s received per week; and number of v i s i t o r s received per v i s i t . The second section requests e i ther [yes] or [no] response to twenty-two lonel iness-associated statements. From an o r i g i n a l group of 110 statements derived from the l i t e r a t u r e , f i f t y - f o u r were selected for pretest , twenty-two for the f i n a l t e s t . The twenty-two statements are divided into three behavioral response categories: perceived behavioral change; perceived freedom to communicate; and perceived relatedness to the nurse. The questionnaire was pretested on twenty pat ients , eleven male, nine female, resident i n one of the hospitals used i n the study. • The pretest population of twenty was excluded from the patient sample required for data c o l l e c t i o n . The hospitals selected for th is study were two general acute treatment h o s p i t a l s , each with a separate but associated extended care uni t and one spec ia l ized r e h a b i l i t a t i o n h o s p i t a l . These hospitals were selected because the i r c l i n i c a l services included a l l those to be studied and t h e i r combined patient population provided s u f f i c i e n t num-bers for data c o l l e c t i o n . The r e h a b i l i t a t i o n hospital supplemented an otherwise d e f i c i e n t c l i n i c a l service population within the two general h o s p i t a l s . The population sample was considered to be a l l patients resident i n these three hospitals on the day selected for the study. The. pedia t r i c wards were excluded from the population sample because of the d i f f i c u l t y i n obtaining parental consent. The emergency and day care patients were also excluded from the population sample because, for the most par t , the i r treatment measures excluded t h e i r p a r t i c i p a -t ion i n the study. Four hundred and for ty- three patients was the popu-l a t i o n tested. This number i s considered s t a t i s t i c a l l y s i g n i f i c a n t for the descr ipt ive method of research used in the study. Patients who required simple reading or mechanical s k i l l s to answer the question-naire were assisted by the inves t iga tor . Patients who were receiving treatment or who were phys ica l ly or mentally incapable of answering the questionnaire were not asked to p a r t i c i p a t e . The Head Nurse or her deputy assisted i n this s e l e c t i o n . The questionnaire was d i s t r i b u t e d and col lec ted by the i n v e s t i -gator. Privacy to answer the questionnaire was provided as much as the s i t u a t i o n permitted. The invest igator asked each patient to p a r t i -cipate in the study. The invest igator c l e a r l y stated tnat t h e i r p a r t i -c ipat ion was voluntary, t h e i r answers were anonymous, and that the purpose of the study was to help nurses better understand pat ients . Any inquir ies which arose from the questionnaire were answered when the invest igator returned to c o l l e c t the completed questionnaire. The data i s analyzed i n three separate sect ions . F i r s t i s the analysis of the population sample in terms of the selected var iab les . The second analysis i s by the chi-square method which is used to deter-mine the degree of association between the three behavioral response categories. The t h i r d section tests the hypotheses of the study. These hypotheses are as fo l lows ; 1. there i s no s i g n i f i c a n t difference i n the response of patients when sex of the patient i s compared; 2. there i s no s i g n i f i c a n t difference in the response of patients when length of h o s p i t a l i z a t i o n i s compared; 3. there i s no s i g n i f i c a n t difference in the response of patients when c l i n i c a l service i s compared; 4. there i s no s i g n i f i c a n t difference i n the response of patients when number of v i s i t s received is compared; and 5. there i s no s i g n i f i c a n t difference in the response of patients when number of v i s i t o r s per v i s i t i s compared. CONCLUSIONS The f i r s t section of analysis deals with the population sample in terms of the selected var iab les . The population sample was 68.2 percent female respondents. Comparison of the male/female d i s t r i b u t i o n by c l i n i c a l service indicates a disproportionate number of females in Extended Care, Psychiatry , Rehabi l i ta t ion and, of course, Maternity. The frequency d i s t r i b u t i o n for length of h o s p i t a l i z a t i o n i s loaded in two categories, 33.4 percent i n - ' l e s s than one week' and 22.3 percent for 'three months or more.' The d i s t r i b u t i o n for c l i n i c a l service by to ta l population ranges from Surgery, 22.3 percent, to R e h a b i l i t a t i o n , 13.3 percent. The majority of respondents, 68.0 percent reported d a i l y v i s i t s , 54.8 percent received two to three v i s i t o r s per v i s i t . 85 The population sample can be described as disproport ionately female, with Surgery, 22.3 percent, the largest respondent group. The major proportion of respondents were hospi ta l ized f o r e i ther less than one week or more than three months. The major proportion of respondents were well v i s i t e d , reporting two to three v i s i t o r s d a i l y most f r e -quently. The second section of analysis deals with the associat ion between the three behavioral response categories. The degree of asso-c i a t i o n i s determined by chi-square ana lys i s . The degree of associa-t ion between a l l three behavioral response categories i s s i g n i f i c a n t . A high degree of perceived behavioral change i s associated with a low degree of freedom to communicate and relatedness to the nurse. The impl icat ion i s that those respondents who reported a high degree of lonel iness-associated behavioral changes did not feel free to communi-cate those feel ings nor did they perceive a high degree of relatedness in which to make th is communication. The association between freedom to communicate and perceived relatedness indicates that these cate-gories test for the same behavioral response. S ignif icance achieved in e i ther of these two categories i s considered s i g n i f i c a n t for the hypotheses of the study. The t h i r d section of analysis determines the s igni f i cance of the hypotheses of the study. Hypothesis 1 i s upheld. There i s no s i g n i f i c a n t difference i n the response of patients when sex of the patient i s compared. Hypothesis 2 i s upheld. There i s no s i g n i f i c a n t difference i n 86 the response of patients when length of h o s p i t a l i z a t i o n i s compared. However, the data i s s i g n i f i c a n t for the category of perceived behav-i o r a l change. The longer the h o s p i t a l i z a t i o n , the more changes were reported. Almost consistent ly the number of changes perceived increased as the length of h o s p i t a l i z a t i o n increased. Hypothesis 3 i s re jected. There i s a s i g n i f i c a n t difference in the response of patients when c l i n i c a l service i s compared. Extended Care respondents reported many behavioral changes in themselves but were i n d i f f e r e n t to the categories of perceived freedom to communicate and perceived relatedness. The impl icat ion is important. Extended Care respondents perceived many lonel iness-associated changes i n themselves but did not feel e i ther the need or the freedom to com-municate these perceptions to the nurse. Maternity respondents repl ied to very few of the lone l iness -associated changes i n behavior. Their response was pos i t ive to the categories of freedom to communicate and perceived relatedness. The pos i t ive trend for relatedness, however, far exceeded that for freedom to communicate. This seems to indicate that Maternity patients very d e f i n i t e l y perceive a sense of relatedness with the nurse even though they are not as d e f i n i t e in t h e i r freedom to communicate with her. Surgery respondents indicated that few behavioral changes were perceived. Freedom to communicate i s of no p a r t i c u l a r s i g n i f i c a n c e , although a pos i t ive sense of relatedness to the nurse was reported. Medicine respondents related more lonel iness-associated be-havioral changes than did the Surgery respondents. Medicine 87 respondent's perception of relatedness was average, but t h e i r percep-t ion of freedom to communicate was negative. The impl icat ion i s impor-tant . Medicine patients perceive a few lonel iness-associated changes in themselves but l i k e Extended Care patients do not perceive the freedom to communicate these changes. Respondents from both these c l i n i c a l services perceived lonel iness-associated changes in the i r behavior but from the data i t seems u n l i k e l y that these changes would be communicated Psychiatry respondents perceived many lonel iness-associated changes in the i r behavior. Unlike Extended Care and Medicine respon-dents, however, Psychiatry respondents perceived a high degree of f ree-dom to communicate and relatedness to the nurse. This observation is not inconsistent with the ward mi l ieu which encourages open communica-t ion and s e l f - d i s c l o s u r e . Rehabi l i ta t ion respondents perceived few lonel iness-associated changes i n themselves. Their response to freedom to communicate was the most negative of any c l i n i c a l serv ice . This i s an in teres t ing observation in view of t h e i r more pos i t ive response to relatedness. These respondents, i t appears, perceived a sense of relatedness to the nurse yet did not or would not allow themselves the freedom to communi-cate with her. One possible explanation for th is divergent pattern may relate to the r e h a b i l i t a t i o n treatment goals . Emphasis on the relearning tasks may predispose the patient to de-emphasize free com-munication in order to get on with the task at hand. However, these relearning tasks require close involvement between patient and nurse, 88 which predisposes the patient to perceive a sense of relatedness to the nurse. Hypothesis 4 was re jected. There i s a s i g n i f i c a n t difference i n the response of patients when number of v i s i t s i s compared. S i g -nif icance i s achieved in two of the three behavioral response cate-gories : perceived behavioral change and perceived relatedness. Respondents who received v i s i t s d a i l y reported very few lone l iness -associated changes in themselves and a high degree of relatedness to the nurse. Respondents who received v i s i t s only once a week per-ceived many of the lonel iness-associated changes but did not perceive a sense of relatedness to the nurse. The impl icat ion i s that reduced relatedness with s i g n i f i c a n t others reduces the relatedness to the nurse and predisposes patients to perceive many lonel iness -associated changes i n t h e i r behavior. Hypothesis 5 was upheld. There i s no s i g n i f i c a n t difference i n the response of patients when number of v i s i t o r s per v i s i t i s com-pared. However, the data i s s i g n i f i c a n t for the category of perceived behavioral change. Respondents who reported one v i s i t o r per v i s i t perceived more lonel iness-associated changes than did those whose v i s i t o r s were more numerous. The pattern of difference between a high degree and a low degree of perceived change for number of v i s i t o r s i s not as s i g n i f i c a n t as when number of v i s i t s i s compared. Loneliness-associated changes i n behavior are s i g n i f i c a n t l y more affected by the number of v i s i t s received per week rather than the number of v i s i t o r s per v i s i t . In summary, the variable of sex of the patient bears no s i g -nif icance on the response of pat ients . The variables of length of h o s p i t a l i z a t i o n and the number of v i s i t o r s received per v i s i t s i g n i f i -cantly affects the response to the category of behavioral changes. Only two v a r i a b l e s , that of c l i n i c a l service and that of number of v i s i t s received per week s i g n i f i c a n t l y af fect the response of patients to lonel iness-associated statements. RESEARCH IMPLICATIONS Frequently during the fol low up v i s i t s regarding tne study, the nursing s t a f f made comments about patients whom they considered lone ly . These comments and remarks were made and gathered in a random manner and are presented here as close to the i r o r i g i n a l context as poss ib le . Frequently, remarks were made with regard to the v i s i t o r s the patient received. Most often there was a d i s t i n c t absence of v i s i t o r s , or v i s i t s , when made, were described as duty-bound or per-functory. The nurses made t h e i r remarks in response to the pat ients ' disappointment, disappointment which one nurse described as 'pathetic sadness. ' Overtalkativeness in certa in patients was seen as a camouflage for lone l iness . The pressure of conversation attempted to keep close the presence of another person. Frequent comment was made about the aura of apartness which the lonely person conveyed. The patient had not so much withdrawn into himself but withdrawn from others. I t was the sense of desperation 90 within this withdrawal which was dis turbing to the nurse. The nurse was often unable or a f r a i d to respond to this plea from the pat ient . Sometimes the nurse openly expressed f r u s t r a t i o n i n her attempts to deal with what she i d e n t i f i e d as loneliness behavior. The nurse's e f for ts to reach out to the patient seemed unanswered, the se lect ion of approaches seemed inadequate, and the resul t ing behavior, was often one of mutual withdrawal. The context s i m i l a r i t y of the observations made by the nurses and the frequency of the i r mention i s noteworthy and indicates a need for further study. Study of the behavioral manifestations of l o n e l i -ness and the nursing measures designed to deal with lonel iness are suggested. Often nurses deal with the i r observation of patients in an automatic, i n t u i t i v e manner without formal iz ing t h e i r goals and plans. I t i s the opinion of the invest igator that nurses already have a great deal to contribute to the study of loneliness i f such a study is i n i t i a t e d . Study of loneliness in any set t ing requires in-depth tech-niques for data c o l l e c t i o n . The questionnaire method i s not such a technique. The questionnaire i s designed e s s e n t i a l l y for wide d i s t r i -bution and i s severely l i m i t e d in the level of information i t seeks to achieve. Its se lect ion for use i n this study is pr imar i ly to v a l i -date empirical data with patient response and to indicate areas for further study. Several areas for further study are indicated by the questionnaire. The variables of c l i n i c a l service and number of v i s i t o r s 91 received per week s i g n i f i c a n t l y affects patient response. To a l esser , though s t i l l s i g n i f i c a n t degree, patient response is influenced by the length of h o s p i t a l i z a t i o n and the number of v i s i t o r s received per v i s i t . The pattern of response for each of these variables appears independent, however, i t could be argued that each of the variables are a function of the other. Factor analysis of each of the variables would indicate the variable most responsible for the response noted. To val idate empirical data with patient response was one of the purposes of th is study. The twenty-two statements were derived from the l i t e r a t u r e pertinent to the loneliness of the hospi ta l ized pat ient . Factor analysis of each of the twenty-two statements would indicate which statements were most i n f l u e n t i a l i n determining the noted outcome. Analysis of the associat ion between the three categories of behavioral responses indicated that two of the three categories (perceived freedom to communicate and perceived relatedness to the nurse) tested for the same behavioral response. Yet , on further analysis for the hypotheses of the study, the response patterns for these two categories were d i s s i m i l a r , often opposing. Despite the close associat ion s t a t i s t i c a l l y between these two categories there appeared to be d i s s i m i l a r elements to which the patients responded. Again, factor analysis of each of the statements wi th in these categor-ies would indicate which statements influenced the noted outcome. The l i t e r a t u r e indicates that a high degree of lone l iness -associated change i s accompanied by a low degree of freedom to 92 communicate. This associat ion was not universa l ly upheld in the data ana lys i s . Factors not i d e n t i f i e d in th is study may have accounted for th is discrepancy. I d e n t i f i c a t i o n of these factors may indicate areas for further nursing considerat ion. SUGGESTED RECOMMENDATIONS The suggested recommendations are as fo l lows : 1. factor analysis of each of the s i g n i f i c a n t variables to i n d i -cate the variable most responsible for the noted response; 2. factor analysis of each of the lonel iness-associated s tate-ments to indicate which statement influenced the noted outcome; 3. study of the i d e n t i f i e d variables and statement in terms of prevention/intervention of the pathology of l o n e l i n e s s ; 4. further study of the loneliness manifestations as i d e n t i f i e d by ward personnel; and 5. invest igat ion of the reaction to and approaches of interven-t ion i n i t i a t e d by ward personnel. BIBLIOGRAPHY 93 94 A. BOOKS A g u i l e r a , Donna. C r i s i s Intervention: Theory and Methodology. S t . Louis : C. V. 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"Lives of Lonel iness , " Nursing Times, 64, No. 12 (March 22, 1968), 391. . "Lonely Old People," Nursing Times, 61, No. 42 (October 15, 1965), 1405-6. . "The Forgotten Men," Nursing Times, 66 (October 8, 1970), 1292. . "The Lonely Adolescent," Nursing Times, 66, No. 44 (October 29, 1970), 1397-98. Gupta, Margaret. "An Interruption i n Lonel iness , " Journal of Psychi - a t r i c Nursing, 9, No. 4 (July-August, 1971), 23-27. Hal leek, Sidney L . "Psychia t r i c Treatment for the Alienated College Student," American Journal of Psychiatry , 124, No. 5 (1967), 642. Harlow, Harry S. and Margaret K. Harlow. "The Effect of Rearing Condi-tions on Behavior," B u l l e t i n of the Menninger C l i n i c , 26 (1962), 34-38. Hendin, H. "Suicide i n Denmark," Who Am I? New York: Del l Publ ishing Company, 1969. Hoeschen, Rhoda L . "Combating Post-Hospital Lonel iness , " Nursing  Outlook, 15, No. 6 (June, 1967), 28-29. Hopper, Columbus B. "The Conjugal V i s i t at M i s s i s s i p p i State Peniten-t i a r y , " Journal of Criminal Law, Criminology and Pol ice Science, 53 (September, 1962), 62-68. Johnson, Dorothy. "Powerlessness: A Determinant in Patient Behavior?" Journal of Nursing Education, A p r i l , 1967, pp. 39-44. Kane, A. H. "Loneliness i n Young Mothers," Nursing M i r r o r , 118, No. 3089 (August 28, 1964), 489-90. Kemp, S y l v i a . "The Widow's M i t e , " Nursing Times, 66, No. 44 (October 29, 1970), 1404. TOO Kohn, M. L . and J . A. Clausen. "Social I so la t ion and Schizophrenia," American Socio logica l Review, 20, No. 3 (June, 1955), 265. Levine, Rhoda L . "Disengagement in the E l d e r l y , " Nursing Outlook, 17, No. 10 (October, 1969), 28-30. L insky , A. "Who Shall be Excluded?" Social Psychiatry , 5 ( Ju ly , 1970), 166-71. Lopata, Helena. "Loneliness: Forms and Components," Social Problems, 17 (1969), 248-62. Lowenthal, M. "Social I so lat ion and Mental I l lness i n Old Age," Ameri-can Sociological Review, 29 (February, 1964), 54-70. MacDonald, A. "Anxiety A f f i l i a t i o n and Social I s o l a t i o n , " Develop- mental Psychology, 3 (1970), 242-54. Mahan, S i s t e r M. B. "Cul tura l and Social Factors i n Mental Heal th , " Mental Hygiene, 50, No. 1 (1966), 176-80. Mechanic, David. "Stress , I l lness and the Sick Role , " American Socio- l o g i c a l Review, 26, No. 1 (February, 1961), 51-58. Miyamoto, Frank S. "A Test of In terac t ion is t Hypothesis of S e l f -Conception," Ame_i_c__ J _ ^ ^ 61 (March, 1956), 399-403. Moustakas, C a r l . " C r e a t i v i t y , Conformity and the S e l f , " C r e a t i v i t y  and Psychological Health. New York: Syracuse Univers i ty Press, 1967, pp. 22-25. Munnichs, Johanna. "Loneliness , I so la t ion and Social Relations in Old Age," V i t a Humana, 1964, pp. 228-38. N e t t l e r , Gwynn. "A Measure of A l i e n a t i o n , " American Soc io logica l  Review, 22 (1951), 670-77. Pacyna, Donna A. "Response to a Dying C h i l d , " The Nursing C l i n i c s of  North America, 5, No. 3 (1970), 38-46. Peplau, Hildegard. "Lonel iness , " American Journal of Nursing, 55, No. 12 (December, 1955), 1476-81. Ross, M. "Death at an Early Age," Canada's Mental Health, x v i i i , No. 6 (1970), 14-17. Rubins, Jack. "On the Psychopathology of Lonel iness , " American Journal of Psychoanalysis, 24, No. 2 (1964), 182-88. Schaectal , K. "On Alienated Concepts of I d e n t i t y , " Who,Am I? New York: Dell Publishing Company, 1969. 101 Seeman, Melv in . "The Meaning of A l i e n a t i o n , " American Soc io logica l  Review, 24 (December, 1959), 783-91. . "Al ienat ion and Hearing i n the Hospital S e t t i n g , " American Sociological Review, December, 1962, pp. 772-78. Sinha, T. C. "On Aloneness," Samiksa, 23, No. 1 (1969), 1-8. Smith, S . ' E . "Mental I l lness and the D i s t r i c t Nurse 3 , " Nursing Times, 66, No. .44 (October 29, 1970), 1395-96. Sommer, R. "Al ienat ion and Mental I l l n e s s , " American Sociological  Review, 23 (1958), 418-20. S p i t z , L . "Hospi ta l i sm," Psychoanalytic Study of the C h i l d , 1 (1945), S t r i c k l a n d , M. "Apartment L i f e i s Just That ," Vancouver Sun, November 22, 1971, p. 42. S t r i c k l e r , M a r t i n , and Betsy Lasor. "The Concept of Loss in C r i s i s Intervent ion," Mental Hygiene, 54, No. 2 ( A p r i l , 1970), 30 - 5 . von Witzleben, Henry'D. "One Lonel iness , " Psychiatry , 21 (1958), 37-43. Wayne, D. "The Lonely School C h i l d , " American Journal of Nursing, 68, No. 4 ( A p r i l , 1968), 774-77. Weigert, E d i t h . "Loneliness and Trust—Basic Factors of Human E x i s -tence," Psychiatry , 23 (1960), 121. W i l l , Otto A. "Human Loneliness and the Schizophrenic P a t i e n t , " Psychiatry , 22 (1959), 205-25. Winnicott , D. "On the A b i l i t y to be Alone , " Psyche H e i d e l , 12 (1958), 341-52. Z i l b o o r g , Gregory. "Lonel iness , " A t l a n t i c Monthly, 61 (1938), 45-54. C. OTHER SOURCES Anderson, Dr. Donald 0. Personal Communication. Bradley, Rosalee. "Measuring Loneliness" (unpublished Doctor's disser-t a t i o n , Univers i ty of Washington, 1969), p. 4. 102 Gormick, Janet. Personal Communication. Kaplan, Abraham. "Lonel iness . " Address at the Univers i ty of B r i t i s h Columbia, May 25, 1972. APPENDIXES 1 0 3 APPENDIX A VERBAL REQUEST TO PARTICIPATE IN THE STUDY 105 " H e l l o . I am Diane Brennan, a Nursing Student at U.B .C . I am doing my Masters thesis now and th is questionnaire i s part of my re-search ." "Would you mind reading i t over and answering i t i f you wish t o , i f you d o n ' t , that ' s O.K. too . " "Your answers w i l l not have your name on i t , so no one w i l l know what answers you put down." " I f you do decide to answer the questionnaire, would you please read over and sign the consent form too . " "Do you have any quest ion." " I ' l l be back l a t e r to c o l l e c t the envelopes, forms." APPENDIX B WRITTEN PATIENT CONSENT FORM 107 PATIENT IN HOSPITAL  CONSENT FORM A. I have been informed that my p a r t i c i p a t i o n in th is study is voluntary, and that I do not have to answer th is questionnaire i f I don't want t o . B. I have been informed that my answers to this questionnaire w i l l remain anonymous and that no one w i l l know what I answered to these questions. Pat ient ' s Signature Date APPENDIX C WRITTEN INSTRUCTIONS FOR PARTICIPANTS 109 This questionnaire you are being asked to f i l l out i s to help nurses better understand some of the feel ings of patients in h o s p i t a l . I would l i k e very much for you to par t i c ipate in th i s study but honesty in answering a l l the questions i s needed. Also i t i s necessary that you answer a l l the questions so that the study w i l l be v a l i d . There are no r ight or wrong answers. I t i s your f e e l -ings that are important. The form I would l i k e you to f i l l out i s inside the brown envelope along with a pencil for you to use. Inside the envelope you w i l l also f i n d a small white one. If you would l i k e a copy of the resul ts of th is study would you please wri te your name and mail ing address on th i s white envelope and I w i l l be happy to send the resul ts to you when everything i s completed. I w i l l be back in about one hour to c o l l e c t your answers. I ' l l c o l l e c t brown envelopes and white envelopes separately so your answer w i l l remain e n t i r e l y anonymous. Thank you very much for your cooperation. S incere ly , A. Diane Brennan. APPENDIX D THE QUESTIONNAIRE i n Part I of Patient i n Hospital Please answer a l l of the fo l lowing questions by placing a check-mark [/] beside the appropriate answer. 1. Are you male [ ] or female [ ] 2. Approximately how long have you been i n hospital for the present admission? less than 1 week [ ] 1 week - less than 2 weeks [ ] 2 weeks - less than 3 weeks [ ] 3 weeks - less than 1 month [ ] 1 month - less than 2 months [ ] 2 months - less than 3 months [ ] 3 months or more [ ] 3. What would the ward you are on be c l a s s i f i e d as? Extended care [ ] Maternity [ ] Medical [ ] Psychia t r i c [ ] Surgical [ ] Rehabi l i ta t ion [ ] Don't know [ ] 4. About how often do you have v i s i t o r s ? d a i l y [ ] twice a week [ ] 112 once a week [ ] almost never [ ] 5. Approximately how many v i s i t o r s do you have each time? one [ ] 2 - 3 [ ] 4 or more [ ] none [ ] Part II of Patient in Hospital Please answer all of the fo l lowing statements by placing a check-mark [/] in e i ther the agree [ ] or disagree [ ] space beside each statement. Agree Disagree 1. I f ind myself day dreaming a l o t now since I came to hospital [ ] [ ] 2. Sleeplessness worries me more since I'm here i n hospital [ ] [ ] 3. The time used to go by so q u i c k l y , now i t seems each day is endless [ ] [ ] 4. Since I 've been here I f ind myself quite often wishing I was someone else [ ] [ ] 5. Since I came into hospital I don't seem to care to plan things l i k e I used to [ ] [ ] 6. People now i r r i t a t e me more than before I came into hospital [ ] [ ] 113 Agree Disagree 7. I'm not as interested i n other people as I was before coming here [ ] [ ] 8. Since I came to hospital I don't seem l i k e the same person any more [ ] [ ] 9. At times I feel extremely hopeless about being here i n hospital [ ] [ ] 10. I would prefer that no one knew I was here i n hospital [ ] [ ] 11. I would t rus t the nurses to confide a personal problem to them [ ] [ ] 12. I have to ta l confidence in the nurses who look af ter me here [ ] [ ] 13. I would t e l l one of the nurses i f I f e l t lonely here [ ] [ ] 14. I think nurses are not allowed to t e l l patients the whole truth about t h e i r i l l n e s s [ ] [ ] 15. I ta lk to the nurses but I r e a l l y don't t e l l them anything about me [ ] [ ] 16. I choose not to l e t people know how I r e a l l y feel inside [ ] [ ] 17. I t ry not to admit i t when I feel I want to be comforted by someone [ ] [ ] 18. I think nurses prefer patients who don't complain very much [ ] [ .] 114 Agree Disagree 19. I think nurses have only time to l i s t e n to physical worr ies , not emotional ones [ ] [ ] 20. Sometimes the nurses pretend not to notice when I'm fee l ing badly [ ] [ ] 21. I believe that the nurses make every e f f o r t to make the patients feel worthwhile [ ] [ ] 22. There i s one nurse who seems concerned about me [ ] [ ] 

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