Journal of Advanced Nursing, 1998, 28(4), 762±770 Integrative literature reviews and meta-analyses

Loneliness: an epidemic in modern society

Colin Killeen BSc (Hon) MSc RGN
Charge Nurse, Elderly Unit, Hope Hospital, Salford, England

Accepted for publication 5 September 1997

KILLEEN C. (1998) Journal of Advanced Nursing 28(4), 762±770

Loneliness: an epidemic in modern society
Loneliness is a little discussed concept in today's self-obsessed climate,
where it is seen as a negative embarrassing condition. It is unique for every
individual, and as such, it is dif®cult to de®ne. There are other closely
related concepts, for example, aloneness and solitude, that further complicate
an already complex issue. Loneliness also has various causes and effects that
can be one and the same, and so it can be confused with similar but different
conditions, for example, depression and self-esteem. But, at the end of the
day, if the word loneliness is mentioned in conversation, everybody will
understand what it means to them, and how distressing an ordeal it can be.
Everyone is lonely to some degree, no matter how much they pretend they
are not: it is part of being human. Nursing literature looks at loneliness from
a rather basic, super®cial perspective, when discussing whether such a
traumatic state of being can be solved, but this is not a solution as such. It is
such an innate part of the human psyche, that it cannot be solved like a
puzzle; it can only be alleviated and made less painful. This can only be
achieved by increasing humankind's awareness of this distressing condition
that everyone has to endure in some way, shape or form, some time during
their lives, about which there is nothing to be embarrassed. If non-lonely
individuals could spare a smile or a word for people who might be perceived
as being lonely, even if in doing so they sel®shly think `there but for the
grace of God go I', such a small gesture might just make their day a little less
of an ordeal.

Keywords: loneliness, alienation, social isolation, estrangement, aloneness,

solitude, depression, taboo, detachment, self-esteem

It is human nature; it is inhuman. It is all-consuming; it is negligible.

It is awareness; it is self-pity. It is laughable; it is pathetic.
It is empty; it is ful®lling. It is everything; it is nothing.
It is pretend; it is real. It is controversial; it is little discussed.
It is your whole world; it is no world. It is emotive; it is non-feeling.
It is unspoken; it does not need to be said. It is overawing; it is numbing.
It is an enigma. It is taboo; it is there.
Everyone is. It is.
It is fact. Colin Killeen
It is objective; it is subjective. March 1997

Correspondence: Colin Killeen, 21 Jersey Street, Ashton-under-Lyne,

Lancashire OL6 6JE, England.

762 Ó 1998 Blackwell Science Ltd

Integrative literature reviews and meta-analyses Loneliness

INTRODUCTION such a function. It may be that loneliness over the centuries

has become on a par with the `®ght, fright or ¯ight' re¯ex in
Loneliness is a very subjective concept, and as such, the
humans, in that in today's society a proximity promoting
approach taken in this piece of work is both qualitative
mechanism such as loneliness, or a `®ght, fright or ¯ight'
and personal. My interest in loneliness began in 1989
re¯ex, are not as functional to human beings as they once
when I moved from student nursing accommodation into a
were, and as such, they have actually become destructive,
house, and a painfully lonely part of my life started which
rather than bene®cial for the human body.
lasted for approximately 2‰ years. I would wholeheart-
Some de®nitions in the literature are detached and
edly agree with Rokach's graphic statement that `acute
methodical, whereas others appear to show that the
loneliness is a terrorising pain, an agonising and fright-
authors have themselves experienced the pain of loneli-
ening experience that leaves a person vulnerable, shaken
ness and have `lived to tell the tale'. It is as though they are
and often wounded' (Rokach 1990 p. 41).
trying to share with the reader how they felt, and how
Loneliness is a pervasive, depressing, debilitating con-
distressing and pervasive such an ordeal can be. Rokach
dition that can affect all of one's life. It can make you feel
states that `loneliness is as natural and integral a part of
as though you are the only person in the world; as if you
being human as are joy, hunger and self-actualisation.
do not want to live any more. It can make you feel totally
Humans are born alone, they experience the terror of
isolated and useless; that your life is without purpose. It
loneliness in death, and often much loneliness in-be-
can make you look for other things to ®ll the painful abyss
tween' (Rokach 1990 p. 39). Since it is a universal
in your life, for example, religion, or alcohol, or both. All
phenomenon, it is surprising how dif®cult it appears to
in all, it is a very destructive condition, and it can cause a
be to de®ne.
vicious downward spiral, because the more lonely one
Peplau and Perlman's (1982) work suggests that loneli-
becomes, the more one is isolated even further from
ness is the psychological state which results from dis-
`normal' society, and without care, one can `go under'. It is
crepancies between one's desired and one's actual
a frightening experience and one that personally I would
relationships. This is objective and clinical and does not
rather not repeat. Lynch (1977 p. 20) evokes the pain of
indicate how painful and all-consuming such a condition
loneliness by suggesting that:
can be. According to Younger, `loneliness is the feeling of
. . . even in its milder forms, loneliness hurts. It creates an being alone in spite of longing for others. The lonely
uncomfortable feeling from which people almost immediately try experience a sense of utter aloneness as well as aimless-
to escape. The problem is that loneliness can be like a spider's ness and boredom' (Younger 1995 p. 59). This is a
web; if a person struggles to escape, he may become all the more powerful, subjective description that does actually evoke
enmeshed, until he becomes so entangled that escape is impos- how you can feel if you are lonely. Lonely people who
sible. read this de®nition might nod their heads in agreement. It
gives an impression of the futility and pointlessness of
Loneliness is still very taboo, and it is almost an
your existence when you are lonely.
embarrassment to admit that you are or ever have been
There are not many attempts in the literature to de®ne
lonely. As well as being embarrassed by such a negative
loneliness. This might be because it can be a nightmare
feeling, people are also scared by it, because of how terrible
condition; one that most people would never want to
it can make them feel. Most people will never admit to
repeat again if they had a choice, and as such, this might
being lonely for if they have survived such an ordeal, then
actually make it dif®cult to think about what loneliness
it is one that they would rather not talk about. Loneliness is
actually is. People would prefer to forget such a traumatic
arguably far more prevalent in today's society than it has
condition rather than analyse and dissect it. You have to
been in previous generations. In writing this paper I feel
confront that time in your life, and in doing so, hopefully
that I am exorcizing a ghost and breaking a taboo.
ensure that it will never happen again. Quite often, people
do not admit to being lonely, and this can make it dif®cult
to elicit a comprehensive de®nition. Loneliness, because
A DEFINITION OF LONELINESS
of its subjective nature, can mean something different for
Before de®ning loneliness, it is worthwhile to look at what all individuals, but it exists, and as such, we should be
loneliness might be from a historical perspective. Bowlby's able to at least attempt to de®ne it.
(1973) work is occasionally referred to by other authors Because of its highly subjective, emotive nature, a two-
(Weiss 1973, Rokach 1989), and he suggests that it is a pronged approach to de®nition is necessary. Unfortunate-
proximity promoting mechanism, in that it made our ly when de®ning such emotive concepts, by nature, a
ancestors aware of their growing isolation between them- de®nition does make it more objective. We need, however,
selves and others, and thus of their vulnerability to danger. to make allowances for its subjective element, therefore
This is an interesting hypothesis, but it is regrettable that it we also need a subjective description. Both are necessary
takes such an intense, destructive emotion to carry out to give an overall picture of loneliness.

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 762±770 763
C. Killeen

From a methodical, objective, viewpoint, my de®nition Solitude appears to be seen as when people `take time out'
of loneliness would be that it is a discrepancy between a to think about where they stand in the scheme of things. It is
person's social and/or emotional needs/wants, and their when people want to be by themselves for positive reasons,
social reality. It is, however, easier to be objective about for example to feel closer to nature, or to `®nd themselves'.
loneliness, because it avoids confronting the pain that It has the sense of a positive, self-ful®lling concept, when
such a concept entails. For this reason, a subjective individuals look at themselves and the world through rose-
description is far more dif®cult. I would suggest that tinted spectacles. Solitude seems to indicate total freedom
loneliness is a condition that describes the distressing, of choice, and although it is on the same continuum as
depressing, dehumanizing, detached feelings that a per- loneliness, of all the concepts mentioned so far, it is the
son endures when there is a gaping emptiness in their life one that can be most readily differentiated.
due to an unful®lled social and/or emotional life. This is a A concept rarely mentioned in the literature but impor-
more powerful description of loneliness, but even this tant in its relation to loneliness, is that of estrangement.
will not adequately describe how some people feel when Andersson (1986) brings our attention to estrangement,
they are lonely. which gives the impression of being more severe and
wretched than loneliness and that a person who is
estranged is even further cut off from society, and as
Related concepts such, might ®nd it very dif®cult to `get back'.
Another concept very similar to estrangement is alien-
What makes the concept of loneliness even more confus-
ation. Rokach (1988) refers to self-alienation when he
ing is the number of closely related concepts. There are
attempts to analyse the loneliness experience, and he
certain words that people might hear or read which would
suggests that `self-alienation describes a feeling of inner
evoke images of loneliness, but they might actually have a
void, a detachment from oneself, and an alienation from
different meaning. Aloneness is one such closely related
one's core and identity' (Rokach 1988 p. 534). Andersson
concept. Someone alone is obviously by themselves, and
(1986) suggests a close relationship between estrangement
therefore they might be lonely, but this might not be the
and alienation but gives no indication of the nature of the
case at all. Loneliness describes somebody who feels that
relationship.
they are by themselves, that they have no choice in the
Younger (1995) manages to unravel the confusion be-
matter, and that they do not want to be in that condition.
tween all these inter-related concepts. The concept of
The term aloneness can indicate that there is an element of
particular interest to her is alienation, but she relates it to
choice in wanting to be by yourself, that you might
other concepts previously mentioned. She describes
actually prefer it to being with other people. Sears et al.
alienation as `an experience of disconnectedness with
(1991 p. 292) and Jacobs (1978 p. 25) mention that there is
oneself; with others; and with one's god, nature or
no direct link between the two concepts: you can be lonely
a transcendent realm of being' (Younger 1995 p. 57). She
in a crowd, and you can be happy alone, but as a rule, it
also suggests that people experience their relationships
would be expected that people are more likely to feel
with others on a continuum that may range from aliena-
lonely when they are by themselves.
tion on the one hand to a full sense of connectedness on
A more confusing relationship is that between loneliness
the other. This does not mean that alienation is an absence
and social isolation. Social isolation is almost a compro-
of connection; it is negative connectedness. This simple
mise concept between loneliness and aloneness, depen-
approach allows us effectively to place all the concepts
dent on whether choice is involved. Loneliness indicates
into some kind of perspective. Younger provides a com-
no choice, and aloneness indicates that there is an element
prehensive idea of the relationship between the previous-
of choice. Social isolation with choice is aloneness, while
ly mentioned concepts. She suggests that loneliness is one
social isolation without choice is loneliness. All these
step along the continuum from alienation to connected-
concepts can be placed on a continuum, and social
ness, and she differentiates alienation from loneliness in
isolation's place is between loneliness and aloneness.
that the latter lacks the antipathy of the former. Younger
Solitude is another concept in the literature closely
also places existential loneliness on the continuum; part
related to loneliness. Solitude has a more optimistic sense.
of life for everyone, when people are aware of being alone
Rokach (1990) states that solitude can be perceived as
in this world, and of their own mortality, and following
refreshing and calming, and can be regarded as respite. He
this is solitude. Finally, at the `positive' end of the
even suggests that it can be very useful in coping with
continuum and not referred to by any other author, is
loneliness. He concludes that:
connectedness, which Younger describes as a `sense of
. . . solitude, unlike loneliness, is often referred to as a positive, being in touch with the eternal, or recognising unity
pleasant experience that is conducive to replenishing one's between self and others, or being part of something that is
energy and resources, and that affords one the time and space greater than ourselves. It is being at one with timelessness,
to re¯ect, be creative, or just enjoy rest. (Rokach 1990 p. 42) self and others' (Younger 1995 p. 60).

764 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 762±770
Integrative literature reviews and meta-analyses Loneliness

Although Younger's work is to be admired, there are

Situational causes and effects
drawbacks. She omits the concepts of social isolation and
aloneness, referring to them as objective states, but I The situational causes of loneliness most frequently
would suggest that they are included on such a continu- referred to are those that involve disruption in relation-
um. They can be perceived as neutral but they still have a ships and friendships with other people; as Rokach (1990
subjective perspective, dependent on who is experiencing p. 379) suggests `loss in general, not necessarily through
them. Younger includes existential loneliness as a sepa- death, was seen as the most common cause of loneliness'.
rate entity on the continuum, but this would appear to be a The most extreme form of loss is bereavement (Lopata
particular type of loneliness. Younger does not include the 1969, Lynch 1997, Creecy et al. 1985, Rodgers 1989,
concept of estrangement although she does suggest that Rokach 1989, Acorn & Bampton 1992, Holmen et al. 1992,
`alienation is an estrangement from others in spite of Carr & Schellenbach 1993, Dugan & Kivett 1994, Adding-
longing for connection' (Younger 1995 p. 58). This would ton-Hall 1995), and it would be expected that this can lead
suggest that there is no differentiation between estrange- to profound loneliness.
ment and alienation, and as such they can be included as Some authors also refer to the importance of marital
being one and the same. status in relation to loneliness (Weiss 1973, Lynch 1977,
Figure 1 illustrates this possible continuum together Berg et al. 1981, Creecy et al. 1985, Sears et al. 1991, Carr &
with the importance of the concept of choice and how the Schellenbach 1993). Research usually indicates that mar-
concepts are perceived by society (a negative-positive ried people are less lonely, but conversely, people in a
continuum). In Figure 1 I have attempted to illustrate the marriage can be very lonely. Another personal situation
relationship between the concepts, including other factors that can initiate or be a consequence of loneliness, is that
that can be regarded as important. Loneliness is a very of a person's social environment (Weiss 1973, Berg et al.
dif®cult concept even without taking into account all the 1981, Creecy et al. 1985, Austin 1989, Steuwe-Portnoff
other closely related concepts. This continuum is an 1989, Rokach 1989, Kraus et al. 1993, Dugan & Kivett
attempt to simplify the relationship between them. 1994). Kraus et al. (1993) mention the importance of an
adequate social network without which loneliness can be
the outcome.
Causes, effects and associated factors in the general
Other situational causes and consequences of loneli-
population
ness include inadequate transport (Ryan & Patterson
This is a complex area. The cause and effect of loneliness 1987, Rodgers 1989), poverty and low income (Creecy et
can be one and the same, for example, depression can be al. 1985, Matteson & McConnell 1988, Sears et al. 1991),
both an initiating factor, and it can also be a consequence. relocation, which is common in today's society (Matteson
There are more obvious situations such as in bereavement & McConnell 1988, Rodgers 1989), and ®nally, of partic-
that cause loneliness but are not an effect. There are ular interest to nurses, hospitalization (Rodgers 1989,
various consequences of loneliness such as suicide, or Acorn 1992). Rodgers (1989), when referring to hospital-
a complete change of lifestyle, that cannot possibly be ization, suggests that `situational factors such as physical
causes. However, many causes can just as easily be effects, surroundings of the subjects, and opportunities for social
and it can be very dif®cult to decide which came ®rst; interaction may have had a signi®cant effect on the
loneliness or the associated factor. The topics related to individual's feelings of loneliness' (Rodgers 1989 p. 17).
loneliness can be categorised as being related to a lonely Some people can be lonely in hospital, but unless they
person's situation or their character; that is situational and are a long-term patient, it is short-term loneliness,
characterological causes and consequences. and they know there is an end in sight. On the other

Figure 1 Alienation-connectedness continuum (including the importance of choice and society's perception of the concepts).

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 762±770 765
C. Killeen

hand, for some patients, hospital is a respite from 1994, Barron et al. 1994). Suicide is not a cause of
loneliness. loneliness; it is the ultimate, terminal effect. According to
McWhirter (1990), `loneliness and the interpersonal
isolation which accompanies it, has been described as a
Characterological causes and consequences
principal cause of suicidal behaviours and suicide poten-
The literature concentrating on the personal characteris- tial' (McWhirter 1990 p. 417). A lot of lonely individuals
tics of the lonely person tends to suggest that he/she is feel that suicide is the only way out. They are in a world
self-possessed and self-centred, and does not often think where they feel that nobody cares and where they are
about other people, but more about themselves (Goswick & totally alone. There is nobody to miss them so they may as
Jones 1981, Iveson-Iveson 1985, Wittenberg & Reis 1986, well kill themselves, and end their misery. There will be
Austin 1989, Green & Wildermuth 1993). Also, it is nobody to grieve when they are gone, so what is the point
suggested that a lonely individual's outlook veers towards of staying alive just to feel unending pain and distress?
negativity rather than looking at positive aspects of their Another effect of loneliness not as ®nal as suicide, that
lives. Lonely people might be self-centred, but this could the literature does not appear to consider, is that of a
be a side-effect of loneliness as well. Loneliness can lead radical change in lifestyle, for example joining a monas-
to self-obsession and vice-versa, depending on the indi- tery or moving to a secluded area. Such people might
vidual. The problem is that if a person is lonely and does change their lives so drastically because they are lonely,
not have much social interaction, they do not have and in such places, they have very little physical and
anybody to think about, and therefore focus their thoughts psychological contract with other human beings, and as
on themselves. such, there is less pain, and they are more likely to be
Much of the literature, when looking at the character- tolerated and accepted. Such an environment can shelter
ological causes of loneliness, concentrates on relating them from the hurt and distress that is `part and parcel' of
loneliness to other rather negative concepts, for example the `big, bad world'.
self-esteem. Loneliness is found to be negatively related to
the following concepts: (a) self-esteem (Loucks 1980,
Other associated factors
Ouellet & Joshi 1986, Booth 1987, Sears et al. 1991,
Jackson & Cochran 1991, Haines et al. 1993, Kraus et al. A considerable volume of research focuses on individual
1993), (b) depression (Roscoe & Skomski 1989, McWhirter factors or situations that are likely to make people
1990, Katona 1994, Foxall et al. 1994), (c) shyness susceptible to loneliness, for example, age. It would
(Kalliopushka 1986, Carr & Schellenbach 1993, Kraus appear that parts of the age spectrum that experience
et al. 1993), (d) anxiety (Ryan & Patterson 1987, Roscoe loneliness more than others are adolescents (Ryan &
& Skomski 1989, McWhirter 1990, Sears et al. 1991, Kraus Patterson 1987, Roscoe & Skomski 1990, McWhirter
et al. 1993), (e) anger and tension (Loucks 1980), (f) greater 1990, Sears et al. 1991, Carr & Schellenbach 1993, Brage
neurotiscism and lower extroversion (Kraus et al. 1993), et al. 1993) and older members of society (Berg et al.
(g) less assertion and more self-consciousness (Sears et al. 1981, Austin 1989, Rodgers 1989, Sears et al. 1991,
1991), (h) self-blame and self-devaluation (Jackson & Dugan & Kivett 1994). Other associated factors include
Cochran 1991), and ®nally (j) lower educational levels gender Ð it is usually considered that females are more
(Baum 1982). Unfortunately, with such a complex con- vulnerable than males (Weiss 1973, Baurn 1982, Rodgers
cept, it is impossible to say whether the correlational 1989, Acorn 1992) Ð and health. The literature on health
concepts cause the loneliness, or are an effect of it. Some and loneliness tends to look at the impact that a
of them can probably occur at the same time, and as such, particular physical ailment can have on a person's
they are not a cause or an effect, but rather, an unwanted interaction with other humans, for example, poor eye-
companion. The nature of loneliness is that it is only sight (Evans et al. 1982, Matteson & McConnell 1988,
related to negative concepts; as Andersson (1993) cyni- Baron et al. 1994, Dugan & Kivett 1994), or hearing
cally points out, `one is still stuck with many correlations dif®culties (Matteson & McConnell 1988, Christian et al.
which may lead some cultures to assume that most 1989, Dugan & Kivett 1994, Chen 1994). Health, as well
miseries have to do with loneliness' (Andersson 1993 as causing loneliness, can be affected by it. The literature
p. 584). indicates that loneliness can lead to declining physical
As a result of loneliness and all its negative associations and mental health (Rodgers 1989, Carr & Schellenbach
with other psychological concepts, it is inevitable that it is 1993), and the most extreme effect that loneliness can
correlated with impaired psychology (Jackson & Cochran have on health is that of death. McWhirter (1990) and
1991, Barron et al. 1994, Foxall et al. 1994), and the Holmen et al. (1992) suggest that an increase in mortality
ultimate possible effect of all these negative concepts has been associated with the social isolation that often
which are so closely intertwined, is that of suicide (Ryan & accompanies loneliness, while Windriver (1993) states
Patterson 1987, Booth 1987, McWhirter 1990, Foxall et al. that loneliness `may result in physical deterioration,

766 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 762±770
Integrative literature reviews and meta-analyses Loneliness

mental illness and even death' (Windriver 1993 p. 15). for the fact that the cause and the effect can be one and the
Death might not be deliberate, in that a lonely individual same.
takes their own life; but can happen over a period of The complexity of loneliness is mentioned by a number
years in that the person might no longer have any of authors, including how it can affect all of humankind.
interest in themselves, with a resulting deterioration in According to Rokach (1989 p. 382):
health. They might cope with loneliness by resorting to
. . .although the human race is made up of different peoples, and
over-eating, drug and alcohol abuse, and other practices
despite the diversity of age, sex, culture, language and religious
that are regarded as being detrimental to their well-being,
beliefs, there are fundamental similarities. One of these similar-
and as such, they might reduce their life span noticeably.
ities is our yearning for love, acceptance and understanding, and
The effect that loneliness can have on a person's life and
conversely our hedonistic nature and aversion to such painful
health, is very much under-estimated by today's society.
experiences as loneliness.
To sum up so far, in looking at causes of loneliness
and the effects that it can have, it can be seen that it is a It comes in all forms; affects the majority of people in all
very dif®cult concept to put into some kind of order. It is kinds of ways, and will never be a concept that is simple
different for every individual who suffers it, it can be and easy to analyse. Loneliness is universal, and every-
caused by a multitude of factors, and can have far- body is touched by it to some degree. But it is a taboo
reaching effects on the suffering individual. Sometimes subject and very rarely discussed, and considering it is so
the cause can also be the consequence, which rather much a part of being human, there is a surprising paucity
confuses the issue, and quite often, it is impossible to say of research. It is a subject that needs to be studied in far
whether loneliness causes various conditions or vice- greater depth, so that ultimately, the expanding informa-
versa. As Rokach summarizes the situation, `although tion on loneliness will increase people's awareness of the
common to all people, the nature of loneliness as a concept; that it is perfectly natural and nothing to be
subjective experience varies from person to person, embarrassed about.
occurring under different conditions, with a multitude
of causes, results and consequences' (Rokach 1990 p. 39).
WHO IS LONELY?
Figure 2 is an attempt to illustrate everything that can
cause or be an effect of loneliness, and to make allowances Anybody and everybody is lonely at some time. Some
literature suggests that certain members of humankind are
more prone to loneliness, for example the elderly or
adolescents, but no segment of society is immune to
loneliness. At the end of the day, it is down to `the luck of
the draw'. Some people are going to have more traumatic
life experiences that are conducive to loneliness, than
others, while others, because of their personality type and
less effective coping strategies, are more likely to be lonely
individuals.
It is probable that loneliness will be an increasing
problem for individuals of any age group because of the
philosophy that underlies today's materialistic society.
Unfortunately, people will always experience traumatic
life events that can precipitate loneliness, and some
people will be more vulnerable than others. This may
never alter, but society and its sel®sh, materialistic out-
look might change.
Every individual is unique, and has different life
experiences and ways of dealing with them, some more
successful than others. Because of this, anybody can
endure episodes of loneliness during their life; it is a
part of being human, but at times it can become
unhealthy and detrimental to the person involved. Rath-
er than researching which type of person was more
vulnerable to loneliness, it would be more helpful if
researchers could look for ways that this distressing
Figure 2 Loneliness: a representation of causes, effects and disorder might be alleviated, with the ensuing psycho-
associated factors. logical pain reduced.

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 762±770 767
C. Killeen

1995), while Austin (1989) emphasizes the importance of

A NURSING SOLUTION?
creativity, in that if people ful®l their creative potential,
In looking at the nursing literature on loneliness and they are less likely to be lonely. All this is doing is
possible solutions, the words that spring to mind are alleviating boredom; the loneliness is still there. It might
naõÈve, practical and idealistic. Loneliness tends to be actually prevent individuals from doing something more
approached at a basic level, as though simple nursing constructive, which could help them to meet other people.
interventions can actually stop people from being lonely. Roscoe and Skomski (1989) found that lonely individuals'
Chen (1994) looks at people with learning dif®culties coping strategies, for example reading and sleeping, were
and suggests that if nurses can detect hearing problems often solitary, and as such self-defeating. Such behaviour
early, they can be referred to the appropriate department could be labelled destructive behaviour, to counter-bal-
and treated accordingly, and loneliness will be no more. ance creative behaviour. Neither are productive, and
Wise (1986) looks at the elderly in the community and neither will make a person less lonely; they only mask
utilized Orem's nursing model. She suggests that the the condition.
problem of isolation can be partly solved by day centres Matteson and McConnell (1988) advocate mutual aid
and in spacing our visits to a patient's home. Acorn (1992) groups, therapeutic groups (such as health education
researched patients in a rehabilitation setting and from a groups), and day care, but people have to want to attend
practical nursing perspective suggested that nurses need- in the ®rst place, and if they are lonely, they are unlikely
ed to assess lonely individuals, and then develop, imple- to do so. The only people likely to attend such groups are
ment and evaluate a plan of care to alleviate loneliness. individuals who are socially adept, and who have no
She states that `care plans should be realistic, practical dif®culties interacting with other people.
and based on input from the entire healthcare team, to Recommendations in the nursing literature are frequent-
ensure continuity of care' (Acorn 1992 p. 24). ly simplistic and idealistic, and therefore do not get to the
According to Rodgers (1989), loneliness can be allevi- root of the problem. Younger (1995) approaches loneliness
ated in hospitalized patients with a thorough assessment, from a psychological perspective that could be useful to
¯exible visitation policies, and encouraging patients to nurses in their practice. She suggests that people need to
bring objects from home. She concludes that hospitaliza- be acquainted with their `shadow side', which consists of
tion is conducive to loneliness, but she gives the impres- negative emotions and traits, which we tend to see in
sion that loneliness begins on admission and ends on everybody else but not in ourselves. It is in accepting
discharge. This only accounts for people who are lonely ourselves with all our human weaknesses, to be aware that
due to being in hospital. No reference is made to chron- they are part of being human, that we can grasp what the
ically lonely individuals, who, when they come into whole person is. This is an approach which suggests that a
hospital, might regard it as a social event. They might see nurse needs to know himself/herself before he/she can
more people in one day than they have in the previous understand and interact effectively with a lonely individ-
month. We need to look further than a patient's hospital ual.
stay; we need to concentrate on people who are lonely pre- Younger does not advocate any typical nursing solu-
admission and post discharge. tions. She simply recommends that we look at ourselves in
Windriver (1993) researched institutionalized residents order to understand other human beings better. If you are
and indicates that the lonely individual might not want to more comfortable with yourself, and you spend time with
interact with other people, and that they should not feel a patient, they can actually feel this themselves, and so
pressured into doing so. If people are pushed into social they might feel more relaxed as a result. Patients can sense
situations, no matter how altruistic the intentions, it is if nurses are genuinely empathetic, even with nothing
likely that the person will isolate themselves even further. being said. There is no magical cure for loneliness;
Acorn (1992) refers to work by Odell (1981), who suggest- sometimes just being there is all that is necessary for the
ed that nurses visit the patients at short, frequent inter- lonely individual.
vals. From personal observation, a large proportion of Younger also emphasizes the importance of silence and
nurses go up to patients at the start of their shift, and if how it is not necessary to have to say something. In certain
they require no hands-on nursing care, that is, they are situations, people feel obliged to talk, and in doing so,
mobile and self-caring, then they will probably have no quite often say the `wrong' thing. From a personal
further interaction with a nurse for the rest of that nurse's perspective, in certain situations such as interacting with
shift. All patients can bene®t from nurses interacting with bereaved relatives, the only thing to be done is to sit with
them regularly throughout their working day. This sug- the person/people involved and say nothing; to say
gestion is not idealistic, and should be a part of everyday something may spoil the moment. Doing this might not
nursing care. cure a person's loneliness, but at least they know that
Some nurses report the importance of pets for some someone cares enough to spend some time with them. All
patients (Castledine 1981, Ebersole & Hans 1994, Sable we can do as nurses and human beings is to be there for

768 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 762±770
Integrative literature reviews and meta-analyses Loneliness

other people, or let them know that we are there if they in the world, and the next, you do not think about it all. It
need somebody. is always there but in every-changing forms. It can be very
If people were more caring and thoughtful about other pervasive one moment; the next it is lying quietly, just
humans there would be fewer lonely people in this world. If waiting to return, but it never quite goes away.
loneliness could be solved, it would not be surprising if the Nurses are being unrealistic if they think that they can
governments of various countries were very interested, not `prevent' or `cure' this distressing condition; they can only
from a caring perspective, but a ®nancial one. Barron et al. alleviate it to some degree. If a lonely person is admitted to
(1991) suggest that nursing interventions directed at the hospital, it can make their lives a little more bearable if
prevention and alleviation of loneliness would not only they meet someone who appears to care, and this is an
ease the suffering of the lonely, but could also be cost- important role that nurses have to play in today's sel®sh
effective. Less loneliness might actually decrease admis- climate. Nurses are perceived by society as `caring' and
sion rates into hospital, which would be politically satis- `angelic', and if they cannot help a lonely individual, then
fying. A materialistic culture with its sel®sh ideals, causes who else can? It is up to the suffering individual to pull
more individuals to be lonely, which in turn can result in himself/herself up the downward spiral of loneliness, but
making people both physically and psychologically ill. it is made less dif®cult with the caring intervention of
This would indicate that in its own way loneliness is an other people, such as nurses.
epidemic. Unfortunately it would appear that most people Keywords are awareness and caring. Loneliness re-
are not aware of the problem and no cure is being attempted. quires an awareness not a solution. If nurses are more
According to Lynch (1977), for some lonely individuals aware of this condition within themselves, they are more
illness is the only legitimate way to gain attention, and likely to empathize with people who are enduring it.
such people are more likely to be admitted to hospital. He Younger's (1995) excellent work suggests that if a nurse is
concludes that `it would seem that society could ®nd less more aware of both his/her loneliness and suffering, and
expensive ways of delivering human attention' (Lynch that of other people, it is more likely that they will be a
1977 p. 209). caring individual. She states that `an understanding of
Even if action was taken to reduce loneliness, it might suffering, alienation and wisdom provides a guide for
not work, because the only way to make people less lonely supplying compassionate presence and care to assist the
is to make society more caring, and this will take more suffering' (Younger 1995 p.67). If the suffering individu-
than just a few token government interventions. In today's als are aware that they are in the presence of people who
self-obsessed climate, I am not sure that loneliness will empathize with their state of being, and that what they
ever go away; it is an unfortunate side-effect. At the end of are going through is not abnormal, it might make them
the day, loneliness will always be with us; it just depends feel less wretched, and more able to integrate back into
to what degree. Loneliness does not have a solution. It is society.
not a puzzle that can be completed. It can be alleviated It really comes down to caring, a word which is
and made less painful, but it cannot be solved. It will increasingly neglected and ignored in today's society.
always be there; it will never go away. It is part of being Nurses are in an ideal position to alleviate loneliness in an
human and that will never change. No matter who the uncaring world. If nurses are more aware of the `darker'
individual is, or whatever the circumstances are, people side of life, and how devastating negatively-perceived
will always be lonely. conditions such as loneliness can be for a suffering
patient, this can only help. If a patient who is admitted
appears to be lonely and indicates this by not wanting to
Conclusion
go home, and/or `making the most' of the company of
Loneliness is a dif®cult-to-de®ne concept that can easily other patients and staff, because it is not often that they
be confused with other concepts commonly used in have the opportunity to interact with other people, hope-
today's society. It has numerous causes and effects which fully the nurse who has experienced or been made aware
can be one and the same, and it `touches' all human beings of loneliness, can put such experience and knowledge into
to some degree. Although it is a highly individual, abstract practice. If nurses cannot empathize with lonely individ-
and complex concept, unfortunately it exists, and as such, uals, it is a sad indictment on today's society. The nurse
it needs to be addressed. It is there in the morning, keeps does not necessarily have to say anything. Just by being
you company for the rest of the day, and goes to bed with there for somebody can loneliness be alleviated or made
you at night. It is a horrible, wretched state of being, and at less painful. Nurses just need to be there.
the same time, it is a strange chameleon-like phenomenon. Ultimately, nurses might make life a little more bearable
It is as individual as your every thought. It can change for lonely individuals; that there are some members of the
every minute of every hour of every day for the suffering human race who care. Nurses can have a pivotal role in
recipient. One moment you are feeling alone but comfort- alleviating the loneliness of human beings who `pass
able; the next minute you feel like you are the only person through' their care.

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 762±770 769
C. Killeen

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