Social Isolation: A Practical Guide for Nurses Assisting Clients with Chronic Illness PDF

Rehabilitation NURSING ON...

Rehabilitation NURSING ON AT I Social Isolation: A Practical UIN G EDUC Guide for Nurses Assisting TIN CON Clients with Chronic Illness Ursula A. Holley, RN KEY WORDS Social isolation is a serious problem in our society, and the chronically ill are especially vulnerable. The lack of needed and chronic illness wanted social contacts is a serious source of discomfort that can lead to further health problems. Many factors are involved, coping including limited mobility, lack of transportation, apparent and hidden disabilities that are socially undesirable, lack of nursing intervention employment, drained relationships with caregivers, changes of social roles, and emotional and psychological stress and social isolation dysfunction. Nurses are in a unique position to intervene on behalf of those social isolates. Practical interventions include contacting peer counselors, referring the patient to a support group, helping to rebuild the family network, enhancing the patient’s spirituality, helping the patient use Internet-based supports, and practicing the therapeutic use of self. Social isolation is a threatening condition for many people, but it has many solutions. In order to provide holistic care, nurses can address this problem on an individual and societal level. Social isolation is an unfortunate, pervasive real- describes the distressing, depressing, dehumanizing, ity for many chronically ill people. In our fast-paced, detached feelings that a person endures when there is youth- and beauty-obsessed society, those dealing a gaping emptiness in their life due to an unfulfilled with illness can be left behind. Much has been writ- social or emotional life” (p. 764). ten about social isolation in the nursing literature, but Like pain, social isolation is what the patient says a practical guide for nurses is lacking. Those who are it is. The client’s perception of his or her situation is already coping with the complexities of managing key in addressing this problem. Simply noting the chronic illness are especially vulnerable to the effects number and frequency of social contacts a person has of social isolation. Many rehabilitation clients are liv- is not adequate in determining whether he or she is ing without the needed social contacts many of us socially isolated. For example, a homebound elderly take for granted. Nurses are in a unique position to woman whose child visits every day may still feel assess, recognize, and begin intervention on behalf isolated and lonely because she no longer visits her of patients who are at risk for social isolation. This peers at the local church. Satisfactory social lives are article summarizes social isolation in the chronically determined by the quality and reciprocity, not quan- ill and offers some practical guidance for the reha- tity and frequency, of contacts. The hierarchy of social bilitation nurse in preventing and relieving isolation needs exists on four levels, as described by Biordi. in this population. The levels begin with self, then involve close confi- dants. The third level involves organizations such as Background schools and churches. Finally, the community level Definition involves connection to the larger social structure In order to intervene appropriately, social isolation and world. Connections on all four levels satisfy a must be understood. A person’s choice to seek soli- person’s social needs. tude at times is healthy. Solitude is voluntarily chosen time alone for reflecting, centering, feeling spiritu- Populations ally connected, and finding inner peace and strength. Social isolation and its effects have been studied A problem exists when social isolation is perceived and written about in different populations of interest as negative and involuntary. Biordi (2002) asserted to rehabilitation nurses in the nursing literature. It that “involuntary social isolation occurs when an is well documented that many chronically ill people individual’s demand for social contacts or commu- suffer from social isolation. Moore (2002) and Riegel nications exceeds the human or situation capability and Carlson (2004) described and addressed isolation of others” (p. 119). Killeen’s (1998) definition is more in the lives of patients with heart failure and their expansive: “Social isolation with choice is aloneness, caregivers. Mukherjee, Reis, and Heller (2003) related while social isolation without choice is loneliness” (p. social isolation in the lives of women with traumatic 764). Killeen describes loneliness as “a condition that brain injury. Rural caregivers and stroke survivors’ Rehabilitation Nursing Vol. 32, No. 2 March/April 2007 51 Social Isolation: A Practical Guide for Nurses Assisting Clients with Chronic Illness needs for emotional and social support were ad- Isolation in Chronic Illness dressed in a study by Pierce, Steiner, Govoni, Hicks, The common research findings related to social Thompson, and Friedemann (2004). More studies isolation in the chronically ill can be summarized. can be found on isolation in those with fibromyal- The first theme evident in the research is functional gia (Cudney, Butler, Weinert, & Sullivan, 2002) and limitations in activities of daily living that hinder cancer, diabetes, rheumatoid disease, and multiple independence (Biordi, 2002; Cudney et al., 2002; sclerosis (Hill & Weinert, 2004). Fitzgerald et al., 2001; Sullivan et al., 2003; Tanner, Research has also shown that older adults, widows, 2004). Decreased mobility, less energy, fatigue, and and widowers (Letvak, 1997; Lynd, 2002; Randers, pain led to diminished social contacts through few- Olson, & Mattiasson, 2002; Stewart, Craig, MacPher- er outings outside of the home. Being secluded and son, & Alexander, 2001), people with HIV and AIDS homebound is a common reality for the chronically (Guillory, 1995; Moneyham, 2003), and the mentally ill. ill (Perese & Wolf, 2005) suffer social isolation to a dis- A second theme is emotional and psychological proportionate degree. Patients and families who live isolation related to illness. Biordi (2002) detailed how in rural areas are also at higher risk for social isolation personality changes related to neurological disorders (Biordi, 2002; Cudney et al., 2002; Fitzgerald, Pearson, can alter one’s ability to interact socially. Mukherjee & McCutcheon, 2001; Sullivan, Weinert, & Cudney, and colleagues (2003) described the struggle women 2003; Weinert, Cudney, & Winters, 2005). living with traumatic brain injury experience. Their personal emotional struggles and strained interper- Significance sonal relationships were furthered by marginaliza- Social contact with others is essential for a full and tion in their communities. These women’s cognitive meaningful life. People are social and interdepen- disabilities often were misunderstood and invisible dent by nature. Social contact is a main component to others, leaving them feeling alone. of human comfort. As nurses we are interested in Loss of social roles is also an important aspect of assessing and ensuring the comfort of our patients. chronic illness. Lack of employment decreased one’s A nursing theory that defines and describes this social circle (Biordi, 2002; Moore, 2002; Mukherjee et concept in depth is Kolcaba’s (2003) comfort theory. al., 2003). Inability to work can also cause financial Kolcaba’s theory includes a sociocultural context strain and leave very little money available for any- in her taxonomic structure of comfort. Her theory thing but the basic necessities for survival and health describes in depth interpersonal, family, and soci- care. Therefore, social activities may become luxuries etal relationships as one of four contexts of human for those with scarce resources. comfort. Incorporating comfort and its sociocultural Difficulty finding transportation is also a major context is important in providing holistic health care. problem leading to isolation. The often complex One can infer from Kolcaba’s theory that the lack of needs of the disabled leave them dependent on social comfort is inherent in social isolation and can specific types of transportation that are not readily have a serious impact on a person’s level of comfort, available. Many studies include people expressing well-being, and health. frustration with a lack of transportation and the neg- Living without social contacts and comfort can ative impact it has on management of their chronic have serious consequences for a person’s health and illness (Biordi, 2002; Cudney et al., 2002; Fitzgerald life. Biordi (2002) asserted that chronically ill peo- et al., 2001; Letvak, 1997; Mukherjee et al., 2003; Sul- ple with the fewest social and community ties are livan et al., 2003). Those living in rural areas struggle three times more likely to die than those with more more often with finding transportation than urban ties. Redman’s (2004) book on self-management of dwellers. chronic disease makes repeated references to needed A final important theme is the social isolation ex- support from others in successful disease manage- perienced by caregivers. Aldred, Gott, and Gariballa ment. Juggling the many tasks needed to maintain (2004) and Moore (2002) found that caregivers of pa- health in a chronic disease state can be daunting even tients with heart failure felt emotionally isolated and with ready help, but to be alone in that situation can lonely and needed to stay at home much of the time. be unbearable. The highest rate of suicide in the Families of brain injury survivors can have difficulty United States is in older men, whose major risk fac- re-entering society because the patient’s inappropri- tors include poor health, living alone, social isolation, ate social behaviors lead them to avoid social situa- and loneliness (American Association of Suicidology, tions. The stress of coping with a family member’s 2004; Lynd, 2002). Social isolates experience myriad chronic illness may lead to drained relationships, and negative feelings, including loneliness. Feeling iso- all family members may need more support. lated and lonely may cause depression and anxiety. Healthcare providers need to be aware that social 52 Rehabilitation Nursing Vol. 32, No. 2 March/April 2007 isolation can be experienced by those in institutions Peer Counseling also. Ready-made social environments such as senior One intervention that can be effective is peer coun- A multitude of housing do not necessarily alleviate social isolation seling. This counseling can be informal or more for- (Biordi, 2002). Residence in assisted living or skilled mal and initiated and supported by the professional support and self- nursing facilities also does not guarantee adequate healthcare worker. Perese and Wolf (2005) discussed help groups exist for social comfort. The other residents may have so few a telephone hotline set up at a clinic that helped peers resources of their own that they cannot share with befriend each other by providing emotional support people coping with others in need. Patients in acute rehabilitation facili- and active listening over the phone. Patients with ties may also feel lonely despite being surrounded by heart failure also used peer support in the Riegel and everything from other patients and providers. The types and quality Carlson (2004) study. The nurse can ask people who are managing well with their chronic illness whether diabetes mellitus of contacts needed by each person, whether at home or in a hospital, must be addressed. they are willing to volunteer as peer counselors. The to the death of a nurse can then offer to arrange a meeting between the Assessment counselor and a patient who is experiencing isolation spouse or a child. As stated earlier, the nurse must appreciate that and who is not managing well. The peer counselor social isolation is whatever the patient says it is. How- volunteer may also be willing to visit clients in in- ever, an assessment of the person’s social situation stitutions who need and desire more social contact. can start with an objective assessment. What are the Peers can also provide a wealth of information on number and frequency of social contacts? On which ways to connect with resources such as assistance of the four levels of social relationships does the per- with transportation, volunteers, friendly visitors, son appear to have contact? Determining whether the private pay aides, or financial aid. patient lives alone, lives in a rural environment, and is able to drive a car is important. Also, checking em- Support Groups ployment status and type of living arrangement (e.g., Referral to a support group is an important and of- single-family home or assisted living apartment) is ten effective intervention. A multitude of support and useful. Finding out whether the person has a signifi- self-help groups exist for people coping with every- cant other and children and how close they live to thing from diabetes mellitus to the death of a spouse one another is also helpful. If the patient belongs to a or a child. The literature includes many studies that peer group organization or already attends a support show how support groups are very effective in meet- group of some kind that will provide background. ing patients’ social needs (Biordi, 2002; Purk, 2004; The second part of the assessment is finding out Stewart et al., 2001). Participants can exchange infor- the patient’s perception of her or his social situation. mation, including how to access help with transpor- Is the patient expressing negativity? Is the person say- tation and other resources. When referring a patient ing that her or his social needs on one or more lev- to a support group, the nurse can gather information els are not being met? Actively listen to the patient’s on what groups are available by contacting local hos- responses without filtering them through your own pitals, nursing homes, community health centers, and preconceived ideas or judgments. Synthesizing all the public health department. Some 12-step support of the information gathered and then verifying its groups have phone numbers for contact people in the validity with the client will provide a solid base on phone book. Accessing Internet sites related to the which to build a plan to either strengthen an existing chronic illness is also helpful because some associa- social support network or perhaps begin building a tions have both national and local support groups. desperately needed one. Lists of support groups according to illness, with their locations, phone numbers, and contact information, Intervention can be made and kept ready for clients seeking help. Social isolation is clearly a problem in our society. Starting a support group or newsletter can fill a gap Nursing interventions to help combat the problem in social support in your area. are being studied and used. Biordi (2002) asserted that social isolation is one of the most important as- Rebuilding Family Networks pects of chronic illness to be managed in the plan of The nurse can be in a position to advocate for the care because of its large impact on the client and his chronically ill person in requesting more social sup- or her support network. Many interventions, from port from family members and significant others. high-touch and no-technology to low-touch and high- Bearing in mind that family ties are powerful and technology use, have been discussed in the literature. sometimes tense, the nurse can make contacts while The following are a few examples with concrete ideas treading lightly until a trusting relationship is estab- on implementation that can be used in any setting lished. Sometimes making a contact with an older where chronically ill people receive services. person’s adult child to discuss the parent’s social situation and its impact on his or her health is very Rehabilitation Nursing Vol. 32, No. 2 March/April 2007 53 Social Isolation: A Practical Guide for Nurses Assisting Clients with Chronic Illness helpful because the lay person does not always intui- cost of basic computer equipment and developments tively know what a chronically ill person needs. The such as Web television, which uses a simple phone client may be embarrassed about feeling isolated and and television combination, make Web access more lonely and may be afraid to burden his or her family. feasible for everyone. Several recent studies have Initiating and supporting contact between the parties tested Internet-based support as an intervention in can greatly enhance family communication and un- managing chronic illness (Biordi, 2002; Dickerson, derstanding about what the patient’s needs are. The 2002; Pierce et al., 2004; Weinert et al., 2005). This sup- nurse may refer to the Biordi (2002) text or literature port is especially helpful for those living in rural areas on family dynamics and family therapy before in- and those who are housebound. Some sites include tervening in more complex cases. Working with and links to local chapters and resources such as transpor- referring to social workers and other disciplines is tation and volunteers. Even if developing a formal appropriate. Exploring ways to redefine self in rela- Internet-based program is not feasible in your area of tion to others is a strategy discussed by Randers and practice, encouraging patients to use e-mail and chat colleagues (2002). Discussing role changes and how rooms can still provide needed contacts. Some health- new roles can provide new opportunities in life can care providers offer to communicate as needed with give clients hope. For example, a new widow may their patients via the Internet. Connecting patients redefine herself as the new head of the family. Keep to each other in cyberspace can be beneficial, too. A in mind that the definition of family is broad. “Fam- list of Internet sites for patients coping with certain ily” support may come from a local church group chronic illnesses can be distributed easily and makes that has volunteers such as friendly visitors. Other the process of finding support easier and friendlier sources of support include youth groups, senior and for them. See Figure 1 for a list of Internet sites for adult daycare centers, county offices of the aging, and patients with brain injuries and their families. Such a visiting nurse agencies and acute care centers with list can be created for different diagnoses and include lists of volunteers. local sites as available. Always caution clients to keep a healthy skepticism when reading any information Enhancing Spirituality gleaned from the Internet and to always confer with Nurses are sometimes reluctant to talk about spiri- their physician about any specific recommendations tuality with their clients, although it is known to be a found before changing their self-care practices. major source of strength for many people. Spirituality is not synonymous with religiosity, and any nurse can Therapeutic Use of Self broach the subject regardless of her or his religious Many patients claim that their healthcare provid- beliefs or those of the patient. The nurse can promote ers are a major source of social support in their lives. the client’s feelings of control, self-esteem, meaning, Nurses are seen as trustworthy, compassionate, and and purpose in life. With compassionate listening knowledgeable confidants in many cases. Presencing and sharing, the nurse can help a patient find mean- and active listening are invaluable tools in providing ing in her or his suffering and ways to relieve the emotional support. An individual nurse may not be pain, if possible. Simply being present and sharing able to greatly increase the number of social contacts someone’s burden can be enough. Helping a patient a person has, but he or she can provide caring, genu- overcome feelings of guilt, regret, sadness, and de- ine, high-quality contacts. Whether you are a nurse pression can greatly enhance her or his quality of life. in an acute rehabilitation setting or making home vis- Some concrete self-care spiritual interventions that its, your presence often is a very important part of can be prescribed are meditation, reading, yoga, tai that patient’s social comfort. Biordi (2002) described chi, and even pet therapy. Walton, Craig, Derwinski- the authentic intimacy a patient and nurse can share Robinson, and Weinert’s (2004) study included many and how powerful that relationship can be. Never useful suggestions for enhancing spirituality in the underestimate the ability you have as a nurse to bring chronically ill. Some of these comforting techniques patients comfort and hope just by being there and include watching videos of nature, journaling, listen- spending a few minutes listening instead of doing. ing to music, and repeating an optimistic mantra or Validating a patient’s importance as a human being quotation. can be as simple as stopping, making eye contact, and gently squeezing his or her hand. Internet Support Universal access to the Internet is fast becoming a Case Example reality in our society, and it can be used as a power- The case of Ms. S and the care she received from ful tool to decrease social isolation. The decreasing her rehabilitation nurse is an informative example. 54 Rehabilitation Nursing Vol. 32, No. 2 March/April 2007 Ms. S is a 60-year-old woman who recently suffered Figure 1. Internet Resources for Brain Injury Patients a moderately severe traumatic brain injury (TBI). She and Their Loved Ones slowly progressed at the inpatient rehabilitation fa- cility, where she developed a close, therapeutic rela- Brain Injury Association of America—www.biausa.org tionship with her nurses. Before her injury, Ms. S was Information on research, education, and advocacy, bilingual. a successful, independent business owner who lived Traumatic Brain Injury (TBI) Resource Guide—www.tbiguide.com alone and had infrequent contact with her only son. Information on TBI, rehabilitation, long-term assisted living, research, adaptive equipment, pharmacology, and free newsletter. She was a long-term recovering alcoholic who was Brain Injury/ Family Village—www.familyvillage.wisc.edu/lib_brim.htm active in Alcoholics Anonymous (AA). As the nurses Contains telephone contact numbers, family helpline, and chat rooms. grew to know Ms. S at the rehab, they noticed she Traumatic Brain Injury—www.neuroskills.com had few visitors. They decided an assessment for po- Information on TBI, brain function, assessment, evaluation, glossary of brain tential social isolation after discharge was appropri- injury terms. ate. Ms. S was asked about her social life and social Virtual Hospital: Acute Brain Injury—A Guide for Family and Friends—www.vh. support, her feelings, the frequency of contacts in org/adult/patient/neurosurgery/braininjury/index.html the past, her expectations on discharge, and her an- Information on how patients respond to TBI, how TBIs are evaluated and treated. ticipated needs and resources. She revealed that she Brain Source—www.brainsource.com was concerned about not having enough emotional Information and resources about TBI, neuropsychological, and professional services. support. She was very concerned about being able to Perspectives Network, Inc.—www.tbi.org attend her AA meetings again because these were her Service organization founded by TBI survivor includes tools such as identification most important sources of support before her injury. cards. Part of Ms. S’s discharge preparation included the National Resource Center for Traumatic Brain Injury—www.neuro.pmr.vcu.edu nurses helping Ms. S make a list of social contacts and Information on rehabilitation and directory of experts. contacting several people before she left the facility. Brain Injury Guide—www.members.aol.com/bigkate4/big.htm They orchestrated two family meetings between the Talk on issues related to TBI, person to person, sharing information, advice, and patient and her son, which helped them to reconnect. hope. Ms. S was computer literate and familiarized herself Head and Brain Injuries—Learn more from MedlinePlus—www.nlm.nih.gov/ medlineplus/headandbraininjuries.html with the list of Web sites for TBI survivors that the News, stories, overviews, research, National Library of Medicine sponsored. nurses provided. Ms. S left rehab with a solid plan in Head Injury Hotline—www.headinjury.com place, including planned weekly visits from her son, Self-directed learning center, discussions, support, current research. an Internet chat room support group on a TBI site, Capital District Center for Independence, Inc.—http://cdciweb.com and a commitment from a volunteer to bring her to Community-based organization offers variety of services to people with an AA meeting once a week. The nurses’ awareness, disabilities. assessment, and interventions, and the willingness People with Disabilities, HUD—www.hud.gov/groups/disabilities.cfm and cooperation of Ms. S, warded off social isolation One-stop resource, directory of links within site and to outside sites. for this potentially vulnerable person challenged Medicaid/SCHIP: People with disabilities, Kaiser Family Foundation—www.kff.org/ with managing a new chronic condition. medicaid/disabilities.cfm Health coverage, long-term care, managed care, Medicare and Medicaid information. Conclusions Jobs for People with Disabilities—www.federaljobs.net/disabled.htm Many chronically ill people suffer from loneliness Government jobs federal sector, options for employment and jobs for disabled due to social isolation. The negative feelings associ- persons. ated with isolation can have serious consequences Untangling the Web, Disability Links—www.icdi.wvu.edu/others.htm and even hasten death. Nurses are in a unique po- Vocational rehabilitation agencies, listed by state. sition to intervene when a patient is involuntarily Reach Out Magazine, Bringing People with Disabilities Together Online—www. isolated. After a nurse has identified a patient at risk reachoutmag.com of being socially isolated, a thorough assessment is Disability Rights and Resources, HUD—www.hud.gov/offices/fheol/disabilities/ completed. Depending on the findings, the nurse index.cfm Sunnyview Hospital and Rehabilitation Center—www.sunnyview.org has several interventions to choose from. One or a A leading provider of inpatient and outpatient rehabilitation services. combination of the following interventions may be most appropriate: connecting the patient with a peer counselor, referral to a support group, supporting Nurses and clients can use their combined resilience family communication, enhancing spirituality, thera- and resources to tackle this problem of social isolation peutic use of self, and assisting patients with use of and spread hope to all people in need of friendship, Internet-based supports. Taking a multidisciplinary strength, and love no matter what they are facing and approach and working with social workers, thera- coping with on a daily basis. Society needs to recognize pists, and other providers the person has contacted that those who need it the most often receive the least can widen the base of support even further. amount of attention, and nurses can begin to change Rehabilitation Nursing Vol. 32, No. 2 March/April 2007 55 Social Isolation: A Practical Guide for Nurses Assisting Clients with Chronic Illness attitudes one person, family, organization, and com- Mukherjee, D., Reis, J., & Heller, W. (2003). Women living with traumatic brain injury: Social isolation, emotional munity at a time. Social isolation is a serious problem functioning, and implications for psychotherapy. Women for many people, but it is a problem that has many so- & Therapy, 26(1/2), 3–15. lutions. In order to provide holistic care, nurses need Perese, E., & Wolf, M. (2005). Combating loneliness among persons with severe mental illness: social network inter- to recognize social isolation and work to address this ventions’ characteristics, effectiveness, and applicability. problem on an individual and societal level. Issues in Mental Health Nursing, 26, 591–609. Pierce, L., Steiner, V., Govoni, A., Hicks, B., Thompson, T., & Friedemann, M. (2004). Internet-based support for About the Author rural caregivers of persons with stroke shows promise. Rehabilitation Nursing, 29(3), 95–99. Ursula A. Holley, RN, is a graduate student in nursing at Purk, J. (2004). Support groups: Why do people attend? Sage Graduate School in Troy, New York. Address correspon- Rehabilitation Nursing, 29(2), 62–67. dence to her at 345 County Highway 112, Gloversville, NY Randers, I., Olson, T., & Mattiasson, A. (2002). Confirming older adult patients’ views of who they are and would like 12078 or [email protected]. to be. Nursing Ethics, 9(4), 416–431. Redman, B. K. (2004). Self-management of chronic disease. References Boston: Jones and Bartlett. Aldred, H., Gott, M., & Gariballa, S. (2004). Advanced heart Riegel, B., & Carlson, B. (2004). Is individual peer support a failure: Impact on older patients and informal careers. promising intervention for persons with heart failure? The Journal of Advanced Nursing, 49(2), 116–124. Journal of Cardiovascular Nursing, 19(3), 174–184. American Association of Suicidology. (2004, December 1). Elderly Stewart, M., Craig, D., MacPherson, K., & Alexander, S. suicide fact sheet. Retrieved October 1, 2005, from www.suici- (2001). Promoting positive affect and diminishing loneli- dology.org/associations/1045/files/ElderlySuicide2002.pdf. ness of widowed seniors through a support intervention. Biordi, D. L. (2002). Social isolation. In I. Lubkin & P. Larsen Public Health Nursing, 18(1), 54–63. (Eds.), Chronic illness: Impact and interventions (pp. 119– Sullivan, T., Weinert, C., & Cudney, S. (2003). Management of 147). Boston: Jones and Bartlett. chronic illness: Voices of rural women. Journal of Advanced Cudney, S., Butler, M., Weinert, C., & Sullivan, T. (2002). Ten Nursing, 44(6), 566–574. rural women living with fibromyalgia tell it like it is. Tanner, E. (2004). Relationship among chronic illness, functional Holistic Nursing Practice, 16(3), 35–45. limitations, and health outcomes in community-dwelling older Dickerson, S. (2002). Internet use by persons with implant- adults. Paper presented at Sigma Theta Tau International able cardioverter defibrillators. Paper presented at Virginia Conference. Retrieved January 22, 2007, from www.nurs- Henderson Library. Retrieved September 15, 2005, from inglibrary.org/Portal/main.aspx?pageid=4040&PID=439 http://nursinglibrary.org/Portal/main.aspx?pageid=404 2&VersionID=1. 0&PID=3539&VersionID=1. Walton, J., Craig, C., Derwinski-Robinson, B., & Weinert, C. Fitzgerald, M., Pearson, A., & McCutcheon, H. (2001). Impact (2004). I am not alone: Spirituality of chronically ill rural of rural living on the experience of chronic illness. dwellers. Rehabilitation Nursing, 29(5), 164–168. Australian Journal of Rural Health, 9, 235–240. Weinert, C., Cudney, S., & Winters, C. (2005). Social support Guillory, J. (1995). Living with HIV: Issues of stigma and dis- in cyberspace: The next generation. Computers in Nursing, closure in women infected with HIV. Paper presented at 23(1), 7–15. Southern Nursing Research Society. Retrieved September 15, 2005, from http://www.nursinglibrary.org/Portal/ main.aspx?pageid=4040&PID=291&VersionID=1. Earn nursing contact hours Hill, W., & Weinert, C. (2004). An evaluation of an online Rehabilitation Nursing is pleased to offer intervention to provide social support and health educa- tion. Computers in Nursing, 22(5), 282–288. readers the opportunity to earn nursing contact Killeen, C. (1998). Loneliness: An epidemic in modern society. hours for its continuing education articles by Journal of Advanced Nursing, 28(4), 762–770. taking a posttest through the ARN Web site. The Kolcaba, K. (2003). Comfort theory and practice: A vision for posttest consists of questions based on this article, plus holistic health care and research. New York: Springer. Letvak, S. (1997). Relational experiences of elderly women liv- several assessment questions (e.g., how long did it ing alone in rural communities: A phenomenologic inquiry. take you to read the article and complete the posttest?). Journal of the New York State Nurses Association, 28(2), 20–25. A passing score of 88% on the posttest and completion Lynd, M. (2002). Living alone: A lived experience of elderly of the assessment questions yield one nursing contact men and women. Paper presented at Sigma Theta Tau International Conference. Retrieved, January 22, 2007, hour for each article. from http://www.nursinglibrary.org/Portal/main.aspx? To earn contact hours, go to www.rehabnurse.org, pageid=4040&PID=2632&VersionID=1. and select “Continuing Education.” There you can read Moneyham, L. (2003). A peer-counseling intervention for rural the article again, or go directly to the posttest assessment. women with HIV. Paper presented at Sigma Theta Tau International Conference. Retrieved September 15, 2005, The cost for credit is $9 per article. You will be asked for a from www.nursinglibrary.org/Portal/main.aspx?pageid credit card or online payment service number. =4040&PID=3857&VersionID=1. The Association of Rehabilitation Nurses is accredit- Moore, R. (2002). The lived experience of a small number of wives caring for men with heart failure. Paper presented at Virginia ed as a provider of continuing nursing education by the Henderson Library. Retrieved September 15, 2005, from American Nurses Credentialing Center’s Commission www.nursinglibrary.org?Portal/main.aspx?pageid=4040 on Accreditation (ANCC COA). &PID=3533&VersionID=1 56 Rehabilitation Nursing Vol. 32, No. 2 March/April 2007