How does protective isolation affect mental health outcomes in HSCT patients NURS7030

ABSTRACT

Background

This literature review evaluates the psychological implications of protective isolation for hematopoietic stem cell transplantation patients. It covers the haematopoietic stem cell transplant patient's process, outcomes, protective isolation, anxiety, depression, and loneliness, as well as coping mechanisms. A hematopoietic stem cell transplant is vital for treating various blood malignancies and disorders, often involving long-term isolation to minimise infection risk. Understanding hematopoietic stem cell transplants aids in comprehending the psychological impact of protective isolation. It's crucial to recognise factors causing haematopoietic stem cell transplant-related stress, as protective isolation can significantly affect patients' mental health, often accompanied by depression and anxiety due to social isolation and treatment uncertainty. Coping skills are essential in mitigating psychological distress, emphasising the importance of addressing patients' emotional needs for improved care and transplant outcomes.

Aim

This literature review aims to delve into the psychological effects of protective isolation in hematopoietic stem cell transplant patients. It examines how isolation impacts their mental well-being, discusses challenges faced during this period, and stresses the importance of addressing psychological needs for better patient care and outcomes. Additionally, it contributes to understanding protective isolation's role in patient emotional health.

Search Strategy

A combination of three electronic databases, namely CINAHL, MEDLINE, and PSYCINFO, was used, in addition to a manual Google search, to retrieve pertinent material. The inclusion criteria encompassed studies published in English between the years 2004 and 2023. A total of 10 publications were chosen for this literature study. The factors were further classified into two primary themes: the identification of additional research through manual searching of relevant papers and the review of reference lists from systematic reviews.

Key Findings

The literature review on the psychological implications of protective isolation in hematopoietic stem cell transplant patients reveals significant challenges faced by individuals undergoing transplantation, including heightened levels of anxiety, depression, and loneliness. Coping mechanisms, such as seeking social support and employing relaxation techniques, emerge as essential strategies for managing the psychological burden of isolation. Promising interventions such as psychoeducation and cognitive-behavioural therapy show potential for improving mental health outcomes for patients. However, further research is warranted to explore the long-term effects of protective isolation, evaluate the effectiveness of interventions, and address cultural and contextual factors influencing patients' coping strategies. Overall, comprehensive psychosocial support is crucial for optimising patient well-being throughout the transplant journey.

TABLE OF CONTENTS

Abstract . iii

Introduction. 1

Search strategy

. 3

Discussion -

Hematopoietic stem cell transplant . 4

Protective isolation in HSCT................................................................. 5

Theme 1 Psychological Aspects of HSCT. 6

Theme1.1 Anxiety and Depression. 7

Theme 1.2 Coping Machanism............................................................. 9

Theme 2 Psycho-Social Issues11

Conclusion...14

Limitations... 15

Recommendations. 16

Proposed Methodology Plan for Systematic Review............................. 17

Reference list. 20

Appendices- Inclusion and Exclusion Criteria

. 23

Appendix 1

Table of Key Concepts and Search Pool

.... 24

Appendix 2: CINAHL Ultimate, Psycho Info . 25

Appendix 3: Prisma Flowchart.. 27

Appendix 4: Summary Tables.......... 28

INTRODUCTION

Hematopoietic stem cell transplantations (HSCTs) are performed to treat various conditions, such as lymphoma, leukaemia, immune-deficiency diseases, congenital metabolic disorders, hemoglobinopathies, and myelodysplastic and myeloproliferative syndromes. Patients go through rigorous myeloablative chemoradiotherapy prior to transplantation, and then stem cell "rescue" follows (Hatzimichael & Tuthill, 2010). According to Biagioli et al. (2016), the survival rates following bone marrow transplantation (BMT) or HSCT have significantly increased during the past decade. Prior to undergoing transplantation, patients are subjected to high doses of chemotherapy, resulting in significant immunosuppression and an increased susceptibility to infections. Hence, it is imperative to avert nosocomial infections in neutropenic patients, as they are associated with increased rates of re-hospitalisation, significant morbidity, and mortality. Protective isolation is used to reduce the risk of infection by minimising the chances of interaction between the patient and the outside world. This is achieved by the use of specialised equipment and strict regulations for healthcare personnel, patients, and visitors. HSCT patients are commonly treated in hospitals under stringent protective isolation until they have fully recovered their neutrophil count and beyond. Protective isolation, while intended to mitigate the risk of infection, may induce distress associated with isolation, diminish one's sense of control, and restrict access to social support (Scala et al., 2017). Biagioli et al. (2016) state that isolation during such a perilous period may diminish the coping abilities of patients by heightening their sense of helplessness and dearth of support. HSCT patients face significant challenges during protective isolation, including heightened levels of anxiety, depression, and loneliness, which can profoundly impact their overall quality of life and treatment outcomes. By exploring these psychological implications, healthcare providers can gain valuable insights into the unique needs of HSCT patients and develop targeted interventions to address their psychosocial concerns. Ultimately, considering the psychological aspects of protective isolation is essential for delivering holistic and patient-centred care, enhancing patient outcomes, and improving the overall transplant experience for individuals undergoing HSCT. The author is aiming to comprehensively evaluate and synthesise existing literature on the psychological implications of protective isolation for hematopoietic stem cell transplant patients. This literature review will focus on understanding the nature and extent of psychological challenges faced by patients during protective isolation and identifying evidence-based interventions aimed at promoting positive psychological well-being for these patients.

SEARCH STRATEGY

For this literature review, a comprehensive search strategy was applied across four electronic databases: CINAHL, MEDLINE, and PSYCINFO, along with a manual Google search to procure the applicable literature. The inclusion criteria stipulated studies published in English language between 2004 and 2023. The search strategy combined keywords and phrases connected to hematopoietic stem cell transplantation (HSCT), psychological implications, protective isolation, patient populations, and coping mechanisms. Specifically, terms such as "HSCT," "Psychological Implications," "Protective Isolation," "Haematology Patient," and "Coping Mechanism" were utilised in various combinations to capture relevant articles. The personalised strategy was used to encompass synonyms and related concepts for each key aspect of the research question. To recognise a breadth of literature addressing the psychological implications of protective isolation among patients undergoing HSCT and their coping mechanisms, a comprehensive approach was used. The chosen studies were set in countries, such as Europe, New Zealand, Italy, France, Brazil, Turkey, Canada, and the United States. The findings of the chosen articles were broadly reviewed. The primary themes highlighted in the review revolve around the psychological aspects of HSCT due to protective isolation and the psychosocial issues associated with HSCT as a result of protective isolation.

The reviewer deemed it necessary to include only studies conducted in English language, as they lacked the ability to translate studies from other languages. The reputed government publications were also included from the World Health Organisation, the National Cancer Registry Ireland, Ireland's Department of Health, and the National Cancer Strategy. These records were selected for their statistical relevance and significance. In addition, the author perused the reference lists of works from both sources. The database searches have discovered primary research and reviews that are essential to confirm the inclusion of all pertinent literature in the review.

DISCUSSION

Haematopoietic Stem Cell Transplant and Protective Isolation

Hematopoietic Stem Cell Transplant: Hematopoietic stem cell transplantation (HSCT) was initially conducted in 1957. Since then, it is estimated that over 50,000 procedures are carried out each year worldwide (Almeida et al., 2024). According to the National Comprehensive Cancer Network (NCCN), HSCT is the process where hematopoietic cells, either from the patient themselves (autologous) or from a donor (allogeneic), are infused after being treated with cytotoxic conditioning regimens. The purpose of this procedure is to completely eradicate the disease and restore normal hematopoietic and immunological function. HSCT has the potential to cure patients with specific forms of blood cancer and is also used to support patients receiving intense chemotherapy for the treatment of particular solid tumours. HSCT is categorised as either autologous or allogeneic, depending on whether the hematopoietic cells used come from the patient themselves or from a donor, respectively. Autologous hematopoietic cell transplantation involves using the patient's own cells, whereas allogeneic HSCT involves using hematopoietic cells from a donor who is either related or unrelated but has compatible human leukocyte antigen (Saad et al., 2023).

Complications following a HSCT might manifest as either acute or chronic. Several variables can influence these negative occurrences, such as age, initial performance level, the origin of the stem cell transplant, and the nature and intensity of the preparative regimen. Within the initial 90 days, individuals may experience immediate complications such as myelosuppression characterised by low levels of white blood cells, red blood cells, or platelets; sinusoidal obstruction syndrome; inflammation of the mucous membranes; acute graft versus host disease; bacterial infections caused by both gram-positive and gram-negative organisms; infections caused by the Herpesviridae family; and fungal infections caused by Candida and Aspergillus. Chronic problems encompass chronic graft versus host disease (GVHD), infection caused by encapsulated microorganisms, and reactivation of the varicella-zoster virus (Khaddour et al., 2023). The initial step in comprehending the fundamental measurements of frailty and cognitive impairment prior to transplantation is to ascertain their prevalence. This will aid in determining if these supplementary preassessments should be incorporated as a crucial component for all patients undergoing HSCT (Mohanraj et al., 2021).

Protective Isolation In HSCT: - In line with a recent concept analysis, isolation is described as a state where an individual encounters a decrease in the usual sensory and social stimulation, potentially accompanied by involuntary constraints on physical space or movement. Gilmartin et al. (2013) and Hayes-Lattin et al. (2005) state that providing care for patients following a stem cell transplant in a protective hospital setting has been deemed standard practice due to the range and complexity of infections that this population with compromised immune systems is prone to. A study done by Biagioli et al. (2017) expresses that the objective of protective isolation is to mitigate the risk of infection by reducing the probability of patient-to-external contact. This is achieved through the implementation of structural equipment and the enforcement of stringent conduct protocols for healthcare professionals, patients, and visitors. Infection epidemics caused by both conventional and opportunistic pathogens serve to underscore the dangers of infection following HSCT. Opportunistic infections caused by fungus, bacteria, and viruses are prevalent following HSCT (Biagioli et al., 2017). The study by Biagioli et al. (2017) looked into the personal experiences of patients who received care in protective isolation after undergoing HSCT. During their arduous battle against malignancy, the individuals readily embraced the stringent isolation measure and viewed it as a protective barrier that effectively safeguarded them, aligning with the defensive purpose of their isolation. Unfortunately, protective isolation may increase patients' levels of anxiety and rage, particularly when perceived as stressful and in comparison, to a prison environment (Tecchio et al., 2012.The study conducted by Lee et al. (2011) aims to explore the experiences of neutropenic people with cancer in isolation rooms and their strategies for managing their situation. By using meta-aggregation, two crucial syntheses were produced. First and foremost, healthcare professionals must acknowledge that when patients are physically isolated, they may also experience social isolation, which can leave them feeling helpless. Furthermore, it is imperative for healthcare professionals to actively promote the use of cognitive coping strategies by patients while they are in solitude. Furthermore, the presence of family, friends, and nurses is crucial, as they fulfil a crucial function in offering aid whenever necessary. Although isolation rooms can have adverse effects on neutropenic cancer patients while they are in the hospital, patients are able to effectively cope with the situation by using cognitive mechanisms and receiving adequate external assistance.

Theme 1: Psychological Aspects of HSCT Due to Protective Isolation

Biagioli et al. (2016) conducted a descriptive phenomenological analysis in an Italian university hospital, following Giorgi's methodology. In order to treat a haematological malignancy, ten patients (seven female and three male, ages 28 to 66) who had received allogeneic HSCT were interviewed regarding their hospital stay in protective isolation. It was determined that isolation was necessary to bring out the transformation of a broad meaning structure. The study identified three key themes, including the significance of transformation, the embodied experience of transformation, and the interplay between internal and external influences. These themes reflected changes observed in the environment, participants' relationships with loved ones, and their own sense of self. The findings suggest that healthcare providers should recognise the psychological impact of isolation practices, as patients may undergo a profound metamorphosis during HSCT while in safe isolation.

The study has drawbacks, such as a limited sample size and only including participants from one Italian university. The application of protective precautions in the haematological ward may have affected the study results. Therefore, the findings cannot be applied to all HSCT patients. During periods of isolation, patients require relationships with others not only to maintain communication with the outside world but also to broaden their perspectives and ideas beyond internal and external circumstances. Biagioli et al. (2016).

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is listed in the International Classification of Diseases 10 (Almeida et al., 2024). A study was conducted to identify patients who are at a greater risk of experiencing isolation. Men who belong to a low-educated sex group and have little satisfaction with visiting hours, as well as poor emotional support from healthcare personnel, are at a higher risk of developing emotional and psychosocial disorders. The study also indicated that the physical debility experienced during and after the therapy can lead to emotional problems. Therefore, healthcare providers should prioritise their efforts towards caring for individuals who exhibit those particular features (Biagioli et al., 2017). Extended periods of protective seclusion can result in social isolation (Vottero & Rittenmeyer, 2012) and other psychosocial implications, such as depression (El-Jawahri et al., 2014); (Tecchio et al., 2012); loneliness (Biagioli et al., 2017); (ElSadr et al., 2009); anger (Vottero & Rittenmeyer, 2012); insomnia (Kunitomi et al., 2010); and anxiety (Abad et al., 2010). Healthcare personnel are responsible for conducting continuous psychological assessments before, during, and after protective isolation. This is done to implement appropriate protective measures or interventions in order to prevent any psychological impact. It assists in preventing the cessation of the therapy (Proia-Lelouey & Letrecher, 2018).

Database searches initially identified 8,718,532 studies, which were narrowed down to 85 through various screening stages. After applying the eligibility criteria, 28 studies were deemed relevant for inclusion in this scoping review conducted in January 2022. These studies revealed that patients undergoing hematopoietic stem cell transplantation (HSCT) are particularly susceptible to developing common mental disorders (CMD) due to the intricate nature of treatment, emotional vulnerability, and traumatic experiences associated with the procedure. The review identified depressive, anxiety, post-traumatic stress, and mood disorders as the most prevalent CMDs, particularly in the post-HSCT period. This comprehensive mapping of CMDs and associated symptoms underscores the importance of recognising and addressing the psychological well-being of HSCT patients to provide optimal care and support throughout their treatment journey (Almeida et al., 2024).

Theme1.1 Anxiety and Depression

Evidence indicates that individuals who are isolated, regardless of the severity of their illness, exhibit heightened symptoms of depression and anxiety (Vottero & Rittenmeyer, 2012). Extended periods of protective seclusion can result in social isolation (Vottero & Rittenmeyer, 2012) and other psychosocial implications, such as depression (El-Jawahri et al., 2014); (Tecchio et al., 2012); loneliness (Biagioli et al., 2017); (ElSadr et al., 2009); anger (Vottero & Rittenmeyer, 2012); and insomnia (Kunitomi et al., 2010). anxiety (Abad et al., 2010). Healthcare personnel are responsible for conducting continuous psychological assessments before, during, and after protective isolation. This is done to implement appropriate protective measures or interventions in order to prevent any psychological impact. It assists in preventing the cessation of the therapy (Proia-Lelouey & Letrecher, 2018). While protective isolation is not usually discontinued due to psychological factors, it might potentially induce depression in patients (Biagioli et al., 2016). A study by Copeland et al. (2020) indicates that a collaborative care intervention specifically designed for HSCT during the peri-transplant period can be both possible and acceptable. This is the initial investigation of a mental health collaborative care intervention with HSCT patients. Both clinicians and patients expressed excellent satisfaction with all parts of the intervention. In the longitudinal prospective model used in the study, as shown by Tecchio et al. (2012), at admission and at predetermined intervals per week during isolation, 107 participants had their anxiety and depression measured using the State-Trait Anxiety Inventory and the Self-rating Depression Scale. The cognitive-behavioural assessment was used to assess the psychological state of the patients prior to isolation. Upon admission, 10% of the patients exhibited clinically severe symptoms of depression and anxiety. Following a period of two weeks in isolation, the number of those experiencing depression increased by more than twofold, whereas the proportion of individuals experiencing anxiety remained relatively stable during the same timeframe .The study found that those who identified as female, experienced higher levels of anxiety and obsessive-compulsive symptoms, exhibited intrusive personality traits, and had a worse performance status were more likely to experience increased depression during periods of isolation.

Tecchio et al. (2012) state that HSCT patients experience significant anxiety and despair while in seclusion. While anxiety levels often remain consistent over time, symptoms of depression notably intensify during periods of isolation. Female patients who have introversion, elevated levels of anxiety, and subpar performance upon admission are more likely to see a rise in symptoms of depression. Hence, using pre-transplant screening to evaluate these attributes could aid in the prompt detection of those who are at a higher risk of developing clinically significant depression. By implementing this, individuals would have the opportunity to receive specific and effective psychological therapy and/or educational initiatives while in isolation, leading to potential benefits. Two previous studies have indicated that the number of patients exhibiting symptoms of depression quadrupled after one or two weeks of protective isolation (El-Jawahri et al., 2014; Tecchio et al., 2013).

A study carried out by Tecchio et al. (2012) During a study on hematopoietic stem cell transplant patients in protective isolation, researchers looked into the levels of anxiety and depression, as well as pre-isolation factors such as socio-demographics, biomedical variables, and personality traits. They found that approximately 10% of the patients experienced clinically significant anxiety and depressive symptoms upon admission. Furthermore, the level of depression more than doubled after 2 weeks of protective isolation.

The study by Sertba et al. (2022) used a pre-post-pilot, randomised, controlled design. The sample group consisted of twenty patients in total. Random assignments were made to place participants in the experimental group (n = 9) or control group (n = 11). Patients were measured using the Hospital Anxiety and Depression Scale both on the day of release and on the first day of admission to the unit. During the patients' hospital stay, experts gave them daily questions about the quantity and quality of sleep. During their stay in the facility, the patients in the experimental group engaged in creative arts intervention for a total of 60 minutes per day, three to four days per week. The outcome demonstrated a significant improvement in sleep quality scores and a substantial decrease in depression and anxiety levels in the experimental group following the intervention. Patients receiving HSCT may benefit from creative arts interventions for their anxiety, depression, and sleep issues.

In brief, anxiety and depression have been extensively reported in patients undergoing HSCT. Although the anxiety level remained stable, the depression symptoms worsened during the isolation period. The study also found that an increase in depressive symptoms and anxiety levels is more likely to occur in female patients. When appropriate measures are implemented, creative therapies generally pose minimal danger to patients. Patients might engage in recreational activities to enjoy their time. There is a hypothesis that suggests that creative interventions can be particularly advantageous for patients who have undergone HSCT. This is because HSCT involves a difficult treatment process and a protracted period of protective isolation, which is the time from when the patient is admitted to when the engraftment process is completed (Sertba et al., 2022).

Theme 1.2 Coping Mechanism

The isolation experience necessitates that patients manage and adjust to a situation that is simultaneously limiting and anxiety-inducing. Individuals differ in their capacity to adapt as well as in their emotional reactions (Vottero & Rittenmeyer, 2012). A review conducted by Vottero and Rittenmeyer (2012) initially evaluated 12 studies but excluded 4 of them because of methodological issues. They included the remaining eight papers for analysis. The main focus of these studies was on the experiences of patients who were hospitalised and undergoing protective isolation. A total of 56 findings were retrieved from the papers that were considered, and these findings were subsequently synthesised into 11 categories. Two significant synthesised findings resulted from these categories. The initial discovery indicates that the feeling of being alone results in a fragmented sense of human connection, underscoring the significance for nurses to deliver care that tackles and alleviates the adverse consequences of this isolation. The second conclusion highlights the importance of nurses being able to identify and address the several aspects that affect a patient's capacity to adjust to an artificial environment. This underscores the intricate nature of the patient's experience while in protective isolation.

In a longitudinal study conducted by Mohanraj et al. (2021), 32 patients who were 18 years old or older and undergoing HSCT were included. The researchers collected data at two specific time points: before HSCT and after HSCT. A range of evaluation measures were employed to evaluate frailty, cognitive impairment, fatigue, and quality of life (QoL), encompassing dimensions such as physical, social/family, emotional, functional, and transplant-related well-being. The analysis unveiled multiple noteworthy discoveries. Initially, individuals with elevated fatigue ratings indicated a decline in quality of life both prior to and during hematopoietic stem cell transplantation (HSCT). Furthermore, there was a clear link between heightened vulnerability and a diminished functional state before HSCT. This was also found to be connected to lower levels of physical, social, and transplant-related well-being following HSCT. In addition, individuals who experienced fatigue also displayed heightened fragility after undergoing HSCT. Furthermore, notable alterations were noted in the physical state and levels of weariness between the visits prior to and following HSCT.

Polomeni et al. (2016) have done a study, and a total of 58 patients who underwent HSCT between 2007 and 2010, along with their immediate family members (parents, partners, and/or adult children), were requested to complete an anonymous questionnaire. The questionnaire consisted of socio-demographic information, a Likert-scale assessment of the effects of HSCT on sexual, couple, family, professional, and social aspects of life, as well as an evaluation of perceived support. The quality of life (QOL) of patients and their close relatives was assessed using the FACT-BMT and WHO-QOL questionnaires. Additionally, the adjustments made by couples (patients and their partners) were examined using the Dyadic Adjustment Scale (DAS). Patients and partners who agreed to participate completed comprehensive interviews. HSCT is an exceptionally physically and psychologically challenging case for both patients and their partners and close family. The findings of the study by Polomni et al. (2016) validate the adverse effects of the transplant process on the professional and social aspects of patients and their partners. Additionally, the research reveals significant alterations in the dynamics of couples and families.

Biagioli et al. (2016) did a study on solitude during protective isolation in patients with haematological malignancies. They discovered that patients in protective isolation experience suffering due to feelings of loneliness, a lack of independence, and overall misery. Developing a sense of self-connection is crucial for managing the experience of isolation. This occurs when patients manage their emotions and adjust their own attitudes in order to adapt to being hospitalised. Patients undergoing protective isolation may encounter symptoms such as tension, anxiety, rage, despair, insomnia, and loneliness. Loneliness, despite its significant impact on coping and quality of life, is not adequately conceptualised and assessed.

Theme 2 Psycho-social Issues

Hospitalisation for HSCT involves several stages, including a conditioning regimen, the transplantation process, engraftment, and a post-transplantation period. Undertaking HSCT poses significant physical and mental challenges for all patients. Patients undergoing autologous HSCT often stay in the hospital for around four weeks, but recipients of allogenic HSCT spend an even longer duration in strict isolation. Patients' psychological well-being is most impacted by acute physical side effects, feelings of loneliness, and dependence throughout this treatment phase (Janicsk et al., 2021). The synthesised findings of the study conducted by Biagioli et al. (2016) suggest that patients may be afflicted with isolation due to feelings of being alone, confinement, and helplessness. Despite potentially experiencing feelings of isolation within the controlled environment, patients do possess the ability to maintain a symbolic doorway to the outside world open and to overcome this isolation through self-reflection.

A prevalent finding from the meta-synthesis carried out by Vottero & Rittenmeyer (2012) is loneliness. Biagioli et al. (2016) state that loneliness encompasses feelings of monotony, boredom, despair, and claustrophobia. It involves a wandering of thoughts, a lack of stimulation, comprehension, and people to engage in conversation with. Loneliness also includes a fear of abandonment and a loss of connection with the outside world. Loneliness, while considered an existential condition rather than a psychological disorder, can be considered a bad experience by cancer patients, particularly when it comes from isolation and causes them distress (Gilmartin et al., 2013). When patients experience feelings of isolation, they may be more inclined to engage with a broader range of individuals than they otherwise would. In addition to their loved ones, they may also view members of the staff or volunteers as important individuals in their lives. Human beings require interpersonal connections to strengthen their souls and discover purpose. (Rykkje et al., 2011). One may develop a relationship with oneself through isolation. When patients regulate their emotions and dispositions in the face of threatening situations, this occurs (Biagioli et al., 2016). Patients develop a relationship with themselves when they attempt to derive value, meaning, and purpose from their protective isolation. This may indicate their coping mechanisms for feelings of helplessness and powerlessness (Lee, 2011).

Patients with haematological malignancies frequently depend on their own resilience and sense of purpose to overcome not only the feelings of isolation but also the experience of being hospitalised and the disease itself. This is because they are reliant on a successful transplant that will enable them to reintegrate into society (Biagioli et al., 2016). The meta-synthesis conducted by Biagioli et al. (2016) can enhance health professionals' comprehension of patients' viewpoints and experiences during isolation, thereby enabling a more comprehensive understanding and fulfilment of patients' individual requirements. These findings can be used by healthcare practitioners to evaluate the requirements of transplant patients in terms of their physical, emotional, and spiritual well-being. Healthcare professionals can assist patients in effectively managing protective isolation by promoting patients' connections with themselves and others. This support aims to maintain patients' pursuit of purpose, facilitate communication with loved ones, and create mutual assistance.

In order to alleviate the feeling of loneliness, it is crucial for healthcare personnel to provide a compassionate presence to patients. This can be achieved by maintaining a pleasant demeanour and engaging in conversations that do not revolve only around the patient's illness. Biagioli1 et al. (2017) conducted a study for the development and initial validation of a questionnaire to assess patients perceptions of protective isolation following hematopoietic stem cell transplantation. The study revealed that at the end of the two weeks of protective isolation, most of the patients loneliness scale was high.

Some patients may experience disrupted human connectivity (Vottero & Rittenmeyer, 2012) as a consequence of the time spent alone in a hospital room without the support and presence of their family members or loved ones (Beattie et al., 2013). Given that HCST is an essential and inevitable aspect of treatment, it is crucial to prioritise both physical and psychological safety. Therefore, additional research is required to explore the impact of protective isolation on the emotional and psychosocial well-being of patients. The creation of a validated instrument will aid in identifying the psychological consequences for a patient who is isolated for protective purposes. These initiatives will aid in strategizing the necessary treatments aimed at preventing and mitigating loneliness, particularly those for distress (Baliousis et al., 2015). A comprehensive holistic evaluation indicates that individuals who undergo hematopoietic stem cell transplantation face distinct psychological difficulties due to prolonged hospital stays in protective isolation. Informants have reported experiencing fatigue, specifically during the middle phase of their hospitalisation. They were unable to participate in leisure activities and experience diversion due to extreme exhaustion (Biagioli et al., 2017).

CONCLUSION

In conclusion, this literature review highlights the profound psychological implications of protective isolation for patients undergoing hematopoietic stem cell transplantation (HSCT). The theme encompassing psychological aspects of protective isolation, anxiety, depression, coping mechanisms, and psychosocial issues underscores the multifaceted challenges faced by HSCT patients during their treatment journey. Despite the necessity of protective isolation for patient safety, it often exacerbates feelings of anxiety, depression, and social isolation. Coping mechanisms play a crucial role in mitigating these psychological effects, yet further research is needed to explore their effectiveness comprehensively. Moving forward, the author's next systematic review question, "What is the effectiveness and practicality of interventions for reducing the psychological implications of protective isolation on patients undergoing hematopoietic stem cell transplantation?" seeks to address gaps identified in this review.

By evaluating the efficacy and feasibility of interventions targeting psychological distress during protective isolation, future research can inform evidence-based strategies for enhancing patient care and well-being. Limitations of this review include potential publication bias, limited generalizability of findings, and variations in study methodologies. Recommendations for further study include conducting longitudinal research to assess the long-term impact of protective isolation, exploring culturally sensitive interventions, and investigating the role of multidisciplinary approaches in addressing patients' psychosocial needs comprehensively. By addressing these limitations and recommendations, future research can contribute to improving the psychological support provided to HSCT patients undergoing protective isolation.

LIMITATIONS

Although this literature review offers valuable insights into the psychological effects of protective isolation for HSCT patients, it is important to acknowledge several limitations. Firstly, the majority of the studies included in this review were observational or qualitative in nature, limiting the ability to establish causality or generalise findings to broader populations. Additionally, the literature predominantly focused on adult patients undergoing HSCT or specific subgroups, such as elderly patients or those with comorbidities. Furthermore, there may be variability in the definition and measurement of psychological outcomes across studies, potentially influencing the comparability and interpretation of findings.

The retrospective nature of some studies and reliance on self-report measures may introduce recall bias or social desirability bias, impacting the reliability of the data. Moreover, while efforts were made to include literature from diverse geographical regions, there may be inherent biases in the selection and publication of studies, potentially limiting the generalizability of findings to different cultural contexts. Despite the ongoing progress in transplantation procedures and supportive care practices, it is important to note that the results of this analysis may not completely represent the current state of psychological support for HSCT patients.

RECOMMENDATIONS

To effectively address the psychological implications of protective isolation in HSCT patients, it is essential to implement comprehensive psychosocial support measures tailored to individual patient needs. This begins with routine psychosocial screening during the pre-transplant evaluation process to identify patients at risk for psychological distress. Early and ongoing psychosocial support services should be provided throughout the transplant journey, encompassing pre-transplant education, counselling, and post-transplant follow-up care. Coping skills training programmes focusing on mindfulness, relaxation techniques, and cognitive-behavioural strategies should be integrated into HSCT care protocols to empower patients with effective stress management strategies. Additionally, facilitating social connection and peer support through virtual support groups and peer mentorship programmes can provide invaluable emotional support to patients facing similar challenges. Clear and consistent communication about the rationale, expectations, and duration of protective isolation is essential to alleviate uncertainty and anxiety.

PROPOSED METHODOLOGY PLAN FOR SYSTAMATIC REVIEW

APPENDICES

INCLUSION AND EXCLUSION CRITERIA

Appendix 1

: Table of Key Concepts and Search Pool

Appendix 2- CINHAL ULTIMATE

MEDLINE

PSYCINFO

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APPENDIX 3

-PRISMA Flow Diagram

APENDIX-4 -SUMMARY TABLE FOR RESEARCH STUDIES

Author and Year	Study Aims & Objectives	Research Design	Sample Size & Sample Type	Data collection methods	Data Analysis Method
Almeida et al. (2024) Common mental disorders in hematopoietic stem cell transplant patients	To map common recurrent mental disorders in patients undergoing hematopoietic stem cell transplantation.	This is a scoping review, developed based on Items for Systematic reviews and Meta- Analyses extension	Online databases and digital repositories of academic dissertations and theses. The studies that addressed the research question successfully achieved the study's objective.	Researchers with onco-haematology experience used a pre-tested form and a scoping review to extract the following variables: database, language, year of publication, country of creation, study purpose, methodological design, quality of evidence, and the most common CMD in HSCT patients.	The data was structured and converted into electronic spreadsheets, accessible in Microsoft Excel 2017. An analysis of the data was conducted to provide descriptive statistics and frequencies .
Findings relevant to the review The study included 28 studies, 14 of which were published in the United States. Depression, anxiety, PTSD, and mood disorders were common. There was a list of twenty symptoms, commonly reported as weariness and insomnia. Differential diagnosis of these conditions is challenging due to their symptoms being similar to those of other health issues. Their potential to hinder patient evolution is significant.

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Author and Year

Study Aims & Objectives

Research Design

Sample Size & Sample Type

Data collection methods

Data Analysis Method

Biagioli et al. (2016) The lived experience of patients in protective isolation during their hospital stay for allogeneic haematopoietic stem cell transplantation

The objective of this study was to look into firsthand encounters with protective isolation in adult patients who had HSCT.

A descriptive phenomenological inquiry

After HSCT for haematological malignancy, 10 patients (7 female and 3 male, ages 2866) were interviewed regarding their hospital stay in protective isolation.

A total of ten patients having clinical check-ups in the haematological unit were selected and questioned by two nurse researchers in a secluded and tranquil room. These researchers had no prior involvement in the patients' medical care. Participants were queried about their hospitalisation experience in solitude through open-ended and unstructured inquiries.

Data were analysed following Giorgi's descriptive method

Findings relevant to the review A certain semantic framework was recognised as being separated in order to accomplish a change. Given that patients may undergo HSCT in protective isolation as a transformative procedure, it is crucial for healthcare providers to closely evaluate the psychosocial consequences of the isolation practice.

Author and Year

Study Aims & Objectives

Research Design

Sample Size & Sample Type

Data collection methods

Data Analysis Method

Biagioli et al. (2017) Being in protective isolation following autologous haematopoietic stem cell transplantation

The objective of this study was to investigate the firsthand experiences of patients diagnosed with haematological malignancies who had autologous hematopoietic stem cell transplantation and were placed in protective isolation during their hospitalisation.

A descriptive phenomenological study was conducted in an Italian university hospital

Patients with haematological malignancies under protective isolation for HSCT were included. They were asked about their isolation during their weekly ambulatory checkups up to 100 days post-transplant. Giorgi's findings described patient-perceived protective isolation.

An unstructured interview technique was adopted for data collection in order to allow informants to express themselves

Giorgis descriptive phenomenological method was followed

Findings relevant to the review- This review identified eight distinct themes. Isolation serves as a protective measure that patients must employ to safeguard themselves against danger. This defence entails adhering to specific norms and carrying the responsibility of defending oneself. Additionally, external techniques and inner strengths are utilised to fortify this defence. Furthermore, defending loved ones is also a part of this defensive process, which ultimately leads to various consequences. The overall framework was articulated as a means of protection against experiencing pain. Amidst the challenging fight against cancer, the majority of informants willingly embraced the stringent isolation measure, viewing it as a protective barrier for a successful defence.

Author & Year

Research Question/ Purpose

Search Strategy/ Inclusion/ Exclusion Criteria

Search Terms

Detail of Literature /Study Selection

Quality Assessment (where applicable)

Data Synthesis (where applicable)

Biagioli et al. (2016) The experiences of protective isolation in patients undergoing bone marrow or haematopoietic stem cell transplantation: systematic review and meta synthesis

The objective is to analyse the qualitative evidence about the experiences and psychological effects of protective isolation in patients with haematological malignancies having BMT or HSCT and to summarise and evaluate these findings.

he participants of interest were onco-haematological patients in protective isolation for autologous or allogeneic transplantation

Meta synthesis, patient isolation, loneliness, social isolation, haematopoietic stem cell transplantation, bone marrow transplantation

Cochrane Library, JBI Library, MEDLINE, CINAHL, Scopus, Embase, ISI, PsycINFO and Psych ARTICLES.

The JBI Qualitative Assessment and Review Instrument was used to evaluate the methodological quality of each study included in the analysis.

A meta-aggregation or synthesis was conducted by generating assertions that formed a category based on at least two related findings.

Findings/Conclusions relevant to the review Out of 69 records identified, 11 qualitative research studies met selection and methodological criteria, included in the review. 26 findings were extracted, categorized into seven groups, and synthesized into three main findings: Isolation as source of suffering, relating with oneself, and staying connected with the outside world. All findings were deemed either credible or unequivocal based on JBI quality assessment.

Author and Year

Study Aims & Objectives

Research Design

Sample Size & Sample Type

Data collection methods

Data Analysis Method

Mohanraj et al. (2021) Factors Affecting Quality of Life in Patients Receiving Autologous Hematopoietic Stem Cell Transplantation

The objective of this study was to assess the correlation between assessments of frailty and cognitive impairment and the presence of fatigue and quality of life (QoL) in adult beneficiaries of hematopoietic stem cell transplantation (HSCT) following autologous HSCT.

Longitudinal study design used

A total of 32 individuals, aged 18 years or older, who had autologous hematopoietic stem cell transplantation (HSCT) were included from a bone marrow transplant centre.

Both subjective and objective assessments were used to extract demographic and clinical data from electronic medical records .

Baseline demographics and clinical outcomes were summarised using descriptive statistics. Clinical features and categorical data (race, ethnicity, household income, education, marital status, gender, and employment status)

Findings relevant to the review Before and after HSCT, fatigued participants had worse QoL. Frailty was linked to lower functional, physical, social, and transplant-related well-being before and after HSCT. After HSCT, fatigue increased fragility. Physical well-being and weariness changed significantly pre- and post-HSCT. Data analysis showed strong relationships between autologous HSCT individuals' QoL, fatigue, and frailty subsets before and after transplantation .

Author and Year	Study Aims & Objectives	Research Design	Sample Size & Sample Type	Data collection methods	Data Analysis Method
Polomni et al.(2016) The impact of allogeneic-hematopoietic stem cell transplantation on patients' and close relatives' quality of life and relationships	Although evidence suggests considerable disruption to families, the impact of Hematopoietic Stem Cell Transplantation (HSCT) on patients' partners and close relatives has not been sufficiently explored. The present mixed-methods study aimed to enlighten allo-HSCT effects on patients' and close relatives' quality of life (QOL) and their relationships	To explore quantitative data, resorted with qualitative approach:	Cross-sectional study	Patients (N = 58) who received HSCT between 2007 and 2010 and their close relatives (parents, partners, or adult children) completed an anonymous questionnaire regarding socio-demographic data, HSCT impact on sexual, couple, family, professional, and social life, and perceived support. Patients and close relatives' QOL (FACT-BMT and WHO-QOL-brief) and couples' adaptations (DAS) were assessed. Patients and partners who agreed were interviewed in depth.	Descriptive statistics
Findings relevant to the review Both the patients (N = 28) and their close relatives (N = 48) reported a range of issues, such as exhaustion, sleep disruptions, sexual dysfunction, emotional anguish, and challenges in their relationships. Patients were particularly concerned about being perceived as a source of inconvenience to their near relatives, while close relatives indicated concerns about alterations in marriage and family relationships, disturbances in daily routines, and the obligation of giving both physical and emotional care. The challenges were intensified following HSCT, especially when patients had to face the enduring repercussions of the treatment .

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Author & Year

Research Question/ Purpose

Search Strategy/ Inclusion/ Exclusion Criteria

Search Terms

Detail of Literature /Study Selection

Quality Assessment

Data Synthesis (where applicable)

Lee et al., (2011) The experience of being a neutropenic cancer patient in an acute care isolation room: a systematic review of qualitative evidence

To understand neutropenic cancer patients' experiences in the isolation room and their coping mechanisms

The study focused on adult neutropenic cancer patients who were 18 years of age or older. An initial search was conducted in MEDLINE and CINAHL to find keywords .

Being isolated Being shut in Intellectualizing the need of isolation

Qualitative studies which focus on adult neutropenic cancer patients' experiences in an isolation room.

N/A

Categories were formed based on aggregation from the similar findings with like meaning. The categories were then read and reread to develop two synthesised findings that were presented as declamatory and generalisable statements to guide and inform clinical practice

Findings/Conclusions relevant to the review Two key findings emerged from the meta-aggregation process. Firstly, healthcare workers must recognize that physical isolation can lead to social isolation in patients, fostering feelings of powerlessness. Secondly, it's vital for healthcare workers to promote the use of cognitive coping mechanisms among patients facing isolation. Additionally, family, friends, and nurses should be proactive in providing support to patients whenever needed.

Author and Year

Study Aims & Objectives

Research Design

Sample Size & Sample Type

Data collection methods

Data Analysis Method

Sertba? et al. (2022) Effects of Creative Arts Intervention on Anxiety, Depression and Sleep Quality Among Bone Marrow Transplantation Patients During Protective Isolation

This study aimed to assess the impact of creative interventions conducted during the period of protective isolation on the levels of anxiety, depression symptoms, and sleep quality in patients who underwent bone marrow transplantation .

This randomized, controlled, pretest and post test pilot design were conducted

Patients hospitalized in an adult BMT unit of a hospital in Istanbul between November 2019 and September 2020

A sample of 20 patients was taken. Nine and eleven participants were randomly assigned to the experimental or control groups. Patients were given the Hospital Anxiety and Depression Scale on admission and discharge .

Data were managed using the IBM SPSS Statistics for Windows, version 21.0

Findings relevant to the review The study found no difference in depression, anxiety, and sleep quality scores between groups post-intervention. However, depression and anxiety scores significantly decreased, and sleep quality scores improved in the experimental group after the intervention. Creative arts intervention may be beneficial for anxiety, depression, and sleep problems among patients undergoing bone marrow transplantation (BMT).

Author and Year

Study Aims & Objectives

Research Design

Sample Size & Sample Type

Data collection methods

Data Analysis Method

Tecchio et al. (2012) Predictors of anxiety and depression in hematopoietic stem cell transplant patients during protective isolation

To examine in a sample of hematopoietic stem cell transplant patients assessed throughout protective isolation (i) levels of anxiety and depression and (ii) pre-isolation factors which might predict higher levels of anxiety and depression during isolation

The study used a longitudinal prospective design

Anxiety and depression were assessed in 107 participants by the State-Trait Anxiety Inventory and Self-rating Depression Scale at admission and weekly at fixed time points throughout isolation. Among pre-isolation factors, patients psychological status was evaluated by the Cognitive Behavioural Assessment

Predictors were explored by random effects mode

Patients were evaluated by using the Cognitive Behavioural Assessment (CBA)

Findings relevant to the review One-tenth of the patients suffered from clinically significant anxiety and depressive symptoms at admission. Although the percentage of depressed patients increased more than twofold after 2 weeks of isolation, that of anxious patients did not significantly change over time. Female gender, higher anxiety and obsessivecompulsive symptoms, introversive personality traits and lower performance status predicted higher depression during isolation

Author & Year	Research Question/ Purpose	Search Strategy/ Inclusion/ Exclusion Criteria	Search Terms	Detail of Literature /Study Selection	Quality Assessment (where applicable)	Data Synthesis (where applicable)
Vottero & Rittenmeyer, (2012)	The purpose of this review was to synthesise the best available qualitative evidence on the experience of hospitalised patients being placed in isolation	The participants were adult (> 18 years old) hospitalised patients in isolation. Both published and unpublished research studies from 1971 to May 2010. This review was limited to papers written in English	patient meaning, patient perception, experience, hospital isolation, reverse isolation, protective isolation, barrier isolation, qualitative, systematic review	Data was extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument	Each paper was assessed independently by two reviewers for methodological quality prior to inclusion in the review using the appropriate Joanna Briggs Institute critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information (SUMARI) package.	Categories were formed based on aggregation of similar findings with like meaning. The categories were analysed to identify synthesised findings that were presented as declamatory and generalisable statements to guide and inform practice
Findings/Conclusions relevant to the review A total of 12 studies were reviewed and, of those, 4 were excluded for methodological concerns and 8 were included in the review. The qualitative studies examined the hospitalised patients? experiences of being in isolation. A total of 56 findings were extracted from included studies. Findings were then synthesised in 11 categories. Two synthesised findings were developed from these categories: (1) The isolation experience causes fractured human connectivity and nurses must provide care that mitigates the negative effects of this; and (2) nurses must attend to the reality that a variety of factors affect the patients ability to adapt to an artificial environment