Correlation between social alienation and psychological resilience in patients with multidrug-resistant organism infections under protective isolation

Abstract

BACKGROUND

Although protective isolation measures are commonly used to control multidrug-resistant organisms (MDROs) transmission in healthcare settings, reducing social contacts often leads to social alienation for patients under isolation, which may lead to negative emotions and negatively affect recovery. Psychological resilience may protect against these effects; however, the relationship between psychological resilience and social alienation in isolated MDROs patients has not yet been studied. This study was aimed to assess social alienation of MDROs patients undergoing protective isolation and its correlation with psychological resilience.

AIM

To address the current situation of social alienation in patients with infected MDROs under protective isolation, and explore its relations to psychological resilience.

METHODS

This study retrospectively investigated the clinical data and psychological assessment of 289 patients with MDROs infections who were placed on protective isolation in our hospital between January, 2020 and March, 2025. Social alienation was measured with the General Alienation Scale, and psychological resilience was assessed by the Chinese version of Connor-Davidson Resilience Scale. The correlation between social alienation and psychological resilience was evaluated by Pearson correlation analysis, and multiple linear regression analysis was performed to determine the influencing factors of social alienation.

RESULTS

The patients’ total social alienation score (29.87 ± 6.52) was at a moderate level, and 76.47% of the patients reported moderate or higher levels of social alienation. The mean general psychological resilience score was (56.34 ± 15.28). Pearson correlation analysis showed that the total score of social alienation was negatively correlated with the total score of psychological resilience (r = -0.463, P < 0.001), tenacity dimension (r = -0.448), strength dimension (r = -0.421) and optimism dimension (r = -0.386) (all P < 0.001). Multiple linear regression analysis indicated that low frequency of family visits, high duration of isolation, low level of education, low level of tenacity and low level of optimism as independent factors associated with social alienation (all P < 0.001), which accounted 49.8% variance in total.

CONCLUSION

Patients with MDROs infection who underwent protective isolation experienced moderate degrees of social alienation that were negatively correlated with psychological resilience. Between clinical attention to the psychological state of patients with long isolation, fewer family visits and lower educational level and implement methods to improve psychological resilience and reduce social alienation.

Key Words: Multidrug-resistant organisms; Protective isolation; Social alienation; Psychological resilience; Correlation

Core Tip: Patients with multidrug-resistant organism infections often undergo protective isolation, which may adversely affect their psychosocial well-being. This study demonstrates that social alienation is prevalent among isolated patients and is moderately negatively correlated with psychological resilience. Lower family visit frequency, prolonged isolation, and lower educational level were associated with higher alienation, while greater tenacity and optimism were protective factors. These findings highlight the importance of integrating resilience-enhancing psychological interventions into the care of patients under protective isolation.

INTRODUCTION

Multidrug-resistant organisms (MDROs) infections are a global public health concern[1]. It has been reported that the detection of MDROs is increasing each year, likely related to the widespread use of antimicrobial agents in recent years. Transmission of MDROs, such as methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE), has become a major challenge to nosocomial infection prevention and control especially in healthcare facilities[2]. Protective isolation measures have thus been widely adopted in clinical practice to break the transmission chain of MDROs in hospital settings, commonly through single-room isolation, contact precautions and limiting access to personnel[3]. But, while containment of the infection spread, isolation measures not only had no insignificant negative effects on patients’ psychology[4].

Social alienation is described as a subjective psychological state in which individuals subjectively perceive some distance or disconnection between themselves and their social environment, manifesting feelings of social isolation, meaninglessness and self-alienation[5]. Non-patient studies have shown that patients who are hospitalized and receiving isolation treatment tend to develop increased levels of social alienation due to limitations on physical space, decreased social activities and disease prognosis[6]. Extended periods of alienation can result in negative psychological feelings, such as anxiety and depression[7], which raises concerns about adherence to treatment and development recovery. Psychological resilience is defined as an individual’s ability to show good adaptation in the face of adversity, trauma, or significant stress[8]. Higher levels of psychological resilience enables people to preserve a positive attitude during managing stress or coping with diseases and support mental health[9]. However, the majority of current domestic and international studies on psychological status in patients with MDROs infections mainly focus on evaluating negative emotions, including anxiety and depression[10], while investigation of social alienation in patients under protective isolation and its relationship to psychological resilience is still insufficient[11]. Based on this background, the purpose of this study was to explore the current status of social alienation in MDROs infections patients under protective isolation and its relationship with psychological resilience to provide reference evidence for clinical nursing interventions[12].

This study is built on these three established frameworks: (1) Seeman’s multiform conceptualization of alienation recognizes five key dimensions – powerlessness, meaninglessness, normlessness, social isolation and self-estrangement – all of which can be systematically evoked through the physical and relational restrictions imposed by protective isolation[5]; (2) According to Lazarus and Folkman’s transactional model of stress and coping individual cognitive appraisal processes mediate the association between objective stressors and subjective psychological outcomes; thus, a patient’s appraissal of isolation as threatening vs manageable may greatly explain the degree of alienation experienced[8]; and (3) Richardson’s resilience reintegration theory suggests that people with stronger psychological resilience are more able to reintegrate in an adaptive way following disruption using internal strengths and external resources to restore a sense of meaning and connection[9]. Thus, these frameworks help to create a cohesive conceptual model for why psychological resilience might protective against social alienation in the context of MDROs isolation and provide guidance for the clinical interventions outlined in this study.

MATERIALS AND METHODS

Study design

We conducted this study as a retrospective analysis using data that were routinely recorded in the hospital’s electronic medical record system and nursing psychological assessment record system to examine if social alienation correlated with psychological resilience in patients with MDROs infections under protective isolation. The Medical Ethics Committee of the hospital approved the study protocol. Since this was a retrospective analysis based on routine clinical assessment records and data were anonymized, the local ethics committee approved the waiver of informed consent.

Study subjects

We retrospectively collected clinical data and psychological assessment records of patients with infections caused by MDROs who had been hospitalized and received protective isolation in our hospital from January 2020 to March 2025. All patients who met the inclusion criteria during the study period were included using consecutive sampling.

Inclusion criteria: (1) Age ≥ 18 years; (2) Diagnosed MDROs infection according to the bacterial culture and antimicrobial susceptibility testing, including MRSA, CRE, vancomycin-resistant enterococci, multidrug-resistant Pseudomonas aeruginosa, and multidrug-resistant Acinetobacter baumannii; (3) Protective isolation measures performed per the hospital infection management regulations with an isolation time of ≥ 72 hours; (4) Clear conscious state as assessed by Glasgow Scale Coma score ≥ 15, normal cognitive functions based on Mini-Mental State Examination score ≥ 24 point, and able to cooperate in completing questionnaires; and (5) Finally for criterion No. five being complete medical records with psychological assessment data.

Inclusion criteria: (1) Patients who completed the questionnaire independently and signed informed consent; (2) Patients aged between 18 years and 75 years; and (3) Patients who had been admitted to the department for at least one week.

Exclusion criteria: (1) Patients with severe mental disorders confirmed by psychiatric consultation (including schizophrenia, acute episodes of bipolar disorder, major depressive disorder, etc.); (2) Critically ill patients with unstable vital signs; (3) Questionnaire data missing more than 20% or showing obvious patterns of responses (e.g., selecting the same option for subsequent ≥ 10 questions ); and (4) Patients transferred to intensive care unit due to disease deterioration during hospitalization. Ultimately, 289 patients were included.

Research instruments

General information questionnaire: The general information questionnaire was developed based on the relevant literature and reviewed by five experts in nursing science and infectious diseases. The contents included demographic data (age, sex, marital status, educational level, employment status) and disease-related data (MDROs type and infection site; isolation duration; length of hospital stay; number of underlying diseases; whether it was the first MDROs infection in this patient; frequency of family visits). Frequency of family visit was classified into: (1) No visits (0 times/week); (2) Occasional visits (1-2 times/week); (3) Frequent visits (3-4 times/week); and (4) Daily visits (≥ 5 times/week).

General Alienation Scale: General Alienation Scale is designed to assess the extent of alienation regarding their terrestrial social environment, as well as from components such as social isolation, meaninglessness, powerlessness and self-alienation. The scale consists of 12 items on a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree), in which the reverse-scored items are: (1) Item 2; (2) Item 4; (3) Item 7; and (4) Item 10. The total score can go from 12 to 48 and a higher score means more social alienation. Total scores were divided into as follows: (1) Low alienation (12-23); (2) Moderate alienation (24-35); and (3) High alienation (36-48).

Psychological Resilience Scale: Data were collected using the Chinese version of the Connor-Davidson Resilience Scale. This scale includes 25 items comprising three dimensions: (1) Tenacity (13 items); (2) Strength (8 items); and (3) Optimism (4 items). A 5-point Likert scale is employed (0 = never, 1 = rarely, 2 = sometimes, 3 = often, 4 = almost always), and the total scores may range from 0 to a maximum score of 100. Higher values indicate greater psychological resilience.

Statistical analysis

Using SPSS 26.0 statistical software to analyze data. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distribution continuous variables were presented as mean ± SD with intergroup comparison by independent samples t-test or one-way analysis of variance. Continuous variables that did not conform to a normal distribution were presented as median with interquartile range, and the comparison between groups was based on either Mann-Whitney U test or Kruskal-Wallis H test. Categorical variables were presented as n (%) and differences between groups were compared with the χ² test. We explored the correlation between social alienation and psychological resilience using Pearson correlation analysis or Spearman rank correlation analysis. Absolute values of correlation coefficient r were classified according to the following: (1) < 0.3 weak correlation; (2) 0.3 ≤ |r| < 0.5 moderate correlation; and (3) |r| ≥ 0.5 strong correlation. Multiple linear regression analysis was conducted in which total score of social alienation was taken as dependent variable, and the variables with P < 0.05 in univariate analysis and scores of each psychological resilience dimension were taken as independent variables to determine influencing factors for social alienation. F-test was used to test the overall regression equation, while t-test was used to test the significance of individual coefficients for independent variables. Data were considered statistically significant when P < 0.05 (two-tailed). In terms of missing data management: As described in the analytical plan, participants with more than 20% of questionnaire items missing were excluded from analyses which resulted in a final sample of 289 individuals. Within included cases, item level missingness was minimal (less than 3 individual items per scale); therefore, these data were managed using mean substitution within dimension, consistent with the scoring procedures recommended for each of the General Alienation Scale and Connor-Davidson Resilience Scale instruments. As a limitation of the current dataset, this was not formally assessed; because of the study’s retrospective design, formal imputation methods were not applied and it could not be determined whether data were missing completely at random, missing at random, or missing no at random.

RESULTS

Characteristics of study subjects

All patients who received MDROs infections during protective isolation from the ward were included (full-final analysis, aged 18-89 years old with mean age of 58.43 ± 14.76 years). Of them, 167 (57.79%) were male and 122 (42.21%) were female. The most prevalent type of MDROs found in this study was MRSA, which was present in 98 (33.91%) cases, followed by CRE with 72 (24.91%) cases, multidrug-resistant Acinetobacter baumannii with 56 (19.38%) cases, Multidrug-Resistant Pseudomonas aeruginosa with 41 (14.19%) cases and vancomycin-resistant enterococci with 22 (7.61%) cases as shown in Table 1. Most of the infections were localized to the respiratory tract (112 cases, 38.75%) length of isolation varied from 3 days to 42 days with 12.58 ± 6.34 days mean period of isolation. Hospitalization period ranged from 7 days to 68 days (mean: 21.73 ± 10.52). The other general characteristics are shown in Table 2.

Table 1 Comparison of social alienation scores among patients with different characteristics, mean ± SD.

Variable	Category	n	Social alienation score	t/F value	P value
Sex	Male	167	29.56 ± 6.38	1.024	0.307
	Female	122	30.29 ± 6.71
Age (years)	18-44	52	27.35 ± 5.89	5.672	0.001
	45-59	78	29.18 ± 6.24
	60-74	104	30.76 ± 6.58
	≥ 75	55	31.84 ± 6.73
Marital status	Unmarried	31	31.42 ± 6.87	4.358	0.014
	Married	198	29.23 ± 6.31
	Divorced/widowed	60	31.48 ± 6.82
Educational level	Primary school or below	67	32.16 ± 6.74	7.893	< 0.001
	Junior high school	82	30.45 ± 6.28
	High school/technical secondary school	74	29.12 ± 6.19
	College or above	66	27.24 ± 5.96
Employment status	Employed	89	29.13 ± 6.27	1.842	0.161
	Retired	132	30.38 ± 6.64
	Unemployed/other	68	29.82 ± 6.53
MDROs type	Methicillin-resistant Staphylococcus aureus	98	29.54 ± 6.42	0.756	0.555
	Carbapenem-resistant Enterobacteriaceae	72	30.18 ± 6.67
	Multidrug-resistant Acinetobacter baumannii	56	30.32 ± 6.58
	Multidrug-resistant Pseudomonas aeruginosa	41	29.46 ± 6.34
	Vancomycin-resistant enterococci	22	30.64 ± 6.89
Infection site	Respiratory tract	112	30.12 ± 6.54	0.423	0.792
	Urinary tract	68	29.68 ± 6.37
	Bloodstream	43	30.26 ± 6.78
	Skin and soft tissue	38	29.34 ± 6.42
	Other	28	29.82 ± 6.56
Isolation duration (days)	3-7	82	27.64 ± 5.86	12.348	< 0.001
	8-14	118	29.72 ± 6.24
	≥ 15	89	32.36 ± 6.78
Length of hospital stay (days)	7-14	76	27.82 ± 5.92	8.965	< 0.001
	15-28	131	29.64 ± 6.28
	≥ 29	82	32.18 ± 6.86
Number of underlying diseases	0-1	54	27.52 ± 5.94	6.873	0.001
	2-3	137	29.68 ± 6.32
	≥ 4	98	31.54 ± 6.82
First MDROs infection	Yes	196	29.24 ± 6.28	-2.316	0.021
	No	93	31.19 ± 6.84
Frequency of family visits	No visits	34	34.56 ± 6.92	14.726	< 0.001
	Occasional visits	87	31.42 ± 6.47
	Frequent visits	102	28.76 ± 5.98
	Daily visits	66	26.58 ± 5.64

MDROs: Multidrug-resistant organisms.

Table 2 General characteristics of study subjects (n = 289).

Variable	Category	n	Percentage
Sex	Male	167	57.79
	Female	122	42.21
Age (years)	18-44	52	17.99
	45-59	78	26.99
	60-74	104	35.99
	≥ 75	55	19.03
Marital status	Unmarried	31	10.73
	Married	198	68.51
	Divorced/widowed	60	20.76
Educational level	Primary school or below	67	23.18
	Junior high school	82	28.37
	High school/technical secondary school	74	25.61
	College or above	66	22.84
Employment status	Employed	89	30.8
	Retired	132	45.67
	Unemployed/other	68	23.53
MDROs type	Methicillin-resistant Staphylococcus aureus	98	33.91
	Carbapenem-resistant Enterobacteriaceae	72	24.91
	Multidrug-resistant Acinetobacter baumannii	56	19.38
	Multidrug-resistant Pseudomonas aeruginosa	41	14.19
	Vancomycin-resistant enterococci	22	7.61
Infection site	Respiratory tract	112	38.75
	Urinary tract	68	23.53
	Bloodstream	43	14.88
	Skin and soft tissue	38	13.15
	Other	28	9.69
Isolation duration (days)	3-7	82	28.37
	8-14	118	40.83
	≥ 15	89	30.8
Length of hospital stay (days)	7-14	76	26.3
	15-28	131	45.33
	≥ 29	82	28.37
Number of underlying diseases	0-1	54	18.69
	2-3	137	47.4
	≥ 4	98	33.91
First MDROs infection	Yes	196	67.82
	No	93	32.18
Frequency of family visits	No visits	34	11.76
	Occasional visits (1-2 times/week)	87	30.1
	Frequent visits (3-4 times/week)	102	35.29
	Daily visits (≥ 5 times/week)	66	22.84

MDROs: Multidrug-resistant organisms.

Social alienation and psychological resilience

The social alienation total score of the 289 patients with MDROs infections under protective isolation was 29.87 ± 6.52, and item mean score was 2.49 ± 0.54. Total 68 Urban patients (23.53%) had low alienation, 178 patients (61.59%) had moderate alienation and 43 patients (14.88%) had high alienation. The mean score of the psychological resilience scale was 56.34 ± 15.28. Results for each dimension are displayed in Table 3.

Table 3 Social alienation and psychological resilience scores (n = 289), mean ± SD.

Scale/dimension	Number of items	Score range	Actual score	Item mean score
Total social alienation score	12	12-48	29.87 ± 6.52	2.49 ± 0.54
Total psychological resilience score	25	0-100	56.34 ± 15.28	2.25 ± 0.61
Tenacity	13	0-52	28.96 ± 8.43	2.23 ± 0.65
Strength	8	0-32	18.52 ± 5.17	2.32 ± 0.65
Optimism	4	0-16	8.86 ± 2.94	2.22 ± 0.74

Comparison of social alienation scores in patients with different characteristics

The results of univariate analysis indicated a statistically significant differences in social alienation scores among patients from different groups, including age, marital status, educational level, isolation duration, hospitalization duration, number of underlying diseases, first MDROs infection or not and frequency of family visits (P < 0.05). Patients with different sex, employment status, MDROs type and infection site had similar social alienation scores (P > 0.05). Details are shown in Table 1.

Correlation analysis between social alienation and psychological resilience

Pearson correlation analysis results showed that the total social alienation score of patients with MDROs infections under protective isolation was negatively correlated with the total psychological resilience score and scores of all dimensions (P < 0.001). The total social alienation score showed moderate negative correlation with total psychological resilience score (r = -0.463), moderate negative correlation with tenacity dimension (r = -0.448), moderate negative correlation with strength dimension (r = -0.421), and moderate negative correlation with optimism dimension (r = -0.386) (Table 4, Figure 1).

Figure 1 Correlation between social alienation and psychological resilience in protective isolation multidrug-resistant organisms patients (n = 289). A: Total psychological resilience score (r = -0.463); B: Tenacity dimension (r = -0.448); C: Strength dimension (r = -0.421); D: Optimism dimension (r = -0.386).

Table 4 Correlation analysis between social alienation and psychological resilience (r values).

Variable	Total social alienation score	Total psychological resilience score	Tenacity	Strength	Optimism
Total social alienation score	1	-	-	-	-
Total psychological resilience score	-0.463c	1	-	-	-
Tenacity	-0.448c	0.956c	1	-	-
Strength	-0.421c	0.924c	0.847c	1	-
Optimism	-0.386c	0.876c	0.798c	0.782c	1

^cP < 0.001.

Multiple linear regression analysis of factors influencing social alienation

With total social alienation score as the dependent variable, variables with statistical significance in univariate analysis (age, marital status, educational level, isolation duration, length of hospital stay, number of underlying diseases, whether first MDROs infection, and frequency of family visits) and scores of each psychological resilience dimension were entered as independent variables in multiple linear regression analysis. The assignment method for independent variables is shown in Table 5.

Table 5 Assignment method for independent variables.

Independent variable	Assignment method
Age	18-44 years = 1, 45-59 years = 2, 60-74 years = 3, ≥ 75 years = 4
Marital status	Married = 1, unmarried = 2, divorced/widowed = 3
Educational level	College or above = 1, high school/technical secondary school = 2, junior high school = 3, primary school or below = 4
Isolation duration	3-7 days = 1, 8-14 days = 2, ≥ 15 days = 3
Length of hospital stay	7-14 days = 1, 15-28 days = 2, ≥ 29 days = 3
Number of underlying diseases	0-1 = 1, 2-3 = 2, ≥ 4 = 3
First multidrug-resistant organisms infection	Yes = 0, no = 1
Frequency of family visits	Daily visits = 1, frequent visits = 2, occasional visits = 3, no visits = 4
Tenacity	Original value entered
Strength	Original value entered
Optimism	Original value entered

Multiple linear regression analysis results showed that frequency of family visits, isolation duration, tenacity, educational level, and optimism were independent factors influencing social alienation in patients with MDROs infections under protective isolation (P < 0.05), explaining 49.8% of the total variance in social alienation (Table 6, Figure 2).

Figure 2 Multiple linear regression analysis identifying independent factors associated with social alienation in multidrug-resistant organisms patients under protective isolation (n = 289). Family visit frequency (β = 0.274), isolation duration (β = 0.211), and education level (β = 0.186) were significant risk factors, while tenacity (β = -0.248) and optimism (β = -0.141) served as protective factors. The model demonstrated good explanatory power (R² = 0.498, adjusted R² = 0.489, F = 56.124, P < 0.001).

Table 6 Multiple linear regression analysis of factors influencing social alienation.

Variable	B	SE	β	t value	P value	95%CI
Constant	36.842	2.054	-	17.936	< 0.001	32.798-40.886
Frequency of family visits	1.924	0.302	0.274	6.371	< 0.001	1.330-2.518
Isolation duration	1.586	0.308	0.211	5.149	< 0.001	0.980-2.192
Tenacity	-0.192	0.038	-0.248	-5.053	< 0.001	-0.267 to -0.117
Educational level	0.968	0.218	0.186	4.44	< 0.001	0.539-1.397
Optimism	-0.312	0.084	-0.141	-3.714	< 0.001	-0.477 to -0.147

R² = 0.498, adjusted R² = 0.489, F = 56.124, P < 0.001.

DISCUSSION

The total score of social alienation of patients with MDROs infections in protective isolation was 29.87 ± 6.52. Moderate level, and 76.47% of patients were moderate or more alienation. The sanity showed that this population social alienation is serious generally. These findings are comparable with domestic survey results on isolated infectious disease patients[13] but indicate higher alienation than those noted in general hospitalized patients[14]. The reasons are probably the patients with MDROs infections not only suffer from the physical and psychological stress brought about by the infectious disease itself but also experience limited social contact due to isolation environment. Healthcare workers with personal protective equipment when entering the patient rooms might also unconsciously augment patients’ feelings of being “isolated”[15]. Moreover, some patients may have cognitive biases regarding MDROs infection, fearing to be judged as the “source of infection”, which creates illness-related stigma and worsens their experience of social alienation[16].

The finding of 76.47% moderate-to-high social alienation among the patients has significant clinical and ethical implications that need to be discussed explicitly. From a clinical standpoint, this prevalence rate indicates that social alienation is not an occasional or minority experience but rather a nearly universal psychological cost of the burden in this group, one that requires systematic – as opposed to discretionary – psychosocial support. Routine alienation screening and proactive psychological support should be integrated as non-negotiable aspects of care within standard MDROs isolation protocols. From an ethical perspective, the data illuminate a tension inherent to protective isolation: A protocol aimed at protecting both the individual patient and larger ward community from infectious transmission simultaneously places measurable and systematic psychological burdens on the very patients whom that protocol aims to protect. Healthcare institutions have an obligation to do no harm according to the bioethical principle of non-maleficence, and therefore a duty of care exists to monitor and combat this unintended harm. Practically, this requires infection control committees to formally evaluate the psychological effects of isolation protocols as part of routine policy reviews; ward-level psychosocial support resources to be provided routinely rather than on an exceptional basis; and isolation environments to be evaluated against established benchmarks for humane clinical conditions – including access to communication technology, natural light, and meaningful structured activity during the period of confinement.

This study showed that patients’ social alienation was strongly correlated with the frequency of visits by family members. The social alienation score of patients without visits were significantly higher than daily visiting ones, which is consistent with the theory of social support[17]. Besides offering emotional comfort, family visits also serve a major function in preserving patients’ connectivity as they venture further into the external world, knowing that they were still being cared for and belonged[18]. Nevertheless, protective isolation measures objectively hinder visits, and some family members decrease frequency of visits out of the worry to become infected[19]. Hence, we recommend a flexible policy to visitation XXXractices in healthcare institutions while infection prevention and control measures are applied at all times strictly; for instance moderate increased visit frequency is acceptable with trained family members them about the rules of protective suggestions conducted uniformly and using video calls as an alternative for face-to-face conversation[20].

There was a significantly positive relationship between the duration of infection isolation and social alienation i.e., longer duration of infection isolation for patients was associated with stronger social alienation feeling. This outcome matches conclusions of earlier research[21]. Long-term restrictions of social roles in a closed environment lead to interference with daily life cycles, and making them more vulnerable to meaninglessness and powerlessness feelings[22]. The social alienation scores were significantly higher in patients whose isolation time was more than or equal to 15 days, which indicated that clinicians should pay attention on the psychological changes of patients who had a long duration of isolation (Table 1). They recommend that health care providers intensify psychological screening among those isolated beyond 2 weeks, identify and treat high-risk patients[23].

Lower educational patients were more socially alienated. This may be associated with their health literacy levels[23], as patients with lower educational levels have a relatively lack of knowledge on MDROs infection and isolation measures, making them more likely to fall into fear and confusion[24]. At the same time, this population has relatively constrained options to access information and emotional support, along with lower cognitive resources to cope with stress[25]. Thus, nursing personnel should emphasize the use of “easy to understand” language in health education and use illustrated materials to help patients further comprehend the necessity and temporary nature of isolation, which can reduce their psychological burden[26].

The main finding of the current study was a significant moderate negative correlation between social alienation with psychological resilience. Both the total score of psychological resilience and all three dimensions, i.e., tenacity, strength, and optimism were negatively correlated with social alienation; specifically, tenacity and optimism emerged as independent protective factors against social alienation in the regression equation. Tenacity indicates a person’s persistence and adaptability when confronting challenges[27]; therefore, patients with high tenacity are more likely to interpret isolation as a temporary phase in the course of treatment rather than a permanent divorce from society. Optimism indicates a person’s hopeful anticipation for the future[28]; optimistic patients are more prone to believe that isolation is temporary and reversible events, at the end of which they’ll be able to resume normal life. There are several complementary theoretical mechanisms that can explain these effects. Rooted in Lazarus and Folkman’s transactional model of stress-coping, psychologically resilient individuals demonstrate adaptive primary and secondary appraisal: Instead of defining isolation as an irreversible fracture in their social fabric, they instead appraise it as a challenge that is time-limited and manageable, promoting the identification of potential coping resources accordingly. From a self-efficacy perspective rooted in Bandura’s social learning theory, tenacity operationalizes as an expectation of one’s ability to persist and overcome adversity – an expectation that serves to mitigate the learned helplessness Implicated in feelings of social alienation. Fredrickson’s broaden-and-build theory of positive emotions illuminates the role played by optimism: As broadened cognitive and behavioral repertoires are opened up by positive emotional states, even isolated patients can sustain social connectedness via channels that have become available (e.g., video communication, written correspondence) and identification of meaning within experience as a means to counter the narrowing effects of alienation. Taken together, these mechanisms indicate that resilience does not simply lessen the emotional effects of isolation but reshapes patients’ cognitive and relational responses to it. These findings indicate that increasing patients’ levels of psychological resilience can be a helpful strategy to reduce social alienation. Previous international studies have suggested that psychological resilience in hospitalized patients can be effectively improved through cognitive-behavioral interventions and mindfulness training[29]. Domestic scholars have applied the positive psychology concept to improve nursing practice of isolated patients with certain effectiveness[30]. Although the promotion of psychological resilience variables should be included in clinical nursing as an example guiding patients to identify their advantages, creating short-term achievable goals and developing a positive pattern of self-talk[31].

The regression model presented In”this’analysis explains 49.8% of the total variance in social alienation, which suggests that close to 50% of the variance arises from other unaccounted for factors. Previous literature implicates nurse-patient relationship quality, comfort of ward environment and back to the fellow patients in room interaction[32] that may also modulate psychological experience in grouped patients even isolation[4]. Moreover, this study was a single-center retrospective study so that the sample representativeness would be limited[33]. The current study has several other limitations that deserve explicit acknowledgment. First, the retrospective design and exclusion of patients who could not complete psychological assessments because of serious illness, unstable vital signs, or cognitive impairment may have created a systematic selection bias in favor of those with better clinical and cognitive status. These excluded people are probably a particularly vulnerable subgroup – those with higher disease burden and, for that reason, likely greater levels of social alienation – whose psychological patterns cannot be gleaned from the current analysis. As a result, the results of this study may not accurately represent both the prevalence and severity of social alienation in the wider MDROs isolation population. Second, there is a limitation of controlling for all potential confounders, since they rely on routine clinical records and are therefore limited to factors that can be measured; unmeasured variables (e.g., ward environment quality, frequency of communication with nursing staff and the individual significance the patients attribute to their disease) cannot be accounted for in analyses. Third, owing to the cross-section design in psychological assessment, conclusions cannot be drawn about the temporal dynamics at work behind social alienation throughout the isolation trajectory or its trajectory beyond discharge.

Several directions for future research are indicated by the findings and limitations of the current study. First, multicenter prospective cohort studies with larger, more representative samples including patients who are currently excluded due to cognitive impairment or critical illness are needed to establish the generalizability of the observed associations and to capture the full spectrum of psychological burden in this population. Second, randomized controlled trials evaluating specific resilience-enhancing intervention programs such as acceptance and commitment therapy, positive psychology-based nursing protocols, or digitally delivered mindfulness training – in MDROs isolation patients are needed to move from correlation to causation and to provide the evidence base required for guideline development.

CONCLUSION

In summary, social alienation in patients with MDROs infections under protective isolation is at a moderate level. Low frequency of family visits, prolonged isolation duration, and low educational level are risk factors for social alienation, while higher levels of tenacity and optimism are protective factors. Clinical nursing should focus on the psychological status of patients with prolonged isolation, lack of family support, and low educational levels, while emphasizing the cultivation of psychological resilience to alleviate patients’ social alienation experience and promote physical and psychological recovery.