"Living Inside the Walls": Systematic Review and Qualitative Meta-Synthesis

Social isolation is a prevalent issue among older people in long-term care facilities (LTCFs), with profound negative impacts on their quality of life and mental health. However, the authentic experiences and underlying mechanisms of social isolation among older people in LTCFs remain understudied. A nuanced understanding of these experiences is essential for designing targeted nursing interventions.

This study aimed to systematically review and synthesize qualitative evidence to explore the experiences of social isolation among older adults in LTCFs and analyze them in terms of causes, mechanisms, outcomes, and strategies.

A systematic review and qualitative meta-synthesis were conducted. We searched PubMed, Web of Science, Embase, PsycInfo, Cochrane Library, CINAHL, Scopus, Chinese Biomedical Literature Database, CNKI, Wanfang Data, and Weipu (VIP) with no restriction on the start year, up to February 2025. Two reviewers (WL and ZM) independently screened studies, extracted data using a Microsoft Excel spreadsheet, and assessed study quality with the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Qualitative data synthesis was performed following Thomas and Harden's thematic and content analysis method, including line-by-line coding of participant quotes, organizing codes into descriptive themes, and developing analytical themes.

A total of 4856 papers were retrieved through systematic searches, and 14 qualitative studies met the inclusion criteria. Four overarching analytical themes were identified: (1) root cause: person-environment mismatch (encompassing 4 interrelated dimensions: imbalance between declining individual capacity and insufficient environmental support, negative self-perception paired with inadequate positive environmental feedback, personal biases conflicting with homogeneous institutional social ecology, and disrupted social roles due to rigid institutional management); (2) overt behavioral patterns: proactive isolation, defensive isolation, and adaptive isolation; (3) inner emotional experiences: feelings of confinement, sorrow, and weariness; and (4) strategies for restoring person-environment match: active engagement in interaction, rational acceptance of coexistence, and passive avoidance and withdrawal. Notably, person-environment mismatch was confirmed as the core mechanism driving the onset and persistence of social isolation in this population.

Person-environment mismatch is the fundamental driver of social isolation among older adults in LTCFs. Interventions should prioritize restoring person-environment alignment-including optimizing physical environments, reconstructing supportive social environments, and enhancing psychological empowerment. Future studies should focus on developing tools to quantify person-environment matching degrees in LTCFs and conduct longitudinal evaluations of targeted interventions to further reduce social isolation and promote active social participation among older people.