Hospital volunteering experiences suggest that new policies are needed to promote their integration in daily care: Findings from a qualitative study

A descriptive phenomenological study design was performed between January and July 2016 and is reported here in accordance with the Consolidated criteria for REporting Qualitative research (COREQ) guidelines (25).

A purposeful sample of volunteers of the Italian Hospital Volunteer Association (AVO) (26, 27) was selected based on the following inclusion criteria: volunteers (a) older than 18 years old; (b) volunteering in different hospitals, wards and long-term facilities; (c) with at least one year of experience in the volunteering association; (d) spending at least three hours per week doing volunteer work; (e) capable of communicating in the Italian language; and (f) willing to be interviewed. All volunteers consecutively approached agreed to participate.

In a first step, the interview guide (available from the Authors) was developed on the basis of previous studies in the field (10, 22, 23). This guide was piloted by conducting one interview, not included in this final report, aimed at evaluating its feasibility and understandability: no changes were required. The interview guide was then used as the basis of the face-to-face semi-structured interviews.

Interviews continued until saturation of data, as judged independently by two researchers, which occurred after 11 interviews. The same researcher (SG), a female nurse with previous volunteering experience in social and health care, and with advanced education in nursing, conducted all the interviews. She received training (28) in conducting interviews, which were audio-recorded after having collected the participants’ informed consent. All interviews took place in one of the researcher’s offices. Only the interviewer and participant were present at the time of interview; the interviewer and the participants met for the first time at the interview.

The same researcher (SG) first listened to the recorded interviews several times and then transcribed them verbatim after each meeting (27). Data were then analysed using a descriptive qualitative approach (29) by performing the following steps: 1) Familiarization: all transcripts were read carefully and repeatedly to obtain a general sense of the content 2) Compilation: members of the research team independently examined each transcript line-by-line, using an open coding approach whereby the most significant words and phrases (units of meaning) were highlighted and recorded in the margins of the transcript; 3) Condensing: the researchers reduced each significant element to a descriptive label (code): the whole context was considered when condensing and labelling meaningful units with codes; 4) Categorization: the researchers compared the labels and grouped them into categories according to their similarities (categories); and 5) Theming: homogeneous categories were gathered into themes (themes). The transcripts were anonymised and representative quotations from the transcribed text were referred to using the interview (I) number (e.g. I2).

According to the Italian law, where no Ethical Authorization is required for studies not concerning patient’s data, on a preliminarily fashion, the President and the members of the board of the AVO associated were contacted and the research protocol was presented. Then, they approved the study (communication available from the corresponding Author, December 18th 2015). All participants gave their informed oral consent to participate; confidentiality and anonymity were guaranteed throughout.

Overall, four males and seven females were approached, all between the ages of 23 and 72 years. Most of the interviewees were unmarried, and only two participants indicated that their parents had volunteered. Four participants were retired, while six were employed, and one was a student; the majority were educated to high school levels. Participants have reported an average of four years of experience (range 1.5-18 years) as HVs in different settings (e.g. medical, surgical units) according to their personal preferences and attitudes (Table 1).

Hospital volunteering emerged as a complex experience that was described by 70 codes gathered into 18 categories and, in turn, into five themes (Figure 1).

Figure 1

The participants reported becoming a HV for different reasons. ‘Helping others’ was the main reason for volunteering; however, for the interviewees to continue to feel motivated, it was also important for them to feel that they were benefiting from the experience. Gains from volunteering were expressed in terms of ‘gaining experience’, ‘making friends’ and ‘overcoming a difficult time’. Other participants mentioned psychological gains, such as ‘finding yourself’, ‘feeling useful’ and ‘feeling better about yourself’. Some interviewees have also reported that they volunteered to ‘kill time’ or because they were ‘looking for a purpose in life’:

‘Volunteering is a form of selfishness because when I stopped working, I felt lost. I had no more tangible goals and so I decided to help others’ (I 3).

The motivations of ‘being thankful for recovery’ and ‘giving something back or giving what you would have wanted to receive’ were linked to having experienced a disease:

‘When I was admitted to hospital, I was alone; I didn’t know anyone […]. I felt lonely […]. In brief, I like to do what I would have wished for myself at the time’ (I 4).

Some participants felt the responsibility to ‘provide or follow an example’, while two mentioned ‘curiosity’ about what a volunteer could do or simply ‘fate’ as a motivating factor.

Participants have reported many skills and personal attributes that they considered essential as HVs. ‘Entering on tiptoe’ was the attribute most frequently reported. Volunteers tried to ‘not disturb’, ‘not meddle’, ‘not interfere’, ‘keep your own place’, ‘not be a substitute’ and ‘withdraw when relatives are there/are present’. Volunteers should provide ‘something different’ compared to health staff and family relatives, by ‘offering what you have’ and by ‘providing moral support for the patient’.

Emotional detachment and maintaining an adequate barrier to avoid emotional involvement have been highlighted as important skills. Simultaneously, they have reported a need to leave their personal problems outside of volunteering:

‘Proper detachment does not mean being cold, but it means maintaining the right distance to avoid emotional involvement since some stories really make you think’. (I 5).

Several participants have reported that volunteers are asked to prioritize their tasks. Moreover, they often act in behalf of relatives when performing small services and take action only after authorization from medical staff if tasks go beyond what is regulated by the association. Therefore, there is the need to recognize when the task requires appropriate authorization:

‘In theory, we could not feed. However, we can help with this activity with staff indication if they determine there is no danger as it is a necessity’ (I 7).

They have reported that volunteers have the responsibility to update their skills to be ready to manage difficult situations and increase their performance. They have also emphasized the flexible nature of volunteering that requires self-reflection and self-directed learning: volunteering in different wards, prolonging their activities beyond scheduled time when their presence is required, and ‘adapting to do what is necessary’, have been reported as examples of flexibility.

Participants have often reported feeling conflicting emotions because of the varied situations they experienced. Most of these emotions were positive, such as serenity, satisfaction, fulfilment ‘for having relieved a burden’. Some reported feeling personal enrichment, which was mostly derived from sharing patients’ life experiences. Moreover, others have mentioned feeling empathy with the patient, particularly with those with prolonged in-hospital stays. All of these positive emotions promoted self-esteem. However, volunteers may feel useless when patients are cared for by their relatives or when poor interaction is possible due to increased workload.

Participants have also experienced some negative emotions, such as anxiety during interactions with disabled patients, anger when they have encountered people who were abandoned in long-term facilities and no longer visited by their families, and guilt when they adopted harsh attitudes towards unpleasant patients. Powerlessness was a frequent emotion linked to death, particularly when children were involved. Similarly, those who volunteered in long-term facilities have reported a feeling of loss and mourning when a patient passed away, because the long stay and the repeated encounters nurtured a deep relationship. This negative impact has often been experienced by participants when they did not develop an appropriate emotional detachment distancing themselves from the issues faced by patients and families: ‘I think [volunteering] is a very positive experience. Sometimes it becomes negative […]. We should wear blinders when we enter the hospital, we should not see or hear, limit the burden and then shake everything off… However, I can’t manage to shake off these thoughts when I come back home after seeing young people who suffer and their families suffering even more’ (I 6).

Negative emotions were also reported as a consequence of feeling that they do not belong to the care team, the fear of violating patients’ privacy or the concern about intruding on nursing activities. According to the majority of the volunteers, simple gestures such as a smile or greeting in the corridor would promote their integration into the care team:

‘I think that receiving some attention […], a half-smile, a more human approach would make you feel part of the group, although you are only a volunteer and, of course, you do not perform nursing, medical or activities of nurses’ aides’ (I 9).

Volunteers have perceived that the higher the hierarchy, the greater the distance – ‘doctors are doctors’ – whereas greater interaction was established with nurses’ aides, who ‘may consider [volunteers] useful for small tasks’. Not feeling part of the care team was often linked to ‘feeling underutilized’. Some volunteers would have performed more tasks, including going beyond what was expected from their volunteer role.

The most frequent resource used by volunteers to help deal with the difficulties encountered during their work, was the health-care professionals, particularly nurses; in addition, discussing issues with other volunteers improved their skills for managing difficult situations and strengthening friendships. Among internal resources, wisdom and experience were both considered helpful for dealing with complex situations:

‘When a person feels sick while I’m volunteering or when a patient is agitated and I’m not able to tranquilize him, I immediately think to ask for the help of the staff’ (I 11).

Participants have reported different strategies for overcoming challenging situations, such as receiving regular ‘training’, creating supportive relationships, especially within the association of volunteers, showing that members are available to help deal with current and future problems (‘When you call me, I’ll be there’) and in offering empathy (‘I act as if I were a patient and give what I’d like to receive’).

Different factors promoted regular volunteering. Two participants mentioned older age (for example, retired) and flexible working times (for example, freelance workers) as factors promoting continuous participation in the volunteering programme. The perception of being useful produced a positive impact, as well as the motivations to be a volunteer, which also affected continuity of service. A higher rate of abandonment was perceived among young people ‘because they find a job or continue to study’ and when initial expectations have been unfulfilled (e.g. people who started volunteering hoping to find a job). All participants reported that the perception of not being obliged to volunteer was a great motivator: indeed, participants revealed that they had abandoned a previous volunteer position when they realized that it was becoming something similar to having a job.

There is a need for more clarity regarding the boundaries between professional and volunteer roles. Several participants have asked for a well-defined list of activities they could perform while avoiding tension with the health-care professionals. Some interviewees reported a precise regulation of their role, while others complained of poor information regarding the activities that they could perform:

‘We are regulated by a statute, which gives us tips’ (I 2).

‘I’d like to talk with people telling you what they expect from you and what you should do. [...] I think [the volunteer] should be taught and explained exactly what is expected from them’ (I 10).

Participants have reported a perception of ‘disconnected association’ at two levels: they perceived detachment among the volunteers and cold interpersonal relationships; simultaneously, they also reported communication problems due to wrong or missed information that had increased the distance between the association and volunteers.

Helping feed patients has emerged as the main source of disconnection, although it is beyond the tasks expected of HVs. Some participants thought that feeding ‘is dangerous’, ‘entails responsibility’ and ‘is beyond the volunteer’s tasks’. However, other interviewees believed that feeding ‘is a useful activity’, ‘helps the patient’ and ‘often the health-care staff does not have the time’. Therefore, some interviewees were willing to perform this task, while others did not want to.

Similarly, participants reported conflicting opinions regarding the training programme. Some of them said that the training they received was better than the training offered by other associations in social and health care. Other interviewees considered the training programme to be insufficient and said they felt abandoned. Most of them perceived a need for training aimed at improving communication and listening skills, non-verbal communication and managing negative feelings. Others would appreciate more manual labs such as making bracelets, which could provide a pretext to approach shy patients. They have recognized the importance of having periodical refreshers on the most frequent health problems (e.g. diabetes) so that they are aware of seemingly trivial requests that may have serious consequences:

‘One morning, I found a volunteer with some money in his hand. “Where are you going?”, I asked. “I’m going to buy some chocolate for a gentleman.” I said: “Have you checked that he is not diabetic?” “Oh, no.” “Go back and ask if you can buy the chocolate.” Actually, he couldn’t eat chocolate. [...] Of course, my colleague was told to be careful during the training program […], but sometimes repetition is useful’ (I 8).

Participants have also reported the need for ‘adjustment to a changing society’ when they entered in long-term facilities and foster homes:

‘We started in hospitals, then we moved on to long-term facilities, and now we are increasing in foster homes [...] Society is changing and we have to adjust to people with different needs’ (I 1).

Although this study provided insights into the motivations, experience and challenges of hospital volunteering, the findings should be read in light of some shortcomings. The interviewees participated on a voluntary basis, thereby introducing the possibility that only the most dedicated volunteers were motivated to take part in the study. Indeed, six of the 11 interviewees volunteered more than three hours per week or were volunteer representatives. However, a maximum variation sampling was adopted to improve the credibility of findings; moreover, volunteers from different hospitals and long-term facilities were interviewed.