Art & science | service evaluation
Introducing on-ward volunteers to work with patients with dementia Ann McDonnell and colleagues evaluate the effect that non-staff support had on an orthopaedic ward Correspondence [email protected] Ann McDonnell is professor of health services research, Sheffield Hallam University Jane McKeown is senior nurse, Sheffield Health and Social Care NHS Foundation Trust Carol Keen is lead therapist, Sheffield Teaching Hospitals NHS Foundation Trust Judith Palfreyman is senior staff nurse, Sheffield Teaching Hospitals NHS Foundation Trust Nicola Bennett is research sister, National Institute for Health Research, Sheffield clinical research facility, Royal Hallamshire Hospital, Sheffield Date of submission February 24 2014 Date of acceptance March 24 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Abstract This article reports on an evaluation of the effect of an on-ward volunteer service in an acute orthopaedic ward with a number of dementia patients. A mixed-methods evaluation was undertaken in 2012. This included interviews with individuals who have strategic, management, operational and clinical roles in the voluntary organisation and the NHS trust, focus group discussions with volunteers, non-participant observations of practice and focused conversations with ward staff. The service had a positive effect on patient experience. Patients were engaged through a variety of activities and enjoyed the volunteers’ presence. Staff valued the initiative because they could see the difference that it made to patients and their own working lives. The lessons learned from the evaluation can inform the development of similar initiatives elsewhere and are relevant, given the emphasis in healthcare policy to improve patient experience. Keywords Acute care, dementia, orthopaedics, patient experience, service evaluation, volunteers AROUND 820,000 people in the UK have dementia (Alzheimer’s Research UK 2014) and this increasingly common disorder also affects inpatient care provision. Older people occupy most acute hospital beds (Department of Health (DH) 2001), and the Royal College of Psychiatrists (2005) estimates that in a typical general hospital patients with dementia occupy more than one fifth of the beds. However, it is recognised that hospitals are particularly challenging environments for these patients, and they have worse outcomes in terms of length of stay, mortality and institutionalisation (DH 2009).
28 May 2014 | Volume 26 | Number 4
The Royal Voluntary Service (RVS) on-ward volunteer service was launched at Sheffield Teaching Hospitals NHS Foundation Trust in November 2011. The purpose of the initiative was to improve the experience of patients with dementia by using on-ward volunteers recruited and trained by RVS, one of the largest volunteer organisations in the UK, supported by a dementia nurse specialist (DNS) employed by the trust.
The project It was envisaged that the volunteers would provide befriending, diversional therapy, companionship and help with eating and drinking, as well as supporting family carers and providing respite time. The volunteer service aimed to complement the care provided by trust staff. Recruitment of volunteers was the responsibility of the RVS, who also provided and funded a training programme and managed the volunteers. The trust appointed a DNS whose role was to direct the volunteers to work with patients and families in the most appropriate way. The volunteer initiative was established as a 12-month pilot project based on an orthopaedic ward that had a high proportion of patients with dementia who were recovering from surgery. Over the 12-month evaluation period, a total of 28 volunteers worked on the ward. The mean number of volunteers on the ward each month was 12, ranging from nine to 19, and the mean number of volunteer hours per month was 64.5 hours, but spanned anywhere from 27 to 105 hours. The DNS guided volunteers on which patients to work with, acted as a role model in the care of patients with dementia, and was a source of knowledge and expertise on a daily basis. A project was developed to capture the learning from this initiative from a number of different NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
perspectives. The evaluation took place between January and December 2012.
Aim The aim of this project was to evaluate the effect of the volunteer initiative. More specifically, the objectives were to: ■■ Describe the care provided by the volunteers. ■■ Explore the perceptions of those with strategic, management, operational and clinical roles in the voluntary organisation and the NHS trust on the potential of the initiative. ■■ Examine the perceptions of ward staff on the effect of the initiative. ■■ Establish the perceptions of volunteers in relation to their experiences in practice. ■■ Identify factors influencing implementation.
Methods This was a mixed-methods service evaluation, which used a range of different approaches to data collection, including individual interviews with strategic stakeholders, focus groups with volunteers, non-participant observations of practice and focused conversations with ward staff. The stages of data collection are summarised in Figure 1. Interviews with stakeholders A purposive sample of seven stakeholders was selected, including individuals in strategic, management, operational and clinical roles in the RVS and hospital trust. Individual interviews were carried out with all participants at the start of the evaluation period. Additional follow-up interviews with two individuals were also undertaken towards the end of the evaluation. The interviews explored perceptions of the potential and actual effect of the initiative as well as factors affecting the success of the initiative in practice. All interviews were audio recorded and transcribed in full. Focus groups with volunteers To explore the perceptions of volunteers over time, three focus groups were conducted during the evaluation period. A convenience sample of volunteers took part in the focus groups (n=four, five and four respectively). Some volunteers attended more than one focus group. In total, ten volunteers took part. All discussions were audio recorded and transcribed in full. Observations of practice The aim of the observations was to gain insight into the work undertaken by the volunteers and a deeper understanding of the context in which volunteers NURSING OLDER PEOPLE
were working. The observations enabled the evaluation team to initiate ad hoc conversations with volunteers, patients and ward staff to understand their experience. Observations were conducted across three time periods between July and December 2012. Six visits took place in total. Eighteen volunteer visits involving 11 different volunteers were observed. Where possible, brief notes were made on the ward and these were written up as field notes soon after the observations. Focused conversations with ward staff A purposive sample of six staff was selected to include a range of staff grades and roles. These conversations explored staff’s perceptions of the effect of the volunteer initiative in practice. Data were recorded through note taking and a structured data collection form was completed as soon as possible after the conversations.
Data analysis The analysis approach drew on the principles of framework analysis (Ritchie and Spencer 1994, Ritchie and Lewis 2003). Framework analysis is a pragmatic approach to qualitative data analysis, which involves a systematic process of sifting, charting and sorting material into key issues and Figure 1
Series of stages involved in data collection Stakeholder interviews (n=7)
Volunteer focus group 1
Volunteer focus group 2
Observations of practice Conversations with ward staff (n=6)
Volunteer focus group 3
Observations of practice
Observations of practice
Follow-up interviews with stakeholders (n=2)
May 2014 | Volume 26 | Number 4 29
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | service evaluation ‘She was there holding hands while the patient was dying and with tears in her eyes and I’ve got nice memories of that’ themes. Using these methods, cross-cutting themes were identified that were shared across the different data collection methods. Ethical considerations NHS research ethics approval was not required as this was a service evaluation and not a research study. However, ethical principles were observed and the evaluation was conducted according to the principles outlined in the Simple Rules Toolkit (Somers et al 2006). This included maintaining confidentiality, voluntary participation, the right of individuals to withdraw and obtaining informed consent from staff and volunteers to take part in interviews and focus groups.
Findings Data analysis revealed themes on the activities undertaken by volunteers with patients, the effect of the initiative on patients and ward staff, and factors influencing the success of the initiative. Volunteer activities The main volunteer activity with patients was conversation. This could be a simple conversation between two people, or it could be guided with the use of memory aids, such as books. Sitting and talking with patients was seen as important and volunteers highlighted how well they got to know individual patients and were able to find out about them through these conversations. Volunteers also described putting music on and dancing with patients, doing artwork and playing games such as cards, dominoes and bingo. One of the perceived benefits was that care was individualised; rather than the same activity being provided for everyone, the volunteers based their interventions on what the patient wanted on that particular day: ‘That’s right, I mean every day you come on it’s different. You never get two days the same, do you? Every shift you do is totally different. Some days you might get four people up and have a game of bingo, and sometimes you might just wander round chatting, or sometimes you might spend longer with one patient than others because they need your time. It all depends on the patients’ (volunteer). Effect on patients Stakeholders saw the potential for patients’ experience to be improved by having 30 May 2014 | Volume 26 | Number 4
someone available who could spend time sitting, talking and supporting those who were distressed. Engaging patients The effect on patients was viewed as greater than anticipated. Patients were seen as less withdrawn or depressed: they appeared genuinely pleased to see the volunteers. Patients loved to talk about themselves and tell stories, and the volunteers loved to listen: ‘Two volunteers spent time in one bay, engaging three of the patients in conversation around the subject of a chair that one of the patients was using. There was a lot of laughter and all the patients were involved in the conversation’ (observation field notes). There were times where patient wellbeing appeared to be enhanced through the volunteers talking, laughing and listening to them: ‘A young volunteer spent time with a patient with advanced dementia. The patient was seen to be responding in an animated way and the patient’s relatives commented later what good spirits the patient was in’ (observation field notes). Patients were seen to gain social activity that they would not receive without the volunteers. This socialisation was multifaceted, between patients and individual volunteers, patients and staff and also between individual patients in the ward. Although patients with dementia could struggle to remember the details of the activities with the volunteer, such as the identity of the person who spoke with them, some could remember that there was a social interaction with another person. After a volunteer visit, one staff member reported a patient saying: ‘I don’t know who they were, but they were lovely.’ Relieving distress The volunteers helped patients who were agitated or restless by occupying them. They relieved distress, for example, comforting patients in a bay where a patient had had a stroke, or comforting those at the end of life: ‘She sat with the patient, was holding their hands and there were no relatives around, like they were abroad and they just couldn’t be there on time, and she was there holding hands while the patient was dying and with tears in her eyes and I’ve got nice memories of that’ (medical consultant). Nutrition Volunteers were not allowed to assist patients with eating or drinking. For some this was a missed opportunity, however it was hoped that by encouraging patients to eat and drink, volunteers might contribute to better nutrition and hydration. In practice, the value of volunteers at mealtimes was mixed: there were examples where volunteers helped prompt patients NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
to eat, but on other occasions volunteers continued talking to patients when their meals arrived, which seemed to prevent patients from eating. Effect on ward staff Staff with insights into care at ward level had a positive view of the effect that volunteers were having on delivery of care by freeing up nurses’ time to do the duties that only nurses could do, such as administering medications. Benefits to staff Throughout the interviews it became evident that the service was highly valued by the ward staff. Volunteers were ‘amazing’, keen and eager to help in whatever way they could. ‘I can’t imagine working without them’ (ward staff member). By sitting and talking with patients, particularly those who were agitated, they were able to free up nursing time on a busy ward: ‘Well, it gives them time to look after patients better. You know, they can spend more time with any patient that’s ill. I know they’re all ill, but someone that is worse. And they don’t need to look after half a dozen; we can talk to a few and keep them busy while the nurse is actually doing her proper job’ (volunteer). The presence of the volunteers on the ward was reassuring for staff. The volunteers were seen as an additional ‘pair of eyes’ in the ward area, which helped staff focus on other duties. Communication with ward staff Communication between ward staff and volunteers improved as the service became established and volunteers and staff had a clearer understanding of their roles and capabilities. When the volunteers arrived, staff directed them to patients who might benefit from their time. In return, the volunteers might suggest patients that they were familiar with from previous visits and would see everyone that they were asked to. In screening patients, ward staff were mindful of patient needs, but also of volunteer safety, especially when asking them to see agitated patients: ‘One volunteer sat with a patient in a side ward, but at a distance, as [name of patient] can be quite feisty’ (ward staff member). Integration The staff saw that the initiative was having a positive effect. It was clear that the role of the volunteer was different to that of the staff – there was no overlap in roles, and therefore no negative effect on staff activities and duties. There was no sense of the volunteers disrupting NURSING OLDER PEOPLE
ward activities or impeding nursing care: they were seen to fit in with ward routines: ‘What they do is very subtle, they blend in’ (ward staff member). Staff saw the volunteers become more confident as time passed and they became increasingly familiar with the ward and its routines: this enhanced their integration. Factors influencing success Implementation of the initiative was challenging. Using volunteers in this way was new for everyone and initially volunteers were not always recognised or welcomed by ward staff. However, the longitudinal nature of the evaluation meant that a picture of the initiative emerged as it developed. Potential problems highlighted in early observations had resolved later in the evaluation period. For example, initially staff were not clear when volunteers might be expected on the ward and were not prepared for them. A system was established to address this using a volunteer rota and sign-in sheets. Volunteers’ confidence also increased over the time span of the evaluation and they felt well supported by each other, the DNS and RVS manager. Role of the DNS The nurse specialist was seen as crucial to the success of the initiative. It was clear that she supported the volunteers, was a valuable source of knowledge and expertise, and the volunteers felt comfortable to approach her and ask for help and guidance. A different service The voluntary nature of the service seemed to help the initiative: employing additional staff members to provide the service offered by the volunteers may not have achieved the same success. This was demonstrated in the comments made by staff, which showed how they appreciated volunteers giving up their time to help. The staff described how they liked to chat to patients, but did not always have enough time. Staff conversations with patients had an alternative agenda or purpose – perhaps to assess needs, or identify information that could be helpful in patients’ ongoing care. The staff compared this to the volunteers, who had lengthy periods of time set aside solely for
Staff saw the volunteers become more confident as time passed and they became increasingly familiar with the ward May 2014 | Volume 26 | Number 4 31
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | service evaluation Volunteers seemed to offer an additional and different role to that of nursing staff and little overlap or conflict was found patient interaction, and could be more social, friendly and relaxed in their conversation: ‘It’s a different level of chat’ (ward staff member). The staff recognised this difference and its value in delivering the service. Support at senior and strategic level in the trust was seen as important in sustaining the intervention, as was good leadership and strong commitment at ward level: ‘Well, you need a) the vision, but b) the kind of drive, “we’re going to make this happen and here’s when we’re going to make it happen”. But you also need the team on the ground who have also got that equal passion, drive and commitment to making it happen and continuing to make it happen’ (senior RVS manager). Adequate training and support for the volunteers was important for retention. Ensuring that volunteers felt wanted and useful on the ward, and were supported by the staff, was important if volunteers were to be retained in the long term.
Discussion A number of limitations to the evaluation were identified. Volunteers participating in the focus groups were based on convenience samples and may not represent the views of all. Observations of practice were based on short visits to the ward and therefore might not capture the full range of practice or activities that took place. However, the strengths of the evaluation lie in the wide range of perspectives gathered and the range of methods used to gather the data over one year. This enabled a complete, multidimensional picture of the initiative to emerge, as opposed to a limited snapshot. Some of the issues identified were consistent across the data sources, which added confidence to the overall findings. The service had a positive effect on patients who were engaged in a variety of ways and enjoyed the volunteers’ company. Ward staff, who were able to witness the difference made to patients’ and their own working lives, valued the project. The volunteers engaged with patients largely through providing company, activity and presence, offering a dimension that nursing staff often struggled with due to their clinical workload. The King’s Fund report (Galea et al 2013) on the use of volunteers in acute hospitals also identified 32 May 2014 | Volume 26 | Number 4
befriending and visiting as the most common roles. These activities were linked to promoting compassion, which is consistent with the service evaluated where volunteer interactions were observed to improve patient experience through improved wellbeing and comfort. The quality of inpatient experience is also high on the policy agenda. The quality standards produced by the National Institute for Health and Care Excellence (2012) reflect many of the issues in this evaluation, including being treated with dignity and being able to experience effective interactions with staff. In particular, ward staff valued volunteers spending time with patients who were agitated or upset. This is significant given that a Royal College of Nursing (2012) report found that 78% of nurses stated that on their last shift, comforting and talking to patients either did not happen or happened to an inadequate level due to workload. An Australian study of volunteers in a nursing home for people with dementia also identified that staff valued the engagement and stimulation of residents by volunteers (van der Ploeg et al 2012). Volunteers seemed to offer an additional and different role to that of nursing staff and little overlap or conflict was found. This reflects the findings of Scott (2006) who reviewed volunteer services in a children’s hospice, where volunteers were perceived to be more relaxed than staff, using their time differently but in a way that complemented staff. Staff in the service evaluation showed respect and regard for the role of volunteers and the fact they were giving up their time to help. This concurs with Teasdale (2007a, 2007b) who found that staff in NHS services appreciated volunteers giving up their own time to help and also noted that volunteers made staff’s jobs easier. The introduction of volunteers to the ward was not without problems. The findings resonate with those of Galea et al (2003) who identified the potential tensions that can develop between paid staff and volunteers. However, the evaluation also demonstrated that, with time and co-ordination, these potential barriers could be overcome. As the initiative developed and there was clearer understanding about the role of the volunteers, they became valued visitors to the ward. The DNS was seen as vital to the success of the initiative by recognising and responding to challenges. Naylor et al (2013) draw attention to the need to provide adequate management and support for volunteers, although there is little literature relating to specific roles for supporting volunteers in practice. NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Naylor et al (2013) report that often trust boards have little understanding of the role of volunteers in their service and as a result can miss potential opportunities for making best use of volunteers. One of the strengths of the volunteer service evaluated here was that the initiative was supported at strategic level, and leadership and commitment were also strong at ward level. Some saw the potential to expand the service by training volunteers to support patients with feeding. This is significant because difficulties in managing at mealtimes are a concern for patients and carers (James et al 2012). However Galea et al (2013) highlight the potential blurring of boundaries between paid staff and volunteers, particularly when volunteers become established and integral to the ward team. Careful consideration is needed in asking volunteers to take on activities that might be seen as essential nursing roles. This is a debate that will no doubt develop as the use of volunteers is increasingly seen as a way to transform health and social care services in the future (Naylor et al 2013).
Conclusion This study evaluated an innovative pilot project where RVS volunteers were introduced on an orthopaedic ward. There was evidence that the
service enhanced the experience of frail older people on the evaluation ward, which was the intended focus of the service when it was first introduced. Patients value the company of the volunteers and take pleasure from a range of activities on offer. The volunteers derived a great deal of satisfaction from their work and this evaluation has described a service which is also valued by ward staff. The on-ward volunteer service complements rather than duplicates the care provided by ward staff. While the initiative evaluated positively from a variety of perspectives, this was with strong support at strategic, managerial and clinical level. The lessons learned from this evaluation can usefully inform the development of similar initiatives elsewhere and are highly relevant given the current policy emphasis on improving patient experience in hospital.
Implications for practice ■■ The use of on-ward volunteers has the potential to improve the experience of people with dementia. ■■ The presence of on-ward volunteers can contribute to improved quality of working life for ward staff. ■■ Volunteers need adequate training and clearly defined support at ward level if initiatives are to succeed in practice.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Alzheimer’s Research UK (2014) Dementia Statistics. www.alzheimersresearchuk.org/ dementia-statistics (Last accessed: March 24 2014.)
James V, Hinchliffe D, Hoban M et al (2012) Shaping Our Age. Local Report Sheffield. Consultations with Service Users and Carers. Unpublished. Cardiff, WRVS.
Ritchie J, Spencer L (1994) Qualitative data analysis for applied policy research. In Bryman A, Burgess R (Eds) Analysing Qualitative Data. Routledge, London.
Teasdale S (2007a) Assessing the Impact of Volunteering in Nottinghamshire Healthcare NHS Trust. tinyurl.com/p746zwx (Last accessed: March 24 2014.)
Department of Health (2001) National Service Framework for Older People. DH, London.
National Institute for Health and Care Excellence (2012) Patient Experience in Adult NHS Services (Quality Standard 15). http://guidance.nice.org.uk/QS15 (Last accessed: March 24 2014.)
Royal College of Nursing (2012) Safe Staffing for Older People’s Wards: RCN Full Report and Recommendations. tinyurl.com/9j5fgjz (Last accessed: March 24 2014.)
Teasdale S (2007b) Assessing the Impact of Volunteering in Luton and Dunstable Hospital NHS Foundation Trust. tinyurl.com/onzassp (Last accessed: March 24 2014.)
Royal College of Psychiatrists (2005) Who Cares Wins: Improving the Outcome for Older People Admitted to the General Hospital. RCPsych, London.
van der Ploeg E, Mbakile T, Genovesi S et al (2012) The potential of volunteers to implement non-pharmacological interventions to reduce agitation associated with dementia in nursing home residents. International Psychogeriatrics. 24, 11, 1790-1797.
Department of Health (2009) Living Well with Dementia. A National Dementia Strategy. DH, London. Galea A, Naylor C, Buck D et al (2013) Volunteering in Acute Trusts in England: Understanding the Scale and Impact. tinyurl. com/q2wdfjh (Last accessed: March 24 2014.)
Naylor C, Mundle C, Weaks L et al (2013) Volunteering in Health and Care: Securing a Sustainable Future. tinyurl.com/d78rbmf (Last accessed: March 24 2014.) Ritchie J, Lewis J (Eds) (2003) Qualitative Research Practice. Sage, London.
NURSING OLDER PEOPLE
Scott R (2006) Volunteers in a children’s hospice. Voluntary Action. 8, 2, 55-63. Somers A, Mawson S, Gerrish K et al (2006) The Simple Rules Toolkit. tinyurl.com/ntmydem (Last accessed: March 24 2014.)
May 2014 | Volume 26 | Number 4 33
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Introducing on-ward volunteers to work with patients with dementia Ann McDonnell and colleagues evaluate the effect that non-staff support had on an orthopaedic ward Correspondence [email protected] Ann McDonnell is professor of health services research, Sheffield Hallam University Jane McKeown is senior nurse, Sheffield Health and Social Care NHS Foundation Trust Carol Keen is lead therapist, Sheffield Teaching Hospitals NHS Foundation Trust Judith Palfreyman is senior staff nurse, Sheffield Teaching Hospitals NHS Foundation Trust Nicola Bennett is research sister, National Institute for Health Research, Sheffield clinical research facility, Royal Hallamshire Hospital, Sheffield Date of submission February 24 2014 Date of acceptance March 24 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Abstract This article reports on an evaluation of the effect of an on-ward volunteer service in an acute orthopaedic ward with a number of dementia patients. A mixed-methods evaluation was undertaken in 2012. This included interviews with individuals who have strategic, management, operational and clinical roles in the voluntary organisation and the NHS trust, focus group discussions with volunteers, non-participant observations of practice and focused conversations with ward staff. The service had a positive effect on patient experience. Patients were engaged through a variety of activities and enjoyed the volunteers’ presence. Staff valued the initiative because they could see the difference that it made to patients and their own working lives. The lessons learned from the evaluation can inform the development of similar initiatives elsewhere and are relevant, given the emphasis in healthcare policy to improve patient experience. Keywords Acute care, dementia, orthopaedics, patient experience, service evaluation, volunteers AROUND 820,000 people in the UK have dementia (Alzheimer’s Research UK 2014) and this increasingly common disorder also affects inpatient care provision. Older people occupy most acute hospital beds (Department of Health (DH) 2001), and the Royal College of Psychiatrists (2005) estimates that in a typical general hospital patients with dementia occupy more than one fifth of the beds. However, it is recognised that hospitals are particularly challenging environments for these patients, and they have worse outcomes in terms of length of stay, mortality and institutionalisation (DH 2009).
28 May 2014 | Volume 26 | Number 4
The Royal Voluntary Service (RVS) on-ward volunteer service was launched at Sheffield Teaching Hospitals NHS Foundation Trust in November 2011. The purpose of the initiative was to improve the experience of patients with dementia by using on-ward volunteers recruited and trained by RVS, one of the largest volunteer organisations in the UK, supported by a dementia nurse specialist (DNS) employed by the trust.
The project It was envisaged that the volunteers would provide befriending, diversional therapy, companionship and help with eating and drinking, as well as supporting family carers and providing respite time. The volunteer service aimed to complement the care provided by trust staff. Recruitment of volunteers was the responsibility of the RVS, who also provided and funded a training programme and managed the volunteers. The trust appointed a DNS whose role was to direct the volunteers to work with patients and families in the most appropriate way. The volunteer initiative was established as a 12-month pilot project based on an orthopaedic ward that had a high proportion of patients with dementia who were recovering from surgery. Over the 12-month evaluation period, a total of 28 volunteers worked on the ward. The mean number of volunteers on the ward each month was 12, ranging from nine to 19, and the mean number of volunteer hours per month was 64.5 hours, but spanned anywhere from 27 to 105 hours. The DNS guided volunteers on which patients to work with, acted as a role model in the care of patients with dementia, and was a source of knowledge and expertise on a daily basis. A project was developed to capture the learning from this initiative from a number of different NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
perspectives. The evaluation took place between January and December 2012.
Aim The aim of this project was to evaluate the effect of the volunteer initiative. More specifically, the objectives were to: ■■ Describe the care provided by the volunteers. ■■ Explore the perceptions of those with strategic, management, operational and clinical roles in the voluntary organisation and the NHS trust on the potential of the initiative. ■■ Examine the perceptions of ward staff on the effect of the initiative. ■■ Establish the perceptions of volunteers in relation to their experiences in practice. ■■ Identify factors influencing implementation.
Methods This was a mixed-methods service evaluation, which used a range of different approaches to data collection, including individual interviews with strategic stakeholders, focus groups with volunteers, non-participant observations of practice and focused conversations with ward staff. The stages of data collection are summarised in Figure 1. Interviews with stakeholders A purposive sample of seven stakeholders was selected, including individuals in strategic, management, operational and clinical roles in the RVS and hospital trust. Individual interviews were carried out with all participants at the start of the evaluation period. Additional follow-up interviews with two individuals were also undertaken towards the end of the evaluation. The interviews explored perceptions of the potential and actual effect of the initiative as well as factors affecting the success of the initiative in practice. All interviews were audio recorded and transcribed in full. Focus groups with volunteers To explore the perceptions of volunteers over time, three focus groups were conducted during the evaluation period. A convenience sample of volunteers took part in the focus groups (n=four, five and four respectively). Some volunteers attended more than one focus group. In total, ten volunteers took part. All discussions were audio recorded and transcribed in full. Observations of practice The aim of the observations was to gain insight into the work undertaken by the volunteers and a deeper understanding of the context in which volunteers NURSING OLDER PEOPLE
were working. The observations enabled the evaluation team to initiate ad hoc conversations with volunteers, patients and ward staff to understand their experience. Observations were conducted across three time periods between July and December 2012. Six visits took place in total. Eighteen volunteer visits involving 11 different volunteers were observed. Where possible, brief notes were made on the ward and these were written up as field notes soon after the observations. Focused conversations with ward staff A purposive sample of six staff was selected to include a range of staff grades and roles. These conversations explored staff’s perceptions of the effect of the volunteer initiative in practice. Data were recorded through note taking and a structured data collection form was completed as soon as possible after the conversations.
Data analysis The analysis approach drew on the principles of framework analysis (Ritchie and Spencer 1994, Ritchie and Lewis 2003). Framework analysis is a pragmatic approach to qualitative data analysis, which involves a systematic process of sifting, charting and sorting material into key issues and Figure 1
Series of stages involved in data collection Stakeholder interviews (n=7)
Volunteer focus group 1
Volunteer focus group 2
Observations of practice Conversations with ward staff (n=6)
Volunteer focus group 3
Observations of practice
Observations of practice
Follow-up interviews with stakeholders (n=2)
May 2014 | Volume 26 | Number 4 29
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | service evaluation ‘She was there holding hands while the patient was dying and with tears in her eyes and I’ve got nice memories of that’ themes. Using these methods, cross-cutting themes were identified that were shared across the different data collection methods. Ethical considerations NHS research ethics approval was not required as this was a service evaluation and not a research study. However, ethical principles were observed and the evaluation was conducted according to the principles outlined in the Simple Rules Toolkit (Somers et al 2006). This included maintaining confidentiality, voluntary participation, the right of individuals to withdraw and obtaining informed consent from staff and volunteers to take part in interviews and focus groups.
Findings Data analysis revealed themes on the activities undertaken by volunteers with patients, the effect of the initiative on patients and ward staff, and factors influencing the success of the initiative. Volunteer activities The main volunteer activity with patients was conversation. This could be a simple conversation between two people, or it could be guided with the use of memory aids, such as books. Sitting and talking with patients was seen as important and volunteers highlighted how well they got to know individual patients and were able to find out about them through these conversations. Volunteers also described putting music on and dancing with patients, doing artwork and playing games such as cards, dominoes and bingo. One of the perceived benefits was that care was individualised; rather than the same activity being provided for everyone, the volunteers based their interventions on what the patient wanted on that particular day: ‘That’s right, I mean every day you come on it’s different. You never get two days the same, do you? Every shift you do is totally different. Some days you might get four people up and have a game of bingo, and sometimes you might just wander round chatting, or sometimes you might spend longer with one patient than others because they need your time. It all depends on the patients’ (volunteer). Effect on patients Stakeholders saw the potential for patients’ experience to be improved by having 30 May 2014 | Volume 26 | Number 4
someone available who could spend time sitting, talking and supporting those who were distressed. Engaging patients The effect on patients was viewed as greater than anticipated. Patients were seen as less withdrawn or depressed: they appeared genuinely pleased to see the volunteers. Patients loved to talk about themselves and tell stories, and the volunteers loved to listen: ‘Two volunteers spent time in one bay, engaging three of the patients in conversation around the subject of a chair that one of the patients was using. There was a lot of laughter and all the patients were involved in the conversation’ (observation field notes). There were times where patient wellbeing appeared to be enhanced through the volunteers talking, laughing and listening to them: ‘A young volunteer spent time with a patient with advanced dementia. The patient was seen to be responding in an animated way and the patient’s relatives commented later what good spirits the patient was in’ (observation field notes). Patients were seen to gain social activity that they would not receive without the volunteers. This socialisation was multifaceted, between patients and individual volunteers, patients and staff and also between individual patients in the ward. Although patients with dementia could struggle to remember the details of the activities with the volunteer, such as the identity of the person who spoke with them, some could remember that there was a social interaction with another person. After a volunteer visit, one staff member reported a patient saying: ‘I don’t know who they were, but they were lovely.’ Relieving distress The volunteers helped patients who were agitated or restless by occupying them. They relieved distress, for example, comforting patients in a bay where a patient had had a stroke, or comforting those at the end of life: ‘She sat with the patient, was holding their hands and there were no relatives around, like they were abroad and they just couldn’t be there on time, and she was there holding hands while the patient was dying and with tears in her eyes and I’ve got nice memories of that’ (medical consultant). Nutrition Volunteers were not allowed to assist patients with eating or drinking. For some this was a missed opportunity, however it was hoped that by encouraging patients to eat and drink, volunteers might contribute to better nutrition and hydration. In practice, the value of volunteers at mealtimes was mixed: there were examples where volunteers helped prompt patients NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
to eat, but on other occasions volunteers continued talking to patients when their meals arrived, which seemed to prevent patients from eating. Effect on ward staff Staff with insights into care at ward level had a positive view of the effect that volunteers were having on delivery of care by freeing up nurses’ time to do the duties that only nurses could do, such as administering medications. Benefits to staff Throughout the interviews it became evident that the service was highly valued by the ward staff. Volunteers were ‘amazing’, keen and eager to help in whatever way they could. ‘I can’t imagine working without them’ (ward staff member). By sitting and talking with patients, particularly those who were agitated, they were able to free up nursing time on a busy ward: ‘Well, it gives them time to look after patients better. You know, they can spend more time with any patient that’s ill. I know they’re all ill, but someone that is worse. And they don’t need to look after half a dozen; we can talk to a few and keep them busy while the nurse is actually doing her proper job’ (volunteer). The presence of the volunteers on the ward was reassuring for staff. The volunteers were seen as an additional ‘pair of eyes’ in the ward area, which helped staff focus on other duties. Communication with ward staff Communication between ward staff and volunteers improved as the service became established and volunteers and staff had a clearer understanding of their roles and capabilities. When the volunteers arrived, staff directed them to patients who might benefit from their time. In return, the volunteers might suggest patients that they were familiar with from previous visits and would see everyone that they were asked to. In screening patients, ward staff were mindful of patient needs, but also of volunteer safety, especially when asking them to see agitated patients: ‘One volunteer sat with a patient in a side ward, but at a distance, as [name of patient] can be quite feisty’ (ward staff member). Integration The staff saw that the initiative was having a positive effect. It was clear that the role of the volunteer was different to that of the staff – there was no overlap in roles, and therefore no negative effect on staff activities and duties. There was no sense of the volunteers disrupting NURSING OLDER PEOPLE
ward activities or impeding nursing care: they were seen to fit in with ward routines: ‘What they do is very subtle, they blend in’ (ward staff member). Staff saw the volunteers become more confident as time passed and they became increasingly familiar with the ward and its routines: this enhanced their integration. Factors influencing success Implementation of the initiative was challenging. Using volunteers in this way was new for everyone and initially volunteers were not always recognised or welcomed by ward staff. However, the longitudinal nature of the evaluation meant that a picture of the initiative emerged as it developed. Potential problems highlighted in early observations had resolved later in the evaluation period. For example, initially staff were not clear when volunteers might be expected on the ward and were not prepared for them. A system was established to address this using a volunteer rota and sign-in sheets. Volunteers’ confidence also increased over the time span of the evaluation and they felt well supported by each other, the DNS and RVS manager. Role of the DNS The nurse specialist was seen as crucial to the success of the initiative. It was clear that she supported the volunteers, was a valuable source of knowledge and expertise, and the volunteers felt comfortable to approach her and ask for help and guidance. A different service The voluntary nature of the service seemed to help the initiative: employing additional staff members to provide the service offered by the volunteers may not have achieved the same success. This was demonstrated in the comments made by staff, which showed how they appreciated volunteers giving up their time to help. The staff described how they liked to chat to patients, but did not always have enough time. Staff conversations with patients had an alternative agenda or purpose – perhaps to assess needs, or identify information that could be helpful in patients’ ongoing care. The staff compared this to the volunteers, who had lengthy periods of time set aside solely for
Staff saw the volunteers become more confident as time passed and they became increasingly familiar with the ward May 2014 | Volume 26 | Number 4 31
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | service evaluation Volunteers seemed to offer an additional and different role to that of nursing staff and little overlap or conflict was found patient interaction, and could be more social, friendly and relaxed in their conversation: ‘It’s a different level of chat’ (ward staff member). The staff recognised this difference and its value in delivering the service. Support at senior and strategic level in the trust was seen as important in sustaining the intervention, as was good leadership and strong commitment at ward level: ‘Well, you need a) the vision, but b) the kind of drive, “we’re going to make this happen and here’s when we’re going to make it happen”. But you also need the team on the ground who have also got that equal passion, drive and commitment to making it happen and continuing to make it happen’ (senior RVS manager). Adequate training and support for the volunteers was important for retention. Ensuring that volunteers felt wanted and useful on the ward, and were supported by the staff, was important if volunteers were to be retained in the long term.
Discussion A number of limitations to the evaluation were identified. Volunteers participating in the focus groups were based on convenience samples and may not represent the views of all. Observations of practice were based on short visits to the ward and therefore might not capture the full range of practice or activities that took place. However, the strengths of the evaluation lie in the wide range of perspectives gathered and the range of methods used to gather the data over one year. This enabled a complete, multidimensional picture of the initiative to emerge, as opposed to a limited snapshot. Some of the issues identified were consistent across the data sources, which added confidence to the overall findings. The service had a positive effect on patients who were engaged in a variety of ways and enjoyed the volunteers’ company. Ward staff, who were able to witness the difference made to patients’ and their own working lives, valued the project. The volunteers engaged with patients largely through providing company, activity and presence, offering a dimension that nursing staff often struggled with due to their clinical workload. The King’s Fund report (Galea et al 2013) on the use of volunteers in acute hospitals also identified 32 May 2014 | Volume 26 | Number 4
befriending and visiting as the most common roles. These activities were linked to promoting compassion, which is consistent with the service evaluated where volunteer interactions were observed to improve patient experience through improved wellbeing and comfort. The quality of inpatient experience is also high on the policy agenda. The quality standards produced by the National Institute for Health and Care Excellence (2012) reflect many of the issues in this evaluation, including being treated with dignity and being able to experience effective interactions with staff. In particular, ward staff valued volunteers spending time with patients who were agitated or upset. This is significant given that a Royal College of Nursing (2012) report found that 78% of nurses stated that on their last shift, comforting and talking to patients either did not happen or happened to an inadequate level due to workload. An Australian study of volunteers in a nursing home for people with dementia also identified that staff valued the engagement and stimulation of residents by volunteers (van der Ploeg et al 2012). Volunteers seemed to offer an additional and different role to that of nursing staff and little overlap or conflict was found. This reflects the findings of Scott (2006) who reviewed volunteer services in a children’s hospice, where volunteers were perceived to be more relaxed than staff, using their time differently but in a way that complemented staff. Staff in the service evaluation showed respect and regard for the role of volunteers and the fact they were giving up their time to help. This concurs with Teasdale (2007a, 2007b) who found that staff in NHS services appreciated volunteers giving up their own time to help and also noted that volunteers made staff’s jobs easier. The introduction of volunteers to the ward was not without problems. The findings resonate with those of Galea et al (2003) who identified the potential tensions that can develop between paid staff and volunteers. However, the evaluation also demonstrated that, with time and co-ordination, these potential barriers could be overcome. As the initiative developed and there was clearer understanding about the role of the volunteers, they became valued visitors to the ward. The DNS was seen as vital to the success of the initiative by recognising and responding to challenges. Naylor et al (2013) draw attention to the need to provide adequate management and support for volunteers, although there is little literature relating to specific roles for supporting volunteers in practice. NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Naylor et al (2013) report that often trust boards have little understanding of the role of volunteers in their service and as a result can miss potential opportunities for making best use of volunteers. One of the strengths of the volunteer service evaluated here was that the initiative was supported at strategic level, and leadership and commitment were also strong at ward level. Some saw the potential to expand the service by training volunteers to support patients with feeding. This is significant because difficulties in managing at mealtimes are a concern for patients and carers (James et al 2012). However Galea et al (2013) highlight the potential blurring of boundaries between paid staff and volunteers, particularly when volunteers become established and integral to the ward team. Careful consideration is needed in asking volunteers to take on activities that might be seen as essential nursing roles. This is a debate that will no doubt develop as the use of volunteers is increasingly seen as a way to transform health and social care services in the future (Naylor et al 2013).
Conclusion This study evaluated an innovative pilot project where RVS volunteers were introduced on an orthopaedic ward. There was evidence that the
service enhanced the experience of frail older people on the evaluation ward, which was the intended focus of the service when it was first introduced. Patients value the company of the volunteers and take pleasure from a range of activities on offer. The volunteers derived a great deal of satisfaction from their work and this evaluation has described a service which is also valued by ward staff. The on-ward volunteer service complements rather than duplicates the care provided by ward staff. While the initiative evaluated positively from a variety of perspectives, this was with strong support at strategic, managerial and clinical level. The lessons learned from this evaluation can usefully inform the development of similar initiatives elsewhere and are highly relevant given the current policy emphasis on improving patient experience in hospital.
Implications for practice ■■ The use of on-ward volunteers has the potential to improve the experience of people with dementia. ■■ The presence of on-ward volunteers can contribute to improved quality of working life for ward staff. ■■ Volunteers need adequate training and clearly defined support at ward level if initiatives are to succeed in practice.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Alzheimer’s Research UK (2014) Dementia Statistics. www.alzheimersresearchuk.org/ dementia-statistics (Last accessed: March 24 2014.)
James V, Hinchliffe D, Hoban M et al (2012) Shaping Our Age. Local Report Sheffield. Consultations with Service Users and Carers. Unpublished. Cardiff, WRVS.
Ritchie J, Spencer L (1994) Qualitative data analysis for applied policy research. In Bryman A, Burgess R (Eds) Analysing Qualitative Data. Routledge, London.
Teasdale S (2007a) Assessing the Impact of Volunteering in Nottinghamshire Healthcare NHS Trust. tinyurl.com/p746zwx (Last accessed: March 24 2014.)
Department of Health (2001) National Service Framework for Older People. DH, London.
National Institute for Health and Care Excellence (2012) Patient Experience in Adult NHS Services (Quality Standard 15). http://guidance.nice.org.uk/QS15 (Last accessed: March 24 2014.)
Royal College of Nursing (2012) Safe Staffing for Older People’s Wards: RCN Full Report and Recommendations. tinyurl.com/9j5fgjz (Last accessed: March 24 2014.)
Teasdale S (2007b) Assessing the Impact of Volunteering in Luton and Dunstable Hospital NHS Foundation Trust. tinyurl.com/onzassp (Last accessed: March 24 2014.)
Royal College of Psychiatrists (2005) Who Cares Wins: Improving the Outcome for Older People Admitted to the General Hospital. RCPsych, London.
van der Ploeg E, Mbakile T, Genovesi S et al (2012) The potential of volunteers to implement non-pharmacological interventions to reduce agitation associated with dementia in nursing home residents. International Psychogeriatrics. 24, 11, 1790-1797.
Department of Health (2009) Living Well with Dementia. A National Dementia Strategy. DH, London. Galea A, Naylor C, Buck D et al (2013) Volunteering in Acute Trusts in England: Understanding the Scale and Impact. tinyurl. com/q2wdfjh (Last accessed: March 24 2014.)
Naylor C, Mundle C, Weaks L et al (2013) Volunteering in Health and Care: Securing a Sustainable Future. tinyurl.com/d78rbmf (Last accessed: March 24 2014.) Ritchie J, Lewis J (Eds) (2003) Qualitative Research Practice. Sage, London.
NURSING OLDER PEOPLE
Scott R (2006) Volunteers in a children’s hospice. Voluntary Action. 8, 2, 55-63. Somers A, Mawson S, Gerrish K et al (2006) The Simple Rules Toolkit. tinyurl.com/ntmydem (Last accessed: March 24 2014.)
May 2014 | Volume 26 | Number 4 33
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 17, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
