Rural nurses’ perceptions of a volunteer program in an acute setting: Volunteers delivering person-centred care for patients with dementia and delirium ()
1. INTRODUCTION
The prevalence of dementia in Australia is expected to increase from 257,000 in 2010 to over 1.1 million in 2050 [1]. In line with the projected increase in dementia prevalence, there is a predicted increase in the demand for dementia care services and shortages in the supply of care for people with dementia [2]. Thus planning now, to accommodate demand for services in the future, is essential for delivering care that meets the needs of this vulnerable population. Additionally, it is predicted that there will be an uneven ageing distribution across regions within Victoria, Australia, with greater increases in rural Victoria [2]. The Access Economics report recommends that there should be an aim of improving the quality of life for all people in Victoria living with dementia, including their families and carers [2].
It is currently estimated that 50% of all people admitted to acute care settings have some degree of cognitive impairment [3]. Occupation of hospital beds by people with dementia and cognitive impairment is well recognised [4-6], as it is the potential for adverse outcomes for these patients in this environment [5,7]. A diagnosis of dementia or delirium is reported to positively correlate with an increased rate of falls and associated with resource utilisation in the acute care setting [8]. Presently, families and other carers report widespread dissatisfaction with general hospital care for confused older people [9], largely related to unmet needs of the person with dementia. Indeed, given the aging population and the concomitant increase in the prevalence of dementia, it is imperative that approaches to sensitive and client-centred care must be developed to meet these unmet needs.
A previous study reported environmental challenges in caring for people with dementia in an acute care setting, in particular wandering behaviour against a backdrop of time pressures and competing demands [10]. These challenges are further described by a more recent study [11] in which nurses in acute care settings reported insufficient resources to provide the necessary care required by people with cognitive deficits.
The utilization of trained “sitters” for people experiencing agitation, wandering and confusion has been identified as an important adjunct to care for people with dementia and delirium in an acute medical or surgical setting [4,10]. While the literature does not further elaborate on the definition of a trained “sitter”, it can be assumed or is quite possible that this refers to volunteers. Volunteers are defined as people who perform an activity in which time is given freely to benefit another person, cause or group [12]. While there are over six million volunteers in Australia, a past survey found that only 12% of these were in the health sector [13]. Given the decreasing resources in the health sector, volunteers are increasingly being utilised to play a crucial role. In addition, it has been identified that there is tremendous scope for further development of the volunteer role, including training and development [13]. There is also evidence of individual benefit for volunteers engaged in meaningful activity that benefits a vulnerable population [14,15].
There is an evidence of improved outcomes for patients with a cognitive impairment in an acute setting, when emotional security and support are provided through a person-centred care volunteer program [16]. Personcentred care (first described by Kitwood [17]) is considered the gold standard model of care for people with dementia [18]. Kitwood [17] identified and described the key needs of attachment, comfort, identity, inclusion and occupation as essential to good dementia care. These needs translate to knowledge and value of a person’s past, a focus on their abilities and fostering choice and communication.
This study is a qualitative evaluation of a volunteer project in an acute hospital setting. Volunteers were recruited from the community, trained in person-centred practices, and utilised to provide person-centred care for people with dementia or delirium in a small rural hospital. The project itself was modelled on a previous research project implemented in a larger regional hospital [16]. Nursing staff working in the acute setting were recruited to undertake interviews with the principal researcher as a form of evaluation of the volunteer program.
Background
The volunteer project was grounded in action research theory. Action research is known by many other names, including participatory research, collaborative inquiry, emancipatory research, action learning, and contextual action research, but all are variations on a theme. Put simply, action research is “learning by doing”—a group of people identify a problem, do something to resolve it, see how successful their efforts were, and if not satisfied, try again. It has previously been described as;
“There is a dual commitment in action research to study a system and concurrently to collaborate with members of the system in changing it in what is together regarded as a desirable direction. Accomplishing this twin goal requires the active collaboration of researcher and client, and thus it stresses the importance of co-learning as a primary aspect of the research process” [19].
A local, active community volunteer reads a newspaper article about utilising volunteers to support care for people with dementia and delirium in an acute setting [16]. The volunteer approached the principal researcher suggesting that a similar program could be implemented at our local hospital. The volunteer also accessed the project report from the original author. A conversation ensued between the principal researcher and nursing staff of the acute care setting. Nursing staff agreed that there was a need for support for people admitted with dementia and/or delirium. Concerns were mainly centred around safety for these patients, falls being a common occurrence with subsequent injury and increased length of stay. Nursing staff also identified that increased confusion frequently occurred in patients with dementia due to being admitted to an unfamiliar environment. There was a perception that nurses have a limited capacity to provide the required cognitive stimulation and unremitting emotional support that these patients require, in a busy acute hospital setting. The resources required (such as a sitter or nurse special) to address these issues were frequently unavailable. Staff agreed that trained volunteers would ameliorate the risks to the patients, but that this required the services of a “dedicated” staff member to oversee and implement the change. State funding from a dementia training study centre, to translate previous research into practice, provided the financial resources necessary to facilitate the introduction of a volunteer program.
The principal researcher (and project coordinator) is a registered nurse, who works as a research academic with the University of Melbourne. The principal researcher recruited the volunteers through articles in the local media, as usual standard practice for volunteer recruitment for the organisation. An advisory committee was convened to guide the project implementation. The advisory committee consisted of nine members, the director of clinical services, the nurse unit manager, four senior nursing staff members, an occupational health and safety representative of the health service, and a volunteer as well as the principal researcher. The advisory group adapted guidelines, policies and a resource manual, from a previous research project with the authors permission [16] to guide the role and duties of the volunteer workers in the current project. A training schedule for volunteer training, specific to the needs of the organisation was also developed, which focused on person-centred practices in delivering care for people with dementia. Alzheimers Victoria also provided resources, such as a training DVD on person-centred care developed for student health service staff. Volunteer training was delivered by a local education service provider over a two day period. At completion of the training, the volunteers undertook the necessary security checks, and were provided with a uniform and identification.
Recognising that staff involvement was critical to the success of the program, prior to the implementation, the project coordinator attended staff handover times to enlist their support to explain the roles and responsibilties of the volunteers to potential patients and their carers. A referal guideline (adapted from a previous project [16]) had been developed by the advisory committee for staff to refer eligible patients into the program, and this was explained to nursing staff. Since staff would responsible for distribution, an information booklet (adapted from a previous project [16]) and consent to participate in the program were also explained to staff. There were posters in the acute ward which provided staff with the researchers contact details should they require further information.
Once training for the volunteers and staff education was completed, the program was implemented. At the time of training, volunteers indicated their availability for allocated shifts at the hospital. Based on previous research studies [16] and in consultation with the nursing staff, volunteer shifts were organised around patient mealtimes (0830 - 1230 hours and 1630 - 1900 hours). There were ten volunteers, who agreed to fill these time slots from Monday to Friday. Volunteers commenced on the acute ward, with the principal researcher physically present for their first two allocated shifts. After this time they carried out their duties independently, but the researcher was contactable by telephone, should they require assistance or clarification of their role.
In keeping with the principles of person-centred care, where the emphasis is on the person and not on the task, volunteers collect information about patients, either by asking the patient themselves (if they have mental capacity) or by asking their carer/family members. The information collected relates to patient preferences, life histories and personal interests, in order to build on the patients strengths. This allows the volunteers to engage patients in meaningful activities tailored to their interests and preferences. This approach to dementia care is based on theoretical rationale [20], including emotion oriented approach (e.g., reminiscence and validation therapy); cognition oriented approach (e.g., reality orientation); and stimulation oriented approach (e.g., recreational therapies and multisensory stimulation). A resource box is available to the volunteers which is stocked with puzzles, books and items of interest.
In consultation with the advisory group and due to the small number of participants, the project was to be evaluated using qualitative methodology. The principal researcher conducted interviews with nursing staff who consented to be involved.
2. METHODS
Evaluation of the project was in keeping with action research methodolgy, which incorporates testing of concepts, concrete experience and observation and reflection [21]. The project was evaluated using semi structured interviews to explore nurses opinions of the implementation of the volunteer project in their work setting.
2.1. Interviewer
The principal researcher conducted the interviews. The interviewer is also a registered nurse who has an existing relationship with the staff interviewed through education and research programs. She does not work clinically with the staff, nor have a position of influence within the organisation. The interviewer has previous qualitative research experience.
2.2. Participants
Purposive sampling was used, in that nurses who worked in the acute setting were invited to undertake the interviews. Nurses were invited by email and through flyers placed in their internal mailboxes, which outlined the time commitment, the interview questions to be asked, and clearly indicated that their participation was voluntary and anonymous to other staff and management of the hospital. Their willingness to participate in an interview was considered consent.
There were 16 eligible nursing staff during the two week time period that interviews were conducted. Permanent night duty staff were excluded due to their lack of involvement in the program, and a further four staff were on planned leave (a total of eight staff). Of the 16 eligible staff, 15 consented to interviews, a response rate of 93%. The reason for non participation was not sought. All of the nursing staff were female, nine were senior registered nurses (employed as after hours managers), four were registered nurses and two were enrolled nurses. Registered nurses in Australia undertake a three year bacculaureate to practice. Enrolled nurses undertake one year of undergraduate training, with a further six months of training required to administer medications.
2.3. Setting
All of the interviews were conducted during the nurses working hours, in a private area of their workplace. Only the interview participant and the interviewer were present.
2.4. The Interview Schedule
The interview schedule was very open ended, with only four questions. It was developed by the project co ordinator and intended only to gain staff perceptions. The first asked them to clarify their role on the acute ward, the second asked them their opinion of the program and the third asked their advice on ways the program could be improved. The final question invited the participants to share any other thoughts or opinions they had about the program.
The interviews were recorded with participants consent, and most were of very short duration of less than five minutes. The interviews were transcribed verbatim and participants confirmed that they were accurate.
2.5. Data Analysis
The transcribed interviews were analysed collaboratively by the project co ordinator and an independent researcher, experienced in qualitative methodology. No data software was used in the analysis due to the small number and length of the interviews. Both researchers read the transcripts and identified key words and recurrent concepts. The short interviews did not warrant a more intensive analysis. The concepts identified by the analysis are supported by quotes which illustrate how the concepts were derived.
2.6. Ethical Approval
Ethical approval to evaluate the project through qualitative interviews was granted by the University of Melbourne Human Research Ethics Advisory Group (No. 1339378). The interviews were conducted in accordance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects.
3. FINDINGS
The intention of the interviews was to evaluate nurses’ perceptions of the utilisation of volunteers in an acute setting. Complex and diverse responses to interview questions were not expected, and were not elicited. Responses were unequivocally positive, the volunteers were valued by staff for the relief of unremitting attention required by patients with confusion or cognitive deficits of dementia or delirium. Respondents perceived benefits for patients as well in provision of cognitive stimulation and improved safety. When offering suggestions for improvement, respondents most frequently wanted the program extended to cover weekends and offered to other patients.
3.1. Improved Time Management for Other Tasks
The unremitting support required by nurses to care for patients with confusion was frequently cited by respondents. They identified that patients with dementia and delirium require increased time for explanations and reinforcement of instructions, something which volunteer presence ameliorated the constant need for. A lack of resources, especially the time required and the competing demands of other patients was also commonly mentioned. Comments included:
These patients are really hard work. We spend a lot of unneccessary time with them just trying to explain things, which they forget again three seconds later. Having volunteers here means they can reinforce things like “don’t try to get out of bed”.
…I find it’s a real relief for my staff because they can go and do the jobs that they need to do without having to spend so much time with one person. What’s been good is that it’s freed up out time to continue with our other work and we’re happy to know that the patients are being looked after.
…those patients are quite disruptive often and they take up a lot of our time just redirecting and the things that volunteers do is engage them, and keep them occupied so that we’re not spending excessive time with them. That gives us time to go on with our other work.
3.2. Increased Patient Stimulation
The majority of respondents cited the benefit to patients from having volunteer assistance. They identified a need for activities that weren’t medically or nursing oriented, which staff themselves did not have time to provide in their current environment. Support and comfort for confused patients was also identified as being provided by volunteers. Comments included:
Reading the newspaper to them, it keeps them more focused on everyday situations, where the nurses don’t sit there and do that with them. They don’t have time to do that and I think all those things are worthwhile.
We can’t read newspapers to them or anything like that. It’s just good that volunteers can come in and help and spend quality time with patients, explain things that they might get confused about and reinforce things that they might forget… it’s good continuity because they have the same volunteer for a long period… having the same person to talk to, I’m sure it helps.
We don’t have time to do what they do. They spend one on one time with people who really need their company. The volunteers help them pass the time.
3.3. Patient Safety
Increased patient safety was a common response from respondents when asked about the benefits of the program. The nurses responded that they had greater peace of mind knowing that patients with delirium and dementia were at lowered risk of injury because the volunteers were there supervising them. The continual presence of a volunteer at busy times was perceived to ameliorate the risks to patients with confusion. Comments included:
We are a small, busy hospital, we can be very busy and it just really helps with the higher risk patients, and its also a great support and comfort for them as well.
We can get on with our work knowing those people are safe, where before it was a constant concern, you know, like “will they fall out of bed while I’m in the next room?” Now we have peace of mind that that won’t happen.
3.4. Extension of the Program
When asked about potential improvements to the program respondents frequently mentioned extending the program to include weekends, not just week days. Additionally, extending the program to include other patients who may benefit from the company and stimulation was also a frequently occuring concept. Comments included:
We are a seven day a week, twenty four hour service after all. Their confusion doesn’t stop at five pm Friday. We’d like it too but it doesn’t. After having volunteers here all week, we really feel it on weekends now.
Others have suggested they’d like to see it extended over weekends. Yeah, weekend would be good, obviously because we’ve got less people around so that would help… The other thing is, sometimes volunteers come in and can’t see that patient because they have family there, but we may have someone else that would benefit, that doesn’t have dementia, but would benefit from a volunteers company.
Weekends would be good and visiting people who don’t have dementia, just those who are lonely or have no one visiting.
4. DISCUSSION
The findings from this small project indicate that the utilisation of volunteers benefits patients with delirium and dementia by providing increased cognitive stimulation and improved patient safety through the constant presence of volunteers at busy times. Nurses also perceived that volunteers relieved them of the unremitting cognitive support required by patients with delirium and dementia and “freed them up” for other tasks. Nurses suggested extending the volunteer program to seven days per week and to include patients without cognitive impairment.
The improved patient safety percieved by nurses in this project is consistent with other research findings [4, 10]. The confusion related to delirium and dementia limits the individuals understanding of their own physical limitations, which often results in falls or other harm [8] and this was recognised by the interview participants in this study. Participants identified that they feared patients would come to harm while they spent time attending to other tasks or other patients. Indeed, hospitals have been described as “dangerous places” for patients with dementia [22]. All of the participants interviewed in this study support the notion that an alien environment, such as a hospital, presents dangers for patients with a cognitive impairment.
The concept of safety overlapped with the findings of being nurses being “freed up” to attend to other tasks. Participants identified that the continual presence of the volunteers during busy times, afforded them (the nurses) the opportunity of attending to other tasks. This finding has also been previously recognised in the literature, with nurses reporting the difficulty of competing demands in this setting [10,11]. Acute care settings are structured and organised in ways which leave little time for providing emotional or cognitive support for patients, the focus being task oriented. There are many “tasks” required in acute care settings, often time sensitive, such as the administration of drugs, the measurement of vital signs and emergency care. Provision of cognitive stimulation and emotional support, required by patients with dementia or delirium, is seen as secondary to potential life threatening situations. The reality of these competing demands is stressful for nurses [10] which the participants in this study articulated. The result of attending to more urgent needs of non cognitively impaired patients, results in unmet needs for patients with dementia or delirium, and is a source of dissatisfaction [9].
While staff in this study acknowledged the need for cognitive stimulation for patients, they also acknowledged their limitations in providing it, due to time constraints in the acute care setting. Interview participants recognised that volunteers provided patients with much needed stimulation that was not technical nor explicitly nursing oriented, such as reading the newspaper or playing games. This important adjunct to care has also been previously recognised as essential to the provision of high quality care for patients with dementia [4]. It is well recognised that cognitive stimulation prevents further decline and potential problematic behavioural and psychological symptoms, such as wandering and verbal disruption [23]. Cognitive stimulation is also recognised to be more effective when it is tailored to individuals needs and preferences [24] in a person-centred care model, as it was in this study.
The provision of volunteers trained in person-centred practices was shown to be effective in this study for patients and staff. Although previous studies also show a benefit for the volunteers themselves [15] it was not measured in this study due to financial and time constraints, but is a potential consideration for further research.
It is predicted that the need for volunteers, especially in rural areas in Australia will continue to grow [13], and further that hospital administrators need to recognise this rich resource. Like this study, previous studies have found that the utilisation of volunteers has a positive impact on patient quality of care and staff time management [13].
Methodological Considerations
This study focused on the perceptions of nursing staff regarding the implementation of a volunteer program in their workplace. It is limited by the small sample size, despite the high participation rate, and the findings may not be generalisable. Ultimately it is the readers who judge whether our findings can be transferred to another context, which is why a detailed description of the actual volunteer program is provided.
Perceptions of the patients themselves were not sought due to their cognitive deficits, which make their observations and perceptions potentially unreliable. In addition patients carers and families were not invited to participate in interviews, as the number was so small, they would have been highly identifiable. Carer and family perceptions of the volunteer program is an area of further research, as the program progresses and the numbers are large enough to preserve their anonymity.
5. CONCLUSION
The implementation of a volunteer program to deliver care to patients with dementia or delirium appears to provide numerous benefits for staff, volunteers, and patients alike. Nursing staff perceived the program to be overwhelmingly positive. Volunteers are a rich resource, which can be readily utilised to supplement the scarce resources available in most health settings. Volunteers provide a cost effective solution to address the identified needs in caring for patients with dementia and delirium in an acute setting.
ACKNOWLEDGEMENTS
The project was funded by the Victorian and Tasmanian Dementia Training Study Centre.
The volunteers program was modelled on a project conducted by Catherine Bateman, who also provided resources and an implementation plan (subject to copyright) which was adapted for our project.
Grateful acknowledgement goes to the volunteers and the Volunteers Advisory Group.
This research has been supported by the Australian Government Department of Health and Ageing through the University Department of Health (UDRH) program.
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