Communication and information exchange between primary healthcare employees and volunteers – Challenges, needs and possibilities for technology support

In European countries, older populations are growing, and their needs are increasing (NOU 2011:11, 2011). This coincides with a reduction in public budgets, posing challenges in providing health services of sufficient quality across Europe. In this context, sustainability and cost-effectiveness requires new approaches to community-based services. Among possible new methods of organising Received: 22 April 2019 | Revised: 10 January 2020 | Accepted: 27 January 2020 DOI: 10.1111/hsc.12958


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FREDRIKSEN Et al. healthcare services, one alternative would be to increase volunteer involvement (The Royal Culture & Church Ministry, 2006-2007NOU 2011NOU :11, 2011. There are several definitions of voluntarism; for the purposes of this study, voluntarism is defined as "any activity in which time is given freely to benefit another person, organization, group, or cause" (Liu, Ching, & Wu, 2017, p. 531). Voluntarism can be categorised as formal or informal. Formal voluntarism is defined as uncoerced, marginally compensated work that is structured by an organisation and addresses a specific need; informal voluntarism is generally understood to involve helping friends and neighbours or caregiving (Sellon, Chapin, & Leedahl, 2017).
In the healthcare sector, collaboration and coordination between healthcare services and volunteers is necessary to ensure the rational use of resources for older adults (Ervik & Lindèn, 2017). However, previous research has shown that cooperation can be challenging (Grudinschi et al., 2013;Lorentzen & Tingvold, 2018;Solbjør, Ljunggren, & Kleiven, 2014) for reasons that include fragmented services and deficits in management and strategies for action (Grudinschi et al., 2013). Communication and coordination deficits also cause serious problems (Andfossen, 2016;Lorentzen & Tingvold, 2018;Solbjør et al., 2014). On that basis, management of collaboration between healthcare services and volunteers should focus on high service quality and how resources and capabilities can interact more efficiently to create social value (Grudinschi et al., 2013). In that regard, there is a need to understand whether and how technology can support more effective organisation of volunteers.
Volunteer coordinators must manage diverse information about their volunteers, including demographic, contact and scheduling details (Voida, Harmon, & Al-Ani, 2011), and innovative technologies and new ways of working afford opportunities for improved interaction (The Royal Health & Care Department, 2014-2015. However, as volunteer coordinators often have little or no training in information systems, many have created their own unique "homebrew" databases, which fail to fully exploit the benefits technology can provide. Noting this issue, Voida et al. (2011) called for more needs-adapted and flexible information systems to support the coordination of volunteers in smaller organisations. However, there is little research on the digital technology required to support such coordination and collaboration.
This study addresses information exchange and communication between healthcare employees and volunteers and gives suggestions of information system requirements that might contribute to better coordination of volunteers.
The research questions are as follows.

| Design
To investigate the information exchange and communication of the target population, we used a qualitative case study approach, addressing three specific cases. This approach is applied to gain an in-depth understanding of the experiences and needs (Stake, 1978), in the communication and information exchange between different stakeholders in primary healthcare and identify their views on how technology might support those needs. The data were collected by means of focus group interviews, which facilitate conversation and help to identify new issues of relevance to the research question (Malterud, 2017).

| Setting
All three cases were in healthcare settings and were chosen because they involve volunteers in the daily practice to participate in social activities with elderly people. The three different cases will give an in-depth understanding of the communication The goal of the In For Care project is to optimise informal and formal networks for innovative service delivery in the public sector. As members of the project consortium, the two participating municipalities will implement and test a digital solution for volunteer coordination and collaboration.

| Participants
Snowball sampling was used to recruit participants. Managers from the two municipalities, and recruited healthcare employees representing the three cases. These healthcare employees participated in the study, but they also helped us recruit participants who worked as volunteers at the different settings and one patient. Due to the nature of the patient groups, only one patient participated in one of the focus groups, but patients were instead represented through participation of relatives. The focus groups consisted of between four and eight participants, and three of the authors were present (see Table 2).

| Data collection
Data were collected from five focus groups conducted during September-October 2017. The purpose was to explore a range of views rather than to achieve consensus, and the open atmosphere encouraged participants to express differing opinions (Kvale & Brinkmann, 2009). Their interactions provided the primary data. A semi-structured interview guide helped so that different perspectives would emerge during the discussion (Malterud, 2017), keeping participants focused on the topic while allowing the group to explore the subject from as many angles as they wished (Kvale & Brinkmann, 2009). The interview guide addressed such topics as how cooperation was organised in the municipalities, how it could be improved, and whether and how technology might assist communication and information exchange. The interviews lasted between 60 and 90 min and were held in a setting considered neutral for all stakeholders, with no interruptions or external influences. All interviews were recorded and transcribed verbatim by the authors; notes were also taken throughout.

Case
Location type Description Purpose

#1
Wards for people with dementia at two different nursing homes in municipality 1.
Institutions certified as "Joy of Life" nursing homes by the national non-governmental organisation, "The Joy of Life for Seniors" (in Norwegian: "Livsglede for eldre").
With support from the government, this organisation has established a national certification scheme where nursing homes can be certified as Nursing Homes of Joy by meeting specific criteria. The criteria include a systematic approach for providing meaningful activities for seniors. The nursing homes engage volunteers to participate in activities with ageing residents.

#2
Two-day centres for seniors connected to the two nursing homes from municipality 1.
Volunteers helping with various social activities at the day centres.

#3
Activities related to the project, "Active social environment for older adults" (in Norwegian: Aktivt seniornettverk, ASEE) in municipality 2.
The purpose of the project was to prevent loneliness, passivity and social withdrawal among older adults living at home. Healthcare services and the volunteer centre cooperated to promote activity, participation, social community and to offer meeting places for lonely older people to be involved in activities with volunteers.

Description of participants (Number)
Case 1 -two focus group interviews. Participants from two nursing homes in M1 Case 2 -two focus group interviews. Participants from two day centres in M1

| Data analysis
The analysis followed Fleming, Gaidys, and Robb's (2003) Gadamerian approach. Based on the hermeneutic circle, this method facilitated indepth understanding through several rounds of dialogue with participants and subsequent analysis of the transcribed text. Importantly, the analysis took account of the authors' preconceptions about the topic, and the authors discussed these. According to Fleming et al. (2003), this discussion enables researchers to understand the phenomenon and to transcend the horizon of their own existing understanding. The analysis consisted of four steps (Fleming et al., 2003); the first of these was to identify stakeholder utterances that reflected the meaning of the text as a whole. To that end, the text was carefully read several times by the research team to gain an understanding of the whole, keeping an open mind, as this reading would influence their understanding of every other part of the text (Fleming et al., 2003). Second, the text was imported to NVivo software, version 11 (QSR International Pty Ltd, Melbourne, Vic., Australia), for analysis. Every sentence and section were investigated to expose its meaning and to enhance understanding. During this process, different themes emerged, providing a rich and detailed overall understanding. Third, each sentence and section were related to the meaning of the whole, so expanding the overall sense of the text (Fleming et al., 2003). Finally, passages were identified that seemed representative of the understanding shared by the research team and participants in relation to communication and information exchange experiences, success factors and challenges (Fleming et al., 2003). At the end of the process, the research team met with participants and presented scenarios based on the findings to validate the researchers' understanding. All authors participated actively in all phases of the analysis.

| Ethical considerations
All data from the case studies have been managed to ensure confidentiality and anonymity. Ethical considerations were respected throughout, and approval (54985/3/HIT) was secured from the Norwegian Science Data Services. The research was designed and implemented according to the Declaration of Helsinki (Bates & Robert, 2006) and the common principles of clinical research (World Medication Association, 2013). All participants provided signed informed consent before participating in the study. They were informed that participation was voluntary, that they could withdraw at any time and that all relevant information and data would be destroyed in that event.
Participants were also informed that all information about them would remain confidential and anonymous in compliance with the GDPR data protection requirements (European Commission, 2018).

| FINDING S
The results reported below relate to three different cases in two municipalities (see Table 1). Two of the cases related to the coordination of volunteers to support activities in nursing home wards and in day centres in one municipality. In the other municipality, the case related to engaging volunteers in social activities for older people living at home. The first of four results sections provides an overview of the process of involving volunteers. The second section addresses characteristics of information exchange and communication in the interaction between healthcare services and volunteers, and the third section concerns related challenges.
Finally, the fourth section presents participants' suggestions regarding how technology might be used to support information exchange and communication.

| Involvement of volunteers: an overview
While employees at the participating nursing home primarily approached patients' relatives as potential volunteers, employees at the day centre and volunteer centre worked in most cases with volunteers who were not family members. In general, volunteers contributed to daily tasks and events. In the Active Social Environment for Older Adults (ASEE) project, volunteers primarily engaged in one-to-one interactions with people who needed social contact.
Volunteer centres in both municipalities were independent of healthcare services. Documentation procedures also differed across the three cases.
In the wards and day centres, routines for documenting activities were informed by the criteria for "Life of Joy" homes, requiring reporting of these experiences on the municipal electronic health record. No documentation was required at the volunteer centre or for the ASEE project.

| Information management in the interaction between healthcare services and volunteers
The analysis revealed three themes related to information exchange and communication between healthcare services and volunteers: informal communication, unsystematic processes and uncontrolled access of information. Uncontrolled access of information: Lack of routines and systems for registration and documentation affected the organisation of information. Contracts, confidential agreements and police certificates of good conduct were mostly paper based, and in all three cases, documents were stored in managers' offices: "They are on a shelf, and when someone quits, I take them and put them in a drawer […]" (C2HE).
As employees also worked from home and sometimes took documentation with them, there was unsecured storage of volunteer contracts, which might contain sensitive information: "It is on my kitchen counter" (C3VM11). Employees felt it was time consuming to change their ways of working.

| Implications of the identified challenges
The nature of stakeholder communication and interaction meant that employees spent time on paperwork and administration that might have been spent caring for service users. As one day-centre manager told us, "All the time I spend on such things is time that I could have spent with elderly users" (C2HE7). Employees found it time consuming to communicate verbally or by written notes to all patients, volunteers and relatives who volunteered, or to ensure that everybody had received the information. Managers at the volunteer centre referred to the many unnecessary inquiries that were not addressed to the right person or organisation, and much of their time was spent relaying this information to the correct recipients.

| Possibilities for technology in the interaction between healthcare services and volunteers
In all three cases, there was discussion of the possibilities for using technology. The patient who participated in case 3 was not technology literate and told us she would be unable to use such applications or solutions. Some participants expressed satisfaction with the existing approach to communication and information exchange. As one relative said, "I believe more in interaction between people… to make inputs in a system, I already feel the hair standing up on the back of my neck." (C1R19).
However, employees and volunteers felt that technological support could help to resolve challenges related to providing an overview of activities, coordinating the distribution of information, communicating more efficiently and storing documentation.
Participants offered a number of suggestions about how technology could ease and systematise communication and information exchange (see Table 3). Volunteers also suggested a list of available tasks they could opt for, but they also wanted to be able to propose tasks. As one vol-   Sector, 2017;Stirling, Kilpatrick, & Orpin, 2011), as personal contact is known to be effective for recruitment purposes (Cnaan & Cascio, 1998;Watts & Edwards, 1983). Participants in this study noted the importance of the first recruitment meeting as an opportunity for employees to build a personal relationship with the volunteer. Previous research has also noted the importance of this first meeting for healthcare employees for clarifying roles and gathering sufficient information to decide whether the volunteer is a good fit for the tasks in question .

| D ISCUSS I ON
Our findings also reveal a lack of systematic processes in  to provide information through multiple channels and favoured a system that would provide an overview of all available activities in the municipality. Voida et al. (2011) reported that volunteer coordinators create their own "homebrew" databases using personal office applications. This poses information management challenges related to local spread sheets, emailing clients and paper-based records. Grudinschi et al. (2013) characterised the use of resources for information exchange between care service suppliers as ineffective.
In municipality 1 in our study, employees found it difficult to define tasks they needed volunteers' help with. In turn, volunteers wanted clear instructions, noting that it was easier to volunteer when they knew where to go and what to do. However; technology cannot always replace the need for human interaction, and volunteers wanted to be met in the first instance by an employee and shown around. Previous research has also reported challenges related to communication, role clarification and the need for follow-up (MacLeod, Skinner, & Low, 2012;. In general, effective communication is essential, and volunteers expect to be informed about relevant organisational and task-related issues (Jamison, 2003). According to Lorentzen and Tingvold (2018), a lack of communication and information exchange between employees and volunteers can create friction among stakeholders.
In all three cases in this study, employees reported that contracts and confidential agreements were paper based and stored in The present findings confirm a need for flexible solutions for working with documentation outside the office while also ensuring that contracts and agreements are stored safely and electronically. It seems likely that cooperation between primary healthcare service employees and volunteers would benefit from clear procedures that ensure security for all parties (Fensli, Skaar, & Söderhamn, 2012). Appropriate electronic storage and communication would need to comply with existing confidentiality and data protection regulations (European Commission, 2018) for public services.
The main implication of our findings is that unsystematic processes and uncontrolled access of information means that time is wasted on paperwork and administration instead of on delivering service to the users. It follows that the information flow between organisations and volunteers would benefit from technology-based solutions, although not at the expense of informal contact.
Appropriate use of information and communication technology can enhance systematisation and security, but for optimal effect, these systems must be based on the needs of users (Borycki & Kushniruk, 2008).
Volunteer coordinators must manage a range of information about volunteers that includes demographic, contact and scheduling details. In this study, information handling was found to be demanding, and employees lacked effective systems for this purpose. Pestoff (2012) argued that information technology is important in the coproduction of public services to facilitate greater interaction between public agencies and citizens, and Burt and Taylor (2003) noted the potential of information and communication technologies to transform voluntary organisations through knowledge management, organisational learning and reconfiguration of relationships.
The participants in our study identified, in particular, a need for technology to support recruitment processes, to overview volunteers and activities, to convey information about activities and for information management. Recruitment was considered especially important, and participants highlighted the need for some means of electronic contact for potential volunteers. This aligns with previous findings that ease of communication supports the ability to reach out, maintain contact and share knowledge (Andersson, Magnusson, & Hanson, 2015). In addition, enhancing electronic messaging by email and SMS may enable staff to reach more contacts in a shorter time (Andersson et al., 2015) and to log all processes in a structured way.
Another issue that emerged from the three cases concerned the availability of information about activities, organising these in a shared calendar and the use of technology to assist coordination within and among organisations. Uryan, Matusitz, and Breen (2012) showed that digital systems can enhance interorganisational relationships or networks, but this technology must be user friendly, and all information should be kept in one place (Christie et al., 2018).
According to Voida, Harmon, and Al-Alani (2012) (Voida et al., 2012). There is also some evidence (e.g., Eimhjellen, 2014) that face-to-face and internet communication is not an either-or phenomenon, as internet use can increase face-to-face interaction in voluntary organisations.
Some participants indicated that they were satisfied with current practices for communication and information exchange and felt there was no need for change. In this regard, it is important to ensure that the introduction of technology responds to real needs and actually improves practices in the relevant areas. For example, in their study of the role of mobile applications in recruiting, managing and retaining volunteers in non-profit organisations, Chui and Chan (2019) found that ease of signing up as a volunteer through a mobile app increased last-minute dropouts and no shows. They noted that technology-based solutions do not ensure volunteer quality and accountability, as volunteering also involves issues such as ethics, social skills and responsibility. They concluded that existing screening processes for volunteers should still be conducted face to face and are unlikely to be replaced by technology, which aligns with our own findings. In general, volunteers who are engaged in what they do are more likely to increase service quality and overall organisational performance (Chui & Chan, 2019).
According to Voida et al. (2011), volunteer coordinators were concerned that technology-based solutions would attract too many volunteers rather than targeting those truly interested in the organisation's mission. Coordinators were also concerned that it would be time consuming to prepare so many volunteers and that they would lose control of the recruiting and scheduling process. However, many volunteer management priorities could benefit from technological support in terms of reduced administrative burden and strategic targeting and maintenance of links with volunteers.
All necessary steps were taken to ensure this study's validity.
Informants in the five focus groups represented key stakeholders (volunteers, relatives who volunteered and employees), but only one patient participated in a focus group interview, as the nature of the patient group made it difficult for project managers in the two municipalities to recruit patient/users. For that reason, the findings are limited to the immediate context. However, the similarity of findings across the three cases suggests that this research may be generalisable to other settings (both in Norway and other countries) where different organisations communicate with and coordinate volunteers to provide primary healthcare services.

| CON CLUS ION
This study identified communication and information exchange needs of health service employees and volunteers, including patients' relatives and general volunteers. The research contributes new knowledge about communication and coordination processes among these stakeholders regarding engagement in social activities with ageing patients in southern Norway. We found that much of the existing communication is informal in character and lacks systematic coordination. This is time consuming for employees, who consequently have less time to spend with service users. Both volunteers and relatives who volunteered would benefit from a more systematic approach to information exchange and communication, and the findings indicate that a technology-based solution that addresses these challenges can strengthen (rather than replace) human interaction.
Future research should implement and test technology-based tools to support information exchange and communication among healthcare organisations, volunteer organisations and volunteers to further clarify challenges and success criteria.

ACK N OWLED G EM ENTS
The authors would like to thank all the employees, volunteers, users and their relatives from the two municipalities that made this research possible.