Being a volunteer encountering older people's loneliness and existential loneliness: alleviating loneliness for others and oneself.

BACKGROUND
The increasing proportion of older people worldwide is challenging society and the healthcare sector to develop new solutions, such as involving volunteers, especially to combat loneliness among older people. Loneliness is a broad concept comprising, for example existential loneliness - a deep feeling of aloneness in the world. We know little about volunteers' experience of encountering older people's loneliness in general and existential loneliness in particular. Such knowledge is important in order to develop high-quality volunteering.


AIM
This study aimed to describe volunteers' experience of becoming and being a volunteer, and encountering older people's loneliness in general and existential loneliness in particular.


METHODS
This descriptive qualitative study is based on eight focus group interviews and twelve individual interviews with volunteers from different organisations, analysed using conventional content analysis.


FINDINGS
Being a volunteer meant being a fellow human being, alleviating loneliness for others and oneself. Becoming a volunteer was a way of finding meaning, and volunteering made the volunteers feel rewarded and simultaneously emotionally challenged. Being a volunteer also meant acting on one's values, challenging boundaries when necessary. Encountering loneliness, including existential loneliness, required sensitivity to others' needs for both closeness and distance.


CONCLUSION
Being a volunteer benefitted not only the older persons the volunteers met, but also the volunteers' own sense of meaning, by alleviating their own loneliness. Sharing existential thoughts and having meaningful conversations about life and death are challenging, but can contribute to the personal growth of the volunteers themselves. It is important to remember that not all volunteers are confident in having existential conversations, so it is important to pay attention to each volunteer's prerequisites and needs. In addition, there is a need for support to volunteers' engagement such as clarifying their role and clarifying the responsibility and expectations from health and social care.


Background
The proportion of older people is increasing worldwide (1), challenging the healthcare sector. Another challenge is that of combating loneliness among older people. Loneliness can have severe consequences for health in terms of, for example, cardiovascular diseases and poorer mental health (2), and a study of nursing home residents found associations between emotional loneliness and mortality (3). In caring for older people, it is therefore vital to find complementary human resources, such as volunteers, to help address these challenges. The Swedish media present volunteers as a resource to reduce older people's loneliness (4). Although a large body of research explores various aspects of the involvement and role of volunteers in different contexts (5)(6)(7)(8), little is known of volunteers' experiences of encountering loneliness. One of the few studies of volunteers' own experiences of encountering loneliness was conducted in the palliative care context by Andersson and € Ohl en (9), who concluded that there is a need for volunteer support, especially focusing on existential issues. We know that older people can experience a deep loneliness, so-called existential loneliness (10), which volunteers caring for older people certainly encounter. However, we know little about volunteers' experience of encountering older people's loneliness in general and existential loneliness in particular.
Loneliness can be measured objectively in terms of the number of friends and social contacts, but loneliness is also the subjective experience of feeling lonely. According to the results of a Swedish national longitudinal study of the long-term predictors of loneliness (11), current social engagement, current close relations and access to social support were important factors counteracting loneliness. The importance of close and meaningful relations was also addressed in the national annual follow-up of the care of and service to older people (12), which found that the experience of loneliness was more frequently reported among residents in residential care, receiving service around the clock, than among older people living at home receiving home care. This is supported by findings of a study of loneliness among older people in residential care, showing that the experience of loneliness was not related to the number of social contacts or even to the number of contacts with family and friends; instead, emotional closeness, giving a sense of security, had an impact on loneliness (13). Feeling lonely thus does not seem to be primarily related to the accessibility of other people, but rather to the accessibility of meaningful relations.
It is important to recall that being alone is a phenomenon with both positive and negative connotations. The literature identifies different kinds of loneliness. A conceptual review of qualitative studies of loneliness (14) identified three overlapping types, that is social loneliness, emotional loneliness and existential loneliness. Social loneliness is related to both the quantity and quality of relationships and can result from the absence of social connections. Emotional loneliness is related to the absence or loss of meaningful relationships (14), and Weiss (15) described it as a subjective response to the absence of a generalised attachment figure. Existential loneliness is regarded as a human condition connected to human existence (16,17) and is more associated with being separate from others and the rest of the world, especially when confronting trauma or mortality (14). According to Applebaum (18), awareness of existential loneliness emerges in moments of silence and slowerpaced activity. One definition of existential loneliness, based on theoretical and empirical studies, is 'the immediate awareness of being fundamentally separated from other people and from the universe, and typically, because of this awareness, experiencing negative feelings, i.e., moods and emotions' (19). Older people themselves have described existential loneliness as being trapped in a frail body, being met with indifference, lacking meaning and purpose in life, and lacking someone to talk to about meaningful aspects of life (10). This is in line with another study of nursing homes and home care service in Sweden, showing that older people experienced a sense of alienation and insecurity and an absence of dialogue with staff (20). Also, patients with cancer and heart disease experience loneliness when they have limited opportunities to share their feelings and experiences with professionals (21). In turn, healthcare professionals find that encountering existential loneliness among older people is challenging (22), although the availability of time and opportunities differs between contexts (23). Volunteers may offer something that healthcare professionals cannot, and could be important complementary human resources, for example contributing something from the outside world (24). As older people seem to have many unmet needs, volunteers could play an important role by providing meaningful conversations as a way to alleviate suffering and loneliness. However, there is a need for more knowledge from the perspective of the volunteers.

Aim
This study aimed to describe volunteers' experience of becoming and being a volunteer, and encountering older people's loneliness in general and existential loneliness in particular.

Design
This study is part of the LONE study (IRRID: 10.2196/ 13607) (25), exploring existential loneliness among frail older people from the perspective of older people themselves, their significant others, healthcare professionals and, in this study, volunteers. The results of the LONE study, encompassing a concept analysis, qualitative studies based on various individual and focus group interviews, and quantitative studies based on questionnaires, will form the basis for developing an intervention focusing on support in encountering older people's existential loneliness. The present study had a descriptive qualitative design (26) and was based on focus group interviews as well as individual interviews with volunteers encountering older people.

Participants
A total of 32 volunteers, 23 women and nine men aged 46-87 years, participated in the focus group interviews (Table 1). They represented different organisations, that is the Swedish Church, the municipal volunteer organisation, the Red Cross and an independent organisation called the Friend-Visitor Service, from different geographical areas in southern Sweden. The selection of organisations was intended to sample different kinds of volunteer assignments and contexts, such as home visiting, volunteering in nursing homes or hospitals, and hosting at community centres. Some participants volunteered in one context only, while others operated in more than one. Depending on the context and assignment, the contacts with the older persons ranged from temporary contacts to relationships lasting several years ( Table 2). The included organisations were active in larger cities, small towns and villages. At the end of the focus group interview, the participants were asked whether they were interested in participating in an individual follow-up interview. All participants showed interest and provided contact information.
Of the participants in the focus groups, 25 were selected as eligible for participation in individual interviews, based on an intention to obtain variation in age, occupational background and organisation. They were invited to participate by mail, e-mail and/or telephone. Five invitees declined, seven did not reply, and one cancelled on short notice. Of the remaining twelve participants who agreed to participate, nine were women and three were men, aged 47-76 years ( Table 1).

Data collection and procedure
Data were gathered from focus group and individual interviews. This combination was used based on the idea that participants in focus group interviews develop their ideas when they share and discuss their experiences with others (27), while individual interviews can contribute to an in-depth understanding of a given phenomenon (28). The main interest in the focus group interviews was the volunteers' experience of encountering older people's loneliness in general and existential loneliness in particular. However, as the focus group discussions concentrated on encountering loneliness in general, the data collection was supplemented with individual interviews to obtain more in-depth data about encountering existential loneliness and about personal motives for becoming a volunteer. The data from the first six focus group interviews have also been analysed to explore volunteers' perceptions of older people's existential loneliness and are presented elsewhere in Swedish (29).
Focus group interviews. The data collection started with two focus group interviews in 2014, serving as pilot interviews. As only minor revisions needed to be made to the pilot interview guide, these interviews were included in the main study. Another six focus group interviews were performed during 2017 and 2018, for a total of eight focus group interviews. The practical arrangements were coordinated by a contact person in each local volunteer organisation who also distributed written information about the study to all members. Those interested in participation contacted the contact person, who in turn informed the researchers.
Each focus group interview was scheduled to last 2 hours and was conducted in a room designated by the organisation. The focus group interviews were performed  in different configurations by a team of four, with the first (MS) and the second (KB) authors leading six of the eight sessions, as either moderator or facilitator. The moderator led the discussion, while the role of the facilitator was to be attentive to issues that otherwise might be overlooked, take notes and summarise the discussions at the end of the focus group. All focus group interviews followed the same structure. The moderator started each session by informing the participants of the study's purpose and then obtaining written consent. All interviews were introduced in the same way, with the participants being asked to reflect on loneliness in general and existential loneliness in particular among older people. Thereafter, questions were asked about their experiences of being volunteers, encountering older people's loneliness and existential loneliness. The moderator asked follow-up questions such as 'Has anyone else had similar experiences?' or 'Do I understand you correctly when you say . . .?' Before ending each interview, the participants were asked whether there was anything they wanted to add. Seven focus groups had three to four participants, while one focus group had seven participants. Demographic information such as age, volunteer experience, and current or previous profession was collected after the interview, apart from the pilot interviews where no such information was collected. One interview lasted 69 minutes and the others 91-111 minutes; the interviews were audio-recorded and transcribed verbatim.
Individual interviews. The individual interviews were conducted between October and December 2018. A pilot individual interview was first performed; as only minor revisions needed to be made to the interview guide used, this interview was included in the main study. The date and place of the interview were chosen by each participant, that is a place connected to the organisation, the interviewee's home or the university. All interviews were performed by the first author (MS), who, before each interview began, presented the purpose of the study, repeated the written information everyone had received in advance and obtained the participant's written consent. The interview guide was semi-structured (30) and included most of the same questions as used in the focus groups, that is initially asking about the volunteers' experience of encountering older people's loneliness, but with a more specific emphasis on encountering existential loneliness. Thereafter, questions about their experience of becoming and being a volunteer, in what way it affected them to encounter existential loneliness and existential issues and about their need of support, were asked. The interviewer asked follow-up questions such as 'What do you mean by that?' and 'Do I understand you correctly when you say . . .?' Before ending each interview, the participant was asked whether there was anything she/he wanted to add. The interviewer finally informed the participant about what had been noted during the interview; the interviewee was asked to confirm these results and was encouraged to further develop his/ her thoughts. This part of the interview also served as a quick member check. The interviews lasted 45-97 minutes (md = 72 minutes), were audio-recorded and transcribed verbatim.

Analysis
Conventional content analysis (31) was used to analyse the data. First, all authors read all interview transcripts from all interviews, that is individual and focus group interviews were read as one unit, to achieve immersion and obtain a sense of the whole. The first and third authors then discussed their impressions and how to proceed. Since the individual interviews were characterised by more in-depth data, the authors started by analysing them. Meaning units related to the aim were identified and coded by the first author, and a coding scheme was created. Next, the focus group interviews were read and coded in the same way. When all data were coded, all three authors discussed the coding and grouped all the codes into 13 meaningful clusters (31) (Appendix). During the analysis, there was constant movement between the parts and the whole, that is between the texts, codes, clusters and tentative categories. According to Hsieh and Shannon (31), researchers might also decide to identify relationships between categories. At this point of the analysis, we identified that codes and tentative categories were related to either of the areas (i) becoming a volunteer, (ii) being a volunteer or (iii) encountering loneliness and existential loneliness, and were sorted into each area. Finally, one overall understanding of becoming and being a volunteer, encountering older people's loneliness in general and existential loneliness in particular, was created.

Ethical considerations
According to the principles of autonomy, nonmaleficence and beneficence (32), the following aspects were considered. All prospective participants were given advance opportunity to consider participation by receiving written information on the study; those who agreed to participate gave their written consent. In some cases, considerable time had passed between the focus group and the individual interviews, so special attention was paid to participant doubtfulness, even though participants had earlier expressed interest in participating. To make the participants feel as comfortable as possible, they chose the place for the individual interviews. As existential loneliness is a sensitive topic, the interviewers tried to be attentive for any signs of discomfort during the interviews.

Findings
Becoming and being a volunteer encountering older people's loneliness and existential loneliness encompassed four categories: one category embracing the experience of becoming a volunteer as 'A way to find meaning', two categories embracing the experience of being a volunteer as 'Feeling rewarded as well as emotionally challenged' and 'Acting in line with one's values, thereby challenging boundaries', and finally one category embracing the experience of encountering loneliness in general, and existential loneliness in particular, as 'Being sensitive to others' needs for closeness and distance'. The overall understanding of becoming and being a volunteer encountering older people's loneliness in general and existential loneliness in particular was 'Being a fellow human beingalleviating loneliness for others and oneself' ( Table 3).
The overall understanding, Being a fellow human beingalleviating loneliness for others and oneself, portrayed the volunteers' specific mission in the care of older people. They emphasised that their role differed from that of the healthcare professionals, in that their role was simply to be fellow human beings. As a volunteer, one usually had more time than the healthcare professionals, who often had someone else waiting for attention. The volunteers said that trusting relations were built over time and that reciprocity was essential, that is meeting as two equal human beings. Volunteering and having close and meaningful relationships with the visited older persons were experienced as alleviating both the older persons' own loneliness and the volunteer's own loneliness. The volunteers also alleviated their loneliness through the opportunity for social activities with other volunteers. The volunteers could relate to their own experiences, which in turn affected their view of loneliness and existential loneliness and how these were experienced and approached.

Becoming a volunteer
A way to find meaning. The decision to become a volunteer was based on various motives and driving forces. One motive was to do good for someone else in general and to older people in particular. A second motive was to do something meaningful. A third motive was to give something back to society, linked to the idea of one's duty as a citizen. To be appreciated, affirmed and needed by another person were other motives mentioned by the volunteers. Several participants started to volunteer shortly after retirement, based mainly on insight into their new situation and a desire to do something with their time to counteract boredom.
Well, I've actually never had a problem with loneliness, more than when my parents passed away. I did feel emptiness then. And, in fact, I had to fill that . . . that emptiness . . . with human contact. I was in the habit of visiting them once a day, so I had to fill that gap with something. (Focus group interview 7) Moreover, some of them mentioned a feeling of still having something to offer others, but not necessarily involving close, long-term relationships. Other volunteers mentioned that their parents, no longer alive, had felt trapped and abandoned when they were nursing home residents, so they volunteered as a way to continue to do good, to restore themselves, or even as part of mourning.

Being a volunteer
Feeling rewarded as well as emotionally challenged. Being a volunteer was considered an honourable and rewarding mission. The mission was described as enriching, meaningful and bringing pleasure, making the volunteers feel valuable. The volunteers considered the ability to create trusting relations and to receive and maintain the older person's trust to be highly important. They also emphasised that the relationship was reciprocal and rewarding for themselves on a personal level. The relationship differed from other relationships, even for those who had previously worked in the healthcare sector.
I mean you're just two individuals, of different generations or whatever, right? It's of course not a matter of . . . if you're staff, you kind of have your professional rolethat you have to maintain a professional manner. And that . . . of course for a volunteer it's not like that at all. (Individual interview 5) Being a volunteer could also mean 'feeling like an outsider' in the care context. Some participants described their frustration at not being included in the setting where they volunteered, being taken for granted by the healthcare professionals in the setting, feeling used or being viewed as an inconvenience, all of which complicated their mission. However, some participants also described the opposite, that is a sense of belonging and being included in the setting or organisation. Depending on the setting, there was freedom as to when and how the voluntary assignment should be performed and to operate in accordance with one's values. Others described the mission as being a cog in a wheel and as something valuable.
The volunteers described their mission not only as one that taught them life lessons, but also as an existential and emotional challenge. There were feelings of frustration, powerlessness and helplessness, and a feeling of inadequacy: 'But then again, sure, there are times when you feel inadequate and would like to be able to somehow break through even more, you know?' (focus group interview 8). When encounters or situations were difficult to handle or distressing, most volunteers had someone in the organisation to whom they could turn when needed. Others described taking a moment to be by themselves as helpful, or to talk with a close family member. The boundary between volunteering and friendship became increasingly blurred the longer the assignment lasted: the older person had become a friend, and at the same time was not one. This relationship affected the volunteers personally, and they highlighted their own need for continuity and the importance of ending a relationship in a positive way.
Acting in line with one's values, thereby challenging boundaries. Being a volunteer meant having a frame for a mission, a space in which to act in line with one's values. Some volunteers emphasised the importance of understanding the limitations of their mission, while others instead expressed uncertainty. As a volunteer, making home visits meant more freedom, while volunteering at the hospital meant adjusting to predetermined routines and boundaries. The mission included encountering the older person as a unique person, so, when necessary, some volunteers challenged boundaries, not being held back by routines.
So, I did some things that a volunteer maybe shouldn't do. Interviewer: What did you do? I became . . . well, I became quite close to her. I accompanied her on visits to the physician and helped her move to another place. These are things that a volunteer is not supposed to do. Interviewer: So you did quite lot of practical things as well? Yes, there was quite a lot of practical work. In between, we sat and talked, and she cried and told me about her life. (Individual interview 3) Being a volunteer meant being able to adjust to these boundaries and what was possible to do, being able to let go and feeling that one had done enough. The mission could include encounters with healthcare professionals and with relatives who did not act in accordance with the volunteers' own values, which was frustrating. Acting in line with one's values could also involve acting as a representative when an older person could no longer fully manage on his/her own, sometimes challenging set boundaries, for example in situations when the older person has no one else to rely on and the volunteer has become the only source of personal support. Furthermore, this entailed keeping up to date about activities that the older person enjoys but can no longer do by him/herself. Being a representative of the older person was not a formal or explicit role, but an informal role as a fellow human being.

Encountering older people's loneliness in general and existential loneliness in particular
Being sensitive to others' needs for closeness and distance. According to the volunteers, some older persons were not ready or lacked the ability to talk about existential loneliness or have existential conversations. Therefore, the volunteer's own ability to be sensitive to the other's needs was essential. Some volunteers described the importance of closeness and of alternation between closeness and distance, while others considered distance to be necessary. Visiting an older person, who seemed to live a slow and monotonous life from the outside, meant adjusting to the situation, mostly talking and just 'being' together. One participant called the visit 'a brief glimpse into existence', aware that the visit lasted only a moment. According to the volunteers, expressing one's existential needs and suffering may be difficult for some older persons, and lack of appropriate words could be one reason for this. The volunteers said that they encountered older people who did not want to be a burden or did not have anyone to confide in, which led them to keep concerns to themselves. The importance of being respectful, being attentive and listening to the older person's needs was emphasised. Words were not always the most important tool, and being comfortable with silence and adjusting to a slower pace were described as undervalued abilities one needs to learn as a volunteer.
What happens happens, you know, so that thoughts can ripen or end up somewhere and then . . . then, like I said, you can of course spend time together and have a sense of togetherness without necessarily talking. And you need a bit of trainingto learn how not to feel some sort of panic if there's only silence, you know, how to simply let the silence be. (Individual interview 1) Volunteers encountering loneliness 543 The volunteers described kindness and consideration, as well as being able to listen without interrupting or judging, as essential for having meaningful conversations. Existential conversations concerning death, guilt or shame were not planned, but emerged spontaneously. The volunteers emphasised how important it was to alternate between depth and surface, depending on the needs of the older person. The volunteers stressed that although they were prepared to have existential conversations, the older person also needed to be ready: it was important to be sensitive and to show respect if someone did not want to deepen the conversation.
At the same time, listening to the older person's existential concerns presupposed self-awareness and having processed one's own beliefs. Some volunteers tried to deflect conversations about loneliness, not giving it too much attention, which could lead to superficial conversations; instead, they would encourage more positive conversations and strive to bring joy and laughter into the older person's lonely existence.
No, but it is that way, usually that's maybe what you start talking aboutnot death, but about this feeling of loneliness . . . I mean, it starts with the old lady saying, like, 'Oh, I'm so happy you came! I've missed you so much! I've been so lonely,' she'll say. And so that's like an opening. And then you get chatting and then I might try to . . . I mean, at the same time I think you shouldn't try to expand on this feeling, make it stronger. (Focus group interview 1) The volunteers described existential loneliness as related to the older person's present as well as past life, including thoughts such as 'What have I done?' and 'What has life given me?' It was a feeling that could not be fully shared with anyone else, but was something that must be partly dealt with on one's own. Participants stated that existential concerns were to be met with respect and authenticity, although some volunteers avoided existential conversations as they thought others were better equipped for them. Although the volunteers mostly discussed simply 'being' with the older person, 'doing' things was also described as important. This could mean taking an active part in planning future activities and meaningful events with the older person, which could include space for existential and meaningful conversations.

Discussion
The overall understanding of becoming and being a volunteer encountering older people's loneliness in general, and existential loneliness in particular, was being a fellow human beingalleviating loneliness for others and oneself. Being a volunteer in the care of older people was beneficial not only for the older persons, but also for the volunteers' own sense of meaning and community. Our findings indicated various motives for volunteering, such as doing good, being needed by somebody, being appreciated and being affirmed. Thus, one driving force of being a volunteer was to find meaning. Viktor Frankl (33) claimed that searching for meaning is a primary force in life, and further described a lack of meaning as an existential vacuum, that is boredom and meaninglessness in life. Volunteering might therefore be one means to counteract one's own existential vacuum. Being a volunteer also taught life lessons, and the relationship with the older person could gradually become more of a friendship than a formal volunteer-'client' relationship. This unique relationship and the specific role of the volunteer have been highlighted in other studies. Volunteers caring for an older person, but not belonging to that person's social circle, offer existential encounters not otherwise available (34), while the presence of volunteers in a palliative care context gives patients an opportunity to talk freely, without having to worry family or friends (35). Sharing existential thoughts about life and anticipated death could even be rewarding for the volunteer and a way of being introduced to existential issues (34). Planalp et al. (36) showed that having meaningful conversations about existential matters, such as the meaning of life, was a challenge for volunteers, but also rewarding in terms of life lessons. This is in line with the present finding that being a volunteer meant being emotionally challenged, but also feeling rewarded. Furthermore, being a volunteer in the care of older people with dementia has been described as a mission that leads to increased learning and self-reflection (37). Sharing existential thoughts and having meaningful conversations about life and death are challenging, but it can contribute to personal growth for the volunteers themselves.
The participants' own life experiences affected their views of loneliness and existential loneliness and seemed to contribute to sensitivity to others' needs for both closeness and distance. A study from Norway in a municipal palliative care context highlighted volunteers' life experience and relational skills, that is being able to talk about disease and death, as advantages (38). A relationship based on reciprocity requires what Schuster (39) calls the presence of personal existential space. According to Schuster (39), personal existential space differs from professional/external space in that the personal space is inherent to our bodies and existence. By affirming one's personal existential space, equal relationships can develop. However, there are situations in which communication difficulties and lack of words to express existential needs can threaten conversations about existential issues. Being sensitive to the older person's vulnerability, using one's imagination and empathy, could be the key to getting closer to the older person (22). Also, providing volunteers with a space in which to act, where their own life experiences are acknowledged as a strength, and making volunteers part of the team seem essential (40). S€ oderhamn et al. (38) further stressed the importance of volunteers having a clear and defined role, not only for themselves but also for healthcare staff. It was crucial to have access to a mentor and to follow-up after a volunteer session, especially at the start of the volunteer engagement. Even so, our results indicate that not all volunteers were confident in having existential conversations, and some avoided them. Perhaps one of the most important things is to have knowledge of each volunteer's prerequisites and needs and to adjust the assignment accordingly. Improvement is needed in several areas concerning support for volunteers in their engagement. Knowledge of this can enable policymakers, nongovernmental organisations (NGOs) and leaders in the health and social care of older people to further develop volunteer service in the best interest of volunteers and the older people they visit.

Methodological considerations
Focus groups and individual interviews are used for different purposes. Focus groups are used to capture various perceptions and experiences (27). Existential loneliness is not a topic usually discussed on a daily basis, so focus groups were used to facilitate the sharing of experience and support reflection on existential loneliness. The individual interviews, on the other hand, enabled the generation of more in-depth data and created a space in which to develop reasoning, experience and beliefs (28). Thus, the individual interview format helped to deepen certain questions and allowed the interviewee to develop their reasoning, but also to focus more on their individual experiences. The combination of the two interview formats can compensate for each method's limitations, but also take advantage of each method's strengths (41). Regarding the number of participants in focus group interviews, Krueger and Casey (27) recommended five to eight participants as the ideal size, though if the topic is complex, fewer participants are recommended. Since loneliness in general and existential loneliness in particular are sensitive and complex topics, smaller groups of three or four participants seemed relevant (27). In this study, the larger groups tended to hold discussions on a general level, while the smaller groups facilitated interaction and the sharing of individual experiences.
The individual interviews ended with a member check. This was an opportunity for the participants to clarify their intentions, confirm what had been said, and, if necessary, to refine their reasoning. The member check can be seen as strengthening the credibility of the present findings (42). To increase the trustworthiness of our findings, quotations from both focus groups and individual interviews have been cited to illustrate that the findings emerged from both types of data (42). Qualitative researchers influence both the collection and interpretation of data, and the understandings and meanings of data are negotiated in a given social context (43). Reflection was therefore vital throughout the research process and was conducted in regular reflective discussions between the authors. Furthermore, the results were presented and discussed in a reference group connected to the LONE study, in which some of the participants were experienced volunteers. Concerning the transferability of the results, it is important to recall that the study was performed in a Scandinavian context, as traditions of volunteers in the care of older people vary between countries.

Conclusion and clinical implications
Being a volunteer was beneficial not only for the older persons the participants encountered, but also for the volunteers' own sense of meaning, alleviating their own loneliness. Sharing existential thoughts and having meaningful conversations about life and death are challenging, but can contribute to the personal growth of the volunteers themselves. It is important to bear in mind that not all volunteers are confident in having existential conversations; it is therefore important to pay attention to each volunteer's prerequisites and needs. There are further several areas of support for volunteers' engagement needing improvement such as clarifying their role and clarifying the responsibility and expectations from health and social care. Knowledge of these matters can enable policymakers, NGOs and leaders in the health and social care of older people to further develop volunteer service in the best interests of the volunteers and the older people they visit, as an essential complement to more formal healthcare services.