The Volunteer as a Facilitator of the Psychosocial Transition Into Long-Term Care Settings

The burden experienced by caregivers of older adults with complicated health issues often results in what has been described as caregiver burnout, the result of which is the decision to place such older adults in institutionalized care settings.^4,5 Placing a family member into long-term care marks a critical turning point in the life of an older adult. As the severities of the cognitive and physical disabilities intensify and the independence of the individual decreases, both the necessity and inevitability of institutionalization increase dramatically.

Because many transitions into long-term care are urgent and unplanned, families and loved ones are largely unprepared for what transpires.⁶ Transitional care strategies within long-term care facilities remain a largely under-recognized need. Because the care staff is often preoccupied with daily tasks and with attending to current residents, it is crucial to seek the support of another partner in the continuum of care who is able to provide an intermediary role in the form of attending to the social needs and interpersonal engagement of new residents. Volunteers can serve in this role, both by aiding the initial transition to the LTC setting and by providing ongoing companionship to new residents.

A long-term care facility (LTCF), as defined by Sarma and associates,⁷ is one that provides extended living accommodations and 24-hour onsite professional health services—including supervision and personal care—to its residents, in order to assist them in daily living. Furthermore, transitional care will be defined as the set of actions designed to ensure the coordination and continuity of healthcare as an older adult transfers between different care settings.⁶ However, these processes and criteria exemplify the bare minimum requirement in caring for older adults. Currently, gaps remain in the continuum of care that need to be addressed if the transition to an LTCF is to be successful. However, amidst an aging population, the availability of resources, funds, and personnel needed to successfully aid in this transition is limited.

For many people, simply the anticipation of moving into a LTCF can be a major source of anxiety, and the move can be perceived as a threat to quality of life and a loss of independence.⁸ Above all, regardless of the health conditions of the older adult, there must always be an effort to maintain acceptable levels of both quality of life and quality of care. Balancing necessity of care with quality of life amongst older adults—whether at home or in long-term care—remains a challenge. For example, even in an LTCF that provides excellent care, residents may not necessarily experience satisfactory quality of life. On the other hand, an older adult may adamantly choose to stay at home, even until death, if being moved into an institution is viewed as detrimental to his or her dignity, privacy, and autonomy. In this regard, the decision to remain at home may result in deterioration in quality of care but would be consistent with an older adult’s perception of an ideal quality of life. This may create tension between the social and medical aspects of care that those involved in the care of older adults continually seek to address.

The time required for a resident to begin to feel comfortable in his or her new environment will vary for each individual. However, it is only after a successful transition that the resident will begin to call the LTCF “home.”^9,10

Brandburg¹¹ outlined four phases in the transition into long-term care: (1) initial reaction; (2) transitional influences; (3) adjustment; and (4) acceptance. Beginning with the initial reaction, this phase is characterized by emotional responses which are not dependent on whether the admission was planned or unplanned. Being overwhelmed and disorganized, as well as feeling “homeless,” are often associated with this emotional response.¹¹ Following this, the resident undergoes what are known as transitional influences wherein new relationships are formed which may foster friendship and welcoming into the facility. However, this is also a vulnerable stage—feelings of rejection by other residents or unpleasant experiences with staff could easily have the opposite effect. The third stage—the adjustment stage—is characterized by interplay between positive and negative transitional influences, each with its own consequences. Thereafter, it is at the arrival of the acceptance phase wherein the older adult will begin to refer to the LTCF as their home. In particular, as the “transitional influences” and “adjustment” stages are heavily governed by the psychosocial aspects (and challenges) of health, it is here that the trained volunteer would play their most effective role in responding to a resident’s varying emotions and anxieties. Once the resident has accepted his or her new living conditions, ongoing long-term relationships may be formed and strengthened. 

Prior studies have suggested that proper transitional care can drastically reduce rates of rehospitalization for residents with complex care needs,^6,12 and that volunteers may be the key to providing this bridge in care.¹³ However, their precise role within these facilities has yet to be solidified. Meanwhile, the same gaps that emerge in medical care also arise in the social and psychological care of an individual during this transition. Chronic illnesses and diseases can be managed, but failure to provide “person-centered care” for residents – fulfilling social desires and need for human interaction – results in the older adult feeling neglected, isolated and burdensome.¹⁴ Camp and associates¹⁵ noted that traditional support interventions common in LTCFs tend to provide suboptimal stimulation for those with cognitive impairment, resulting in a more rapid loss of motor and communication skills. Depressive symptoms are also recognized as significant predictors of functional health.¹⁶ Finally, King and associates¹⁷ found that nurses working in skilled nursing facilities (SNFs) identified a particular need to understand a patient’s psychosocial history in order to facilitate a safe, high-quality transition. 

However, current research proposes that nonpharmacological support interventions in nursing homes have proven to be an effective alternative to antipsychotic medications in managing disruptive behavior in those living with dementia.^18,19 The reasons that these basic needs cannot be met—especially when it is expected that human interaction would be simpler than prescribing medication—generally include a lack of time and resources. As will be discussed, the establishment of a strong and committed volunteer program within the LTCF would assist greatly in providing therapeutic measures without undue burden on the care staff.

Recognition of the importance of community volunteers and the services they provide is not a new phenomenon.²⁰ However, current research on the expanding scope of volunteerism in patient-centered care remains limited.²¹ In long-term care settings, it is becoming common to see volunteers of any age who demonstrate maturity and resilience playing a role in the support system of the facility. The inclusion of the volunteer’s role has already proven effective in end-of-life hospice care,²¹ and such a role readily extends to addressing the needs of older adults in long-term care.

The role of the volunteer amongst an older adult population must be proactive rather than reactive.²² Although many community organizations simply speak of the “value” of their volunteers, they should be viewed as nothing less than a critical component in the integration of residents into long-term care. As Lawrence and associates¹⁸ noted, group psychosocial interventions are beneficial but resource-intensive. Therefore, in order to address the most at-risk residents entering the LTCF, individualized and targeted psychosocial stimulation would prove most effective. In order to accomplish this, it is worthwhile to have volunteers properly matched to their role and the work matched to the volunteers’ motivations. In general, when interventions are tailored to an individual’s backgrounds, interests, and skills, the result is an increased satisfaction of both the volunteer and the individual served.^19,20 With respect to the diversity of residents in LTCFs, more conscientious matching would be based on shared hobbies, common cultures, or languages spoken. Due to the fact that each older adult differs in terms of cultural background, language, educational status, and ability, the degree of attention required by any individual can vary dramatically. Although long-term care as a whole is grounded on structure and conformity, wherever possible, one should strive for relationship-centered care.²³ 

Furthermore, although older adults often make a conscious effort to protect their families by masking their true feelings regarding entering a LTCF, it has been reported that they would readily convey these same feelings to an attentive and supportive “outsider.”²⁴ This desire may be due to having an appreciation of those who listen, who show compassion, and who avoid infantilizing them. For the resident, an attentive and empathetic volunteer exemplifies the qualities of this outsider. In particular, research has shown that interventions specifically involving individuals from outside the facility have proven especially valuable in allowing those living with dementia to establish concrete memory aids.¹⁸ As residents of an LTCF may subconsciously contrast the behaviors of volunteers with those of staff members—those with whom they interact on a daily basis—the volunteer will have an advantage in eliciting hidden concerns crucial to the resident’s well-being. As such, the volunteer can act as a liaison between the resident, family, and LTCF staff. In periods of absence of the resident’s family, the volunteer can also provide some measure of reassurance through one-on-one attention, with the aim of decreasing isolation and offering emotional support when the family is unavailable. This provides equal reassurance to family members who are concerned about the attention a loved one is receiving.

In their role, trained volunteers will act to support the care staff of a LTCF. Firstly, they are in a position to encourage the residents to become engaged in the social and physical recreational activities of the LTCF. Recreation staff undergo a great degree of psychological demand as they are continually concerned about meeting each residents’ needs for social interaction.²⁵ One common, albeit costly, solution is to increase the ratio of staff to residents. Having instead the foundation of a coordinated volunteer services department within a LTCF would be greatly beneficial in working to achieve this social interaction without undue burden to the current staff. As such, strong communication between the recreation department and volunteer is crucial.

Furthermore, Sullivan and Sharpe²⁶ observed how Special Care Aides, in addition to their normal daily routines, became engaged in encouraging the residents under their care to socialize and exercise. However, it was further noted that continuing this encouraging behavior over time resulted in Special Care Aides being prone to burnout. If this were the case, the volunteer would be in a fitting position to assume this responsibility. Finally, it has been reported that using volunteers alongside the nursing staff to provide assistance at mealtimes has been shown to significantly enhance resident experience.²⁷

Ideally, after a period of adjustment, an older adult will eventually reach a level of comfort wherein they can actively become involved in recreational activities and socialization while autonomously expressing their wishes and concerns to both the staff of the facility and their family.

The role of volunteers in long-term care is but one example of the overarching importance of coordinated care services within an LTCF. Establishing a care team is a crucial component in ensuring a smooth and effective transition for new residents entering long-term care. Extensive research has shown that trained volunteers—especially in community-based healthcare—are a cost-effective resource which are critical to the services provided by patient/client-centered operations.²⁸ Attentive screening of volunteers before selection and policies requiring a minimum time commitment have been shown to maximize the benefit of volunteer cost savings.²⁹ The current organization of current care teams within an LTCF is unable to address the entirety of the needs of new residents. Much of the literature fails to include the volunteer as a crucial member of this team, while still commenting that each resident’s unique needs are being ignored during the transition.^17,30,31 Clearly distinguishing between the duties and responsibilities of each participant of the care team will ensure that the multiplicities of the needs of each resident are met, and the utility of the volunteer should not be under-recognized. One proposed schema is for the nursing staff, family, recreation staff, and volunteer—who in particular has direct contact with residents—to work in partnership to fulfill the entirety of the social and interpersonal needs of new residents to long-term care.

A discussion of the integration of volunteers in older adult transitions into LTCFs necessitates recognition of various challenges and limitations of this role. Firstly, similar to how mental and emotional exhaustion of family caregivers may lead to burnout, there remains a similar risk to volunteers. Continued exposure to difficult life situations places volunteers in a vulnerable position, often, although not always, due to their lack of formal training and exposure in long-term care. This may lead to emotional distancing towards the residents and an increased rate of attrition of the volunteers of LTCFs. This risk is unclear, however, as there exist few investigations into volunteer burnout at the level of long-term care. However, Remington³² reported several studies on volunteer burnout in elderly hospices, which may give insight into this phenomenon. By understanding a volunteers’ motivations, fears, and experience, strong emotional support by professional staff and providing opportunities for debriefing will mitigate potential volunteer burnout.^19,27,33,34 This is especially true after the passing of a resident with whom the volunteer has developed a close relationship. If the correct structure of support is properly established, as discussed in the literature, volunteers will learn to overcome these challenges and will achieve strong personal growth.²¹ Conversely, a challenge also exists in the unintentional crossing of professional boundaries¹⁹ between volunteer and resident. Attention must be paid that these relationships remain professional in nature.

A further argument could be made regarding safety concerns of both the resident and an untrained volunteer (eg, assisting in mealtime, assisting in mobility, being confronted with behavioral issues, etc). Graff²⁸ identifies the need for new volunteers to undergo position-specific training. Furthermore, orienting volunteers to their role, such as addressing expectations, noting boundaries, and identifying a supervisor to whom they can address any concerns (eg, being asked to perform a task outside one’s comfort zone) will prove invaluable in ensuring the safety of all. Above all, it is important to remember that the volunteer themselves may also be experiencing a similar transition into a LTCF for the first time.

Collecting ongoing feedback from both the volunteers and residents can ensure continual improvement in the operations of the LTCF. An effective transition model is one that establishes a care plan unique to each resident from their moment of entry into long-term care, with continual input from residents and their families with regards to care directives. As with any care personnel, with proper guidelines and support, the impact of the volunteer is far-reaching. 

Moving into long-term care is both an emotionally and psychologically difficult transition for all involved. However, an open dialogue between LTCF staff, volunteers, family, and the older adult can help to reduce these anxieties. Although many seniors who live with degenerative functional or cognitive illnesses may need to enter long-term care, ensuring that their sense of self-worth is maintained should remain a top priority.

Ultimately, more often than not, an older adult living in long-term care simply appreciates a companion who will spend some time in their company. Even as they become accustomed to their new home, contemplation of one’s life is a crucial element of maintaining a sense of self—a quality that may become clouded during this transition. Needless to say, this phase of life need not be met with turmoil, anxiety, or sadness. It is important to acknowledge this challenging time and allow the resident to reach a level of comfort that will enable them to reflect on these thoughts in the presence of a supportive and attentive individual. The volunteer can become a companion during this difficult period, a facilitator of thoughtful and emotional discussion, a rehabilitator of quality of life, and a therapeutic catalyst for the integration of an older adult into long-term care. 

Author: Andrew Perrella, BHSc

Affiliations:
University of Toronto, Ontario, Canada

Disclosures: 
The author reports no relevant financial relationships.

Acknowledgements:
The author thanks Dr. Carrie McAiney of
McMaster University – professor, thesis
supervisor and mentor – for her knowledge
of geriatric psychiatry and continued
guidance in the writing of this paper.

Address correspondence to:
Andrew Perrella, BHSc
1893 O’Neil Court
Mississauga, Ontario L5L5X6
andrew.perrella@mail.utoronto.ca
(647) 986-3577