Keeping hospice palliative care volunteers on board: Dealing with issues of volunteer attrition, stress, and retention
This article explores the issues of hospice palliative care volunteer attrition and retention (i.e., why volunteers leave and how to keep them interested). In addition, common sources of stress for volunteers will be identified and suggestions for alleviating stress will be offered. Volunteers are special people; patients and families greatly appreciate the care and support they provide and the other staff members' (e.g., nurses) jobs are often made easier because of them. Thus, maintaining a committed group of volunteers is an extremely important task for volunteer coordinators. The literature reviewed in this article focused mostly on North American studies and was limited to research that specifically involved hospice palliative care volunteers as participants.
Keywords: Attrition, hospice, palliative care, retention, stress, volunteers
Hospice palliative care volunteers have been called a "national treasure,"  a "priceless treasure,"  the "backbone of the hospice movement,"  the "hallmark of hospice care,"  and the "life-line of hospice."  Clearly, volunteers are vital members of the hospice palliative care team. Without the volunteers' nonmedical services, it would be very difficult to offer quality end-of-life care to dying patients and their families.
Following extensive training, volunteers can do many things to help depending on what patients and families need and possible constraints (e.g., hospital regulations) of the program they work for. A typical direct patient/family care volunteer will help patients and their families by providing emotional support (e.g., listening to life stories, talking about fears, worries, and hopes), sharing interests and hobbies, providing friendship and companionship, reading to the patient, playing cards or board games with the patient, helping with letter writing or telephone calls, offering spiritual support, providing respite for family members, acting as a source of information to patients and their families, and, in some cases, providing bereavement support to help families through their loss. In community-based programs, volunteers are available to help patients and families in their homes and/or in the hospital. In addition to the above tasks, volunteers in the patient's home might also assist with pets (e.g., walking the patient's dog), driving the patient to medical appointments, running errands (e.g., picking up prescriptions), helping the patient in and out of bed, feeding, doing a bit of light housework, and so on. The culture of hospital-based programs, however, is different. In a hospital, the chief role of the volunteers is to provide emotional and social support - regulations and union contract rules often prevent volunteers from performing "hands on" care for hospitalized patients. After training, some volunteers prefer to help indirectly by, for example, working in the volunteer program's office (e.g., writing newsletters), helping with fundraising, and doing speaking presentations in the community (to raise public awareness about hospice palliative care).
In addition to enhancing patient and family care, direct patient/family care volunteers can also make other staff members' (e.g., nurses) work easier. ,,, For example, a volunteer can notify the doctor or nurse if the patient's condition changes drastically (e.g., "Mr. Smith is not breathing very well," "Mrs. Smith is in pain"). In Claxton-Oldfield et al.'s study,  for some nurses, knowing that the patient had a volunteer with them (i.e., was not alone) made their jobs easier. While doctors and nurses tend to focus on the patient's disease, volunteers have a different kind of relationship with patients , ; they focus on the person with the disease. Unlike the professional (paid) staff who are more task-oriented, volunteers have the time to sit back and be there for patients and their families - they are not always busy seeing to other patients and doing administrative things  - and, unlike family members, who are often distressed by what is going on with their loved one, volunteers are removed from the family (i.e., objective), making it easier for patients to talk openly to them about how they really feel rather than risk-upsetting members of their family.
Volunteers are often the one constant for patients and their families, whereas the other staff members (e.g., nurses) coming into the home or hospital room may change from day-to-day. As a result, volunteers get to know the patients and families much better than the doctors and nurses do. Volunteers occupy a special place in their patients' and families' lives, and they look forward to spending time with them and advocating on their behalf. , For all of these reasons, keeping volunteers satisfied and feeling supported, appreciated and accepted at the same level as the doctors, nurses, and other staff members is of paramount importance to the success of the volunteer program; otherwise, they may decide to leave their volunteer positions. In addition, as many researchers have noted, hospice programs spend a lot of time, money, and effort recruiting, screening, training, and supporting volunteers. ,,, "When a volunteer leaves, the hospice program loses not only a valuable resource, but also the time invested in that individual and the time required to recruit a replacement."  (p. 46)
This article examines the reasons why volunteers leave hospice programs, sources of volunteer stress in hospice palliative care, and ways of alleviating stress and retaining a committed team of caring and supportive volunteers. Most of the studies described in this article were conducted in North America and specifically involved hospice palliative care volunteers.
Attrition (or drop out) rates for hospice palliative care volunteers have been reported in only a handful of studies. Amenta,  for example, reported that 18 of the 42 volunteers (43%) in her study dropped out between 4 and 11 months after completing their training. In comparison to the persisting volunteers in Amenta's  sample, those who left the program had lower purpose in life scores and higher death anxiety scores. She also speculated that the volunteers who withdrew "may have been subject to the demands of young children or career circumstances" (p. 983). Finn Paradis and Usui  found that 32 of the 113 volunteers (28%) in their study dropped out several weeks after undergoing training; again, volunteers with higher anxiety scores were less likely to stay in the program. Reasons for dropping out "varied from personal crisis to an awareness that caring for terminal patients was not something for which the volunteer would be suited" (p. 23). Interestingly, a number of professionals took the training for the continuing education credits only, without actually intending to volunteer. Thirteen of the 75 volunteers (17%) in Lafer's  study dropped out of the program 6 months after completing the training course; compared to those who remained in the program, dropouts had higher death anxiety scores.
Seibold et al.  specifically examined the reasons for volunteer turnover. Eighty hospice volunteers (mostly inactive and former volunteers) responded to an open-ended question on a mailed out survey that asked them about their reasons for leaving the program. A total of 95 reasons were cited, which the authors grouped into three main categories: personal reasons, geographical relocation, and reasons linked to the program. Personal reasons for leaving, which included things like job, family responsibilities, and personal illness were cited by 51 respondents; 30 respondents cited moving away as a factor in their decision to leave. Both of these categories reflect reasons that are beyond the control of the program. In other words, there is nothing a volunteer coordinator can do to stop someone from taking a new job, getting sick, or moving to a new city. Only 14 respondents cited reasons that were directly related to the program and, therefore, potentially controllable. These included the attitudes of floor nurses toward volunteers, being underutilized, and loss of interest (i.e., got bored). Interestingly, issues of stress or burnout rarely contributed to former volunteers' decision to leave the program. In Brichacek's  study, 24 inactive volunteers responded to a 41-item checklist composed of different reasons for volunteer turnover; 74% of the reasons for leaving were administratively uncontrollable (e.g., personal reasons, geographic relocation). The potentially controllable reasons respondents checked for leaving included not having enough to do on the palliative care unit and nurses' attitudes toward volunteers. More than half of the inactive volunteers in Brichacek's  study considered themselves "temporarily inactive" (i.e., they planned to return to the hospice program in the future). Briggs  used both closed and open-ended questions to examine hospice volunteers' reasons for becoming inactive. Of those who responded, half cited other commitments or interests as the main reason for leaving (open-ended); other frequent responses included volunteering required too much time (23% - closed), personal health reasons (18% - open-ended), and time to move on (16% - closed). In a 1987 survey of hospice volunteers by Patchner and Finn,  respondents who considered themselves inactive had either moved away or had a work or family conflict. Only one former volunteer left the program because the work was not enjoyable.
[Table 1] contains a partial list of some of the reasons why volunteers leave hospice palliative care programs. This list is based on the preceding review of the literature as well as information obtained at hospice palliative care conferences and forums attended by the authors. The 41-item checklist of reasons for inactivity designed by Brichacek  is included in an appendix at the end of his article.
The following are offered here as tips for volunteer coordinators when volunteers drop out of their program.
The findings that volunteers who have lower levels of death anxiety (i.e., are less fearful of death) are more likely to stay in the program  may have implications for volunteer coordinators during the initial selection process. Administering the Collett-Lester Fear of Death Scale,  for example, might be an effective way to screen out individuals who may not be suited for this kind of work.
There is very little research focusing on the stress that hospice palliative care volunteers experience in their work; most of the research has focused on the professional (paid) hospice staff (e.g., hospice nurses, administrators). ,, For a review of staff stress in hospice palliative care, see Vachon  for details. Because of the nature of their work, it is inevitable that volunteers will experience death, dying, and grief. Many volunteers work in hospice palliative care because they have lost family and friends through death  ; for these individuals, being with a "terminal patient may resurrect their own feelings of loss and helplessness."  For this reason, prospective volunteers who have experienced personal losses within the past year (or have unresolved past losses) are dissuaded from volunteering.(p. 173)
Although helping dying people can be sad, difficult, and challenging, "the stresses associated with dying people may be counterbalanced by the satisfaction of working with patients and their families."  (p. 58) Indeed, it is not unusual for volunteers to describe their work as rewarding, challenging, and uplifting. , Unlike the paid members of the hospice staff who work full time around the dying, volunteers usually commit to working a few hours per week in the hospital or the dying person's home and give freely of their time to do so. As a result, they are less exposed to the various stressors associated with caring for the dying and they are with patients and their families because they want to be there.
In their 1987 study, Finn Paradis et al.  conducted in-depth interviews with 17 hospice volunteers to identify the sources of stress they faced. They identified four main areas of stress, which they categorized as follows: (1) role ambiguity (i.e., uncertainty about what they can or cannot do as volunteers - do they attend team meetings?, can they provide hands on patient care?, and can they call the patient's doctor?); (2) status ambiguity (i.e., what is their place in the hospice palliative care team?); (3) stress related to patients and families (e.g., not knowing what to do or not being able to do more, lack of support from staff, patients, and/or families); and (4) stress related to individual personality characteristics (i.e., things going on in the volunteer's own life that may be a source of personal strain - an unsupportive partner, family responsibilities). Role ambiguity (uncertainty) was also identified as a source of stress among hospice volunteers by Vachon. 
In a study involving volunteer and paid hospice staff, Mor and Laliberte  found that volunteers reported less burnout (emotional exhaustion and depersonalization) than did staff members who work around dying patients on a full-time basis. More recently, Dein and Abbas  conducted two focus groups with a total of 17 volunteers to examine the stresses associated with their work in a hospice. Some of the stresses mentioned included losing patients, witnessing physical disfigurement, and feeling sad when parents left young children behind; these were identified as being temporary stresses. Interestingly, most of the volunteers in this study "pointed out that the work was generally free from stress and could in fact alleviate stress" (p. 60). Four of the 22 volunteers who were asked about compassion fatigue in Claxton-Oldfield and Claxton-Oldfield's  study mentioned they did not see anything stressful about their hospice palliative care work and two of them said "that their volunteer work was their relaxation" (p. 3).
Alleviating volunteer stress
The research suggests that life in a hospice palliative care setting is generally not stressful for volunteers and, according to Finn Paradis et al.,  the effects of many of the difficulties mentioned above can be eliminated (or reduced) during the training process. For example, the roles and responsibilities of volunteers should be clearly and unambiguously defined during the recruitment/selection process and be reinforced during the training sessions. This is important because "undefined roles can leave individuals feeling insecure about their accomplishments and may in turn create stress for the volunteers."  (p. 718) Other staff members (e.g., doctors, nurses) should be given information about the types of tasks volunteers can (and cannot) perform and the kind of training they receive. For example, Claxton-Oldfield et al.  found that 73% of the nurses surveyed were not sure or did not know what topics were covered in the volunteers' training; a couple of nurses were not even sure if the volunteers received any training. Likewise, the volunteers should have a clear understanding of the roles and responsibilities of the other members of the team (e.g., social workers, therapists) and how their role fits with the roles of others. Ideally, volunteers and staff should train together to facilitate team building. At the very least, volunteers should be involved in team meetings when their patients/families are being discussed. More recognition of the volunteer role would help to reduce the problems of role and status ambiguity (i.e., they are not "just volunteers"); educating the other members of the team about what the volunteers actually do, the extent of the training they receive, and the value of having them, is key. Many volunteers also bring years of life and work experience (e.g., nursing experience) to the program.
Insufficient patient information was a source of stress mentioned by volunteers in Finn Paradis et al.'s study.  At the very least, volunteers need to know the reason for the referral to the hospice program, why a volunteer was requested, the patient's disease, and, if care is being provided in the home, the other professionals involved. In another study, volunteers rated medical and relationship information as more important to them than personal information.  Without this information, volunteers cannot provide good care. Difficult (e.g., angry and aggressive) patients and family members can also be a source of stress for volunteers. How to handle difficult patient and family emotions is something that can be discussed during training.
When Claxton-Oldfield and Claxton-Oldfield  asked 22 volunteers what they do to prevent burnout, six volunteers said that they have outside interests they find enjoyable (e.g., reading, listening to music, painting, and doing crafts); these activities allow them to "escape" from their volunteer work and relax. Others mentioned the importance of having a supportive social network - someone they can talk to (e.g., partner, friends, fellow volunteers, and staff members) - or taking a break (i.e., a holiday or simply time away) from volunteering. Some programs have specific policies in place to prevent burnout (e.g., volunteers cannot serve a particular patient/family for more than 6 months).
The Finn Paradis et al.  sum it up nicely by stating that "Those volunteers with a clear idea about their role in the organization, an understanding of their status among other providers, and a feeling of support from both family and staff will find hospice work rewarding and have low job stress" (p. 181).
[Table 2] lists a number of measures that might help to prevent (or reduce) potential sources of volunteer stress. These ideas come from the literature on hospice staff and volunteer stress. 
Retention of volunteers
The final section of this article deals with the issue of volunteer retention. As noted earlier, only a few studies have reported volunteer attrition rates . ,, Although the reported attrition rates ranged from 17% to 43%, anecdotal evidence suggests that keeping hospice palliative care volunteers on board is usually not a problem. Flickinger  reported that, "of each volunteer class, approximately 85% remain active after 5 years" (p. 53). According to Finn Paradis and Usui,  "the most stable volunteers have lived in the same community … for four or more years, have done other volunteer work, have no extensive child-rearing responsibilities, and have only one paid job" (p. 137). This is consistent with the profile of a typical North American hospice palliative care volunteer, who is most likely going to be a middle-aged or older (i.e., children have grown up), white married female with some college education and involvement in other volunteer activities. ,
Hospice palliative care volunteer programs have devised a number of different activities to retain their volunteers.  These include planned social gatherings (e.g., Christmas dinners, dances, volunteer picnics and/or barbecues, and Thanksgiving meal) and volunteer recognition/appreciation events (e.g., pins for hours or years of service, gifts for volunteers) so that volunteers feel valued. , Other activities that foster high-retention rates include holding regular (e.g., monthly) education/information sessions for volunteers, closure conferences following the death of a patient (i.e., acknowledging grief and sharing losses can help prevent burnout), having a physical space (e.g., a volunteer office) for the volunteers to use, and good communication between staff and volunteers. [Table 3] contains a list of some activities that may contribute to volunteer retention. This list is based on a review of the literature , as well as information obtained at hospice palliative care conferences and forums attended by this article's authors. Most of the activities in [Table 3] are ones that would be initiated by the program's volunteer coordinator.
In addition to the satisfaction that comes from helping patients and families in their time of need and knowing that they have made a difference to the patient and provided comfort and rest to the family, the activities listed in [Table 3] should give the volunteers even more reasons for wanting to remain in the program. Future research could assess which of these activities are most important to active volunteers. As Korda  points out, identifying what volunteers get out of their hospice experiences may be helpful for retaining them.
From the available research, it would appear that many volunteers do not perceive their work in hospice palliative care as particularly stressful; in fact, for some, volunteering is their relaxation. Most of the things that volunteers find stressful about their work are temporary. For example, they get close to patients who die, which makes them feel sad, but they also find it rewarding and uplifting to know that they have helped those patients and their families in some way and, after a suitable period of time off to grieve their loss, they are ready to help others. Some of the potential stressors for volunteers are preventable during the training sessions (e.g., through clarifying the roles of the volunteer and other team members) and/or can be alleviated through various support mechanisms (e.g., volunteer support groups, support from staff, family, and friends). Finally, when volunteers do leave hospice palliative care programs, their reasons for doing so are often administratively uncontrollable - there is nothing the volunteer coordinator can do about it. One exception to this is the finding that some volunteers leave because of the other team members' (e.g., nurses) attitudes toward them. This can be addressed by educating doctors, nurses, and others about the roles and responsibilities of volunteers, their importance to the team, and the real difference they make in the lives of the patients and families they care for.
[Table 1], [Table 2], [Table 3]