Does context matter? Voluntary work in long-term care

Introduction: Increased voluntary work in long-term care (LTC) is encouraged in white papers in Norway as well as in many other western states. This is due to the growth in the number of service recipients and a subsequent economic burden for the state. Voluntary work in nursing homes and home care services take place in different spatial contexts, but little attention has been paid to how the different contexts may potentially influence the possibilities for voluntary work. The aim of this study is to obtain new knowledge of the significance of context in recruitment of volunteers in LTC. Method: A cross-sectional study was conducted among leaders in nursing homes and home services in 50 municipalities across all regions of Norway. Descriptive analysis was used. Results: According to the leaders, home care services had less voluntary work than nursing homes. Respondents from home care scored “poor flow of information” and “low interest in the municipality” as major hinderances, more so than respondents from nursing homes did. Discussion: Nursing homes typically have many residents under one roof following a similar schedule. Thus, volunteer-run activities are held more easily at set times and incorporated into the daily life of the institutions. On the


Introduction
In Norway, a call for volunteers to contribute to long-term care (LTC) services has been repeatedly made in recent decades. Official policy documents and white papers state that new forms of cooperation between public and private sectors must be sought (Ministry of Health and Care Services, 2013, p. 11;Ministry of Health and Care Services, 2006, p. 41;Ministry of Health and Care Services, 2017, p. 61;Ministry of Health and Care Services, 2015, p. 47).
Similar requests are put forward internationally and reflect an overall concern with the ageing of the population, a growth in demand and expenses for care services and a future deficit of health staff (Groenou & De Boer, 2016;Hussein & Manthorpe, 2005).

Despite the fact that the general participation in voluntary organisations in
Norway is high Jegermalm et al., 2019), a study showed that voluntary work in the LTC sector is relatively modest (Andfossen, 2016). This might indicate a discrepancy in expectations between the present strong call for the contribution of volunteers and a relatively stable low prevalence in LTC. Several important issues seem to be overlooked in official documents. One such issue concerns which tasks and types of activities volunteers are supposed to carry out in LTC. However, white paper no. 25 (2005)(2006) specifies the importance of enhancing the quality of care by increasing volunteer social and cultural activities in nursing homes and home care services (Ministry of Health and Care Services, 2006;Ministry of Health and Care Services, 2018). Yet, two issues that remain largely undebated concern the recruitment of volunteers and the coordination of their effort along with the staff in municipal care services. How is the bringing in of volunteers to be organised in a field with professional care workers? Studies so far indicate that voluntary work in LTC is offered and organised differently in municipalities (Rønning, 2011a;Solbjør et al., 2014;Andfossen 2020) or between organisations (Greenfield et al., 2016). For example, a survey of recruitment and follow-up of LTC volunteers in Norway found that less than half of the 429 municipalities had any organised activity in recruiting new volunteers in the care sector (Johansen & Lofthus, 2011). A survey mapping voluntary work for the elderly in Oslo also showed variations in how districts recruited volunteers (Romsaas, 2011). Districts that actively developed a culture for cooperation with volunteers reported more contact and communication between volunteers and service suppliers at all levels (Romsaas, 2011). Furthermore, the division of tasks between professional care, volunteers and informal carers appears somewhat blurred and causes coordination challenges (Tingvold & Skinner, 2019;Skinner et al., 2020;Fredriksen et al, 2020); systems of cooperation are put into operation in a multitude of ways (Hoad, 2002), triggering questions on the best volunteer management in differentiated settings (la Cour, 2019;Hager & Brudney 2015). Lack of procedures to inform LTC service recipients about the availability of volunteers had also been found (Luijkx & Schols, 2018), as well as a lack of routines for sharing information between professional carers and volunteers (Fensli et al., 2012a;Ingebretsen, 2005).
These studies show that introducing volunteers into LTC services might be a more complicated task than suggested by various governments. It is particularly expected that more difficulties could arise in introducing and running activities by volunteers in nursing homes, as these institutions are formalised in the domain of professional care workers and access is more regulated and restricted. Further, it may be expected that the proportion of individual volunteers to care recipients are higher in private homes due to easier access to neighbours, friends and others in the local community. For this study, "voluntary work" is defined as the unpaid contributions that are given without reward or compensation that benefit individuals or groups outside family and close friends (Førland, 2015;Snyder & Omoto, 2008).
Individual unpaid work carried out by volunteers through voluntary organisations and volunteer centrals is also included, as well as work done by those who do voluntary, unpaid work independently of formal organisations.
Unpaid work, informal care or help given to members of one's family, friends or neighbours is not defined as voluntary work in this study. The term "service recipients" in this research denotes persons receiving public care, either in nursing homes or in home care services.

Background
The welfare state and the Norwegian long-term care Norway is placed within the Nordic welfare model, characterised by a high degree of governmental control, tax-financed interventions and welfare programmes (Christensen & Waerness, 2018;Esping-Andersen, 1990;Kautto, 2010). LTC services consist of nursing homes (NH) and home care (HC) services, and both branches are a part of a comprehensive infrastructure of statutory services administered by local authorities (municipalities). NH constitute a principal public care alternative and are regarded as vitally important, particularly for the oldest citizens with advanced chronic illnesses and multiple diagnoses (Naess et al., 2013). NH are generally associated with severe loss of health (physical and/or psychological), but they are also connected to the loss of a private home, individual status and freedom to shape everyday life (Bergland & Kirkevold, 2006;Malmedal et al., 2009;Ågotnes, 2016). NH in Norway have previously been under criticism for not offering enough assistance to their residents, and the quality of care has been repeatedly discussed (Malmedal et al., 2009). One study found that staff were not sufficiently present during meals and did not provide enough assistance to the residents in the areas of personal care, hygiene and psychosocial care (Slagsvold, 1999). After several years of intellectual and practical activity to improve the facilities, researchers stated that quality in nursing homes remains a major concern (Kjøs et al., 2010). Recent studies suggest that general care is at a relatively high level, while physical and social activities in nursing homes is relatively low (Førland & Rostad, 2019). In response to these 159 NJSR -Nordic Journal of Social Research Vol. 12, 2021 concerns, campaigns have been launched to increase the level of activities in nursing homes. It is assumed by the government that volunteers can be involved in such tasks (Helse-og omsorgsdepartementet, 2013; Helse-og omsorgsdepartementet 2017) and contribute to improved services.
Home care (HC) constitutes the secondand currently the largestbranch of LTC in Norway. Its services originated in the third sector in the beginning of the 1970s, consisting of national and local associations of women and local churches undertaking voluntary work. Vabø and Szebehely (2012) claimed that voluntary organisations have played a role in pressuring the state to take responsibility for the care of elderly individuals. In Norway, HC services have since developed from providing mostly practical assistance to elderly care receivers at the outset; it is now comprised of advanced medical tasks and care (Fjørtoft et al., 2020). This is a consequence of political reforms aimed to move the responsibility for general medical follow-up tasks from the specialist levelin hospitalsto the general level within the municipalities (Ahgren, 2014;Gautun & Syse, 2017). The number of HC recipients have grown considerably over the last decades. The user groups have become diverse and represent all age groups, from young children to elderly individuals at the end of life. Central beneficiaries of home care are people with physical disabilities, mental illnesses and handicaps, drug-related disorders and progressive illness.
Nursing home recipients in long-term care are increasingly frail elderly individuals characterised by multi-morbidities, cognitive failure and polypharmacy (Helvik et al., 2010) leading to an increased need for advanced nursing competence (Bing-Jonsson et al., 2016). More time is spent on caring for the acutely and critically ill as well as on documentation and reporting, which leaves professionals with less time for direct social contact with residents (Vabø, 2012).
Against this background, official documents such as white paper no. 25 (2005)(2006) specified the importance of enhancing the number and types of social and cultural activities in long-term care (Helseog omsorgsdepartementet, 2006). This was followed up through recent governmental documents (e.g., as complementary to the formal LTC services as well as constructed to increase the well-being of residents (Skinner et al., 2018).

Contextual differences between home care and nursing homes
In sociological theory, nursing homes are institutions that contain a formal and informal structure with permanence and duration (Repstad, 1991). Material conditions such as physical and architectural structure provide frameworks and guidelines for the social structure in the nursing home. The degree of privacy for institutional residents is determined by the construction of the building in addition to how dependent the residents are on help from employees to perform daily functions. Repstad (1991)  Nursing homes are institutionseither publicly owned or owned by private organizationsfor persons with lower levels of functions characterised by multi-morbidity and complex medical conditions (Gulla, 2018). Nursing homes are also run with strict guidelines and rules of operation. The residents must follow these requirements on the premises of the institution. Many residents are living under the same roof and receive LTC services from the same staff members; they must adapt to the daily routines guiding the pace of the institution. For example, there are set times for when meals are served, when medication is given, when the physician is visiting, and so on. There are also generally set times for social and cultural activities. The residents have their own rooms that ideally have a "homelike" look (Hauge, 2004). However, the residents are often too sick to regulate who is coming and going in and out of their "home", and staff are likely to enter accordingly. The residents in NH are mostly fully dependent on the care staff for carrying out daily functions such as personal care, assistance to move and attending social activities; residents therefore have asymmetric relations to the care staff (Garsjø, 2008).
In comparison, care recipients living in their own home are in their personal space and hold property rights. The owner can independently make decisions as to the appearance of the home and has autonomy and independence to decide who can access it (Twigg, 1999). He/she is also free to form rules for the house and its members and to decide both how the home will be 161 NJSR -Nordic Journal of Social Research Vol. 12, 2021 maintained and what behaviour is expected from guests. Upon illness and old age, the home dweller may have to accept assistance and leave the independence to others, making the home environment potentially more challenging to handle (Haak et al., 2011). Home care staff primarily perform their work tasks individually and make judgements alone by taking an autonomous role looking after the specific and changing needs of home dwellers (Vabø, 2012). A visit from the home care lasts from 10-40 minutes, depending on the task for which assistance is required (Førland et al., 2017).
Shaping different settings for both ageing and receiving care, these contextual variables for nursing homes and individual homes consist of different organizational features, codes of conduct and power relations (Scharlach, 2017) and also different operational setting to volunteers.

The volunteers and their motives
Volunteers' motives seem to have become more complex and varied in recent years, as have the group of volunteers themselves (Bussell & Forbes, 2001;Clary & Snyder, 1999). Prior to 1990, most voluntary work was based on membership in national voluntary organizations whose members shared common values. Over the last decade, volunteers are less attached to organizations and motives for volunteering are increasingly related to personal development for the volunteer (Wollebaek & Sivesind, 2010;Wollebaek & Selle, 2002) as a form of "organized individualism" (Wollebaek & Sivesind, 2010). Habermann (2007) studied motives for volunteering in a Danish context and found a large variation. Motives included volunteering for a case one has sympathy for, learning (i.e., volunteers wanting to acquire new skills), identity (i.e., volunteers are a part of an identity and a meaning-forming project), values (i.e., to be able to transmit specific values and beliefs, such as religious beliefs, humanitarian ideals or ethical obligations), influence (i.e., volunteers looking for influence or recognition as a central person in a local community), companionship (i.e., desire for social affiliation with other people) or career (i.e., the work provides an experience that can be of use in the workplace).
Haberman pointed out that the motives can be complex and composed in different manners; as an example, altruistic values can coincide in an individual with self-esteem thinking (Habermann, 2007). A similar panorama of motives was found in studies of the Norwegian volunteer centrals, and these encompassed situations such as realizing important humanitarian, religious or political values, learning (i.e., acquiring new skills), social reasons (i.e., the desire to belong to a group), work training (i.e., improving skills or preparing for paid employment) and so on (Lorentzen et al., 1995).

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NJSR -Nordic Journal of Social Research Vol. 12, 2021 With this background in mind, the purpose of this research is to discuss the scope and type of volunteer activities in long-term care, as well as the leader's perceptions of barriers for volunteer recruitment. This study argues that possibilities for voluntary work must be understood in the context of locality, the theoretical frameworks for "homes", "institutions", motives to volunteer and the development of the welfare state.

Method
In 2015, survey data was collected over a two-month period in a sample of 50 The electronic questionnaire consisted of primarily closed-end, multiple-choice questions. It was stated at the beginning of the questionnaire that questions would be asked about voluntary activities that were organised in cooperation with the formal services/municipalities. Voluntary activities were defined as activities or services that were carried out using unpaid labour. Cooperation was defined as municipal involvement, such as economic support or direct municipal coordination of voluntary activities.

Measures and analyses
The study used a screening question which asked whether the service location had any activities with volunteer involvement in the last four weeks regarding the following thirteen areas: social activities, cultural activities, library/reading services, physical activities, visiting schemes, food delivery, practical assistance, day centres, helplines/counselling services, transport/taking out services, self-help groups, activities certified by volunteer

Type and amount of voluntary work in nursing homes and home care services
The response rate was 77% involving 244 participants. There were no notable differences between the response rates among the NH and HC units. Among the respondents, 67% were educated nurses, 17% were other health/care professions and 16% had other types of education. The prevalence of voluntary work activities is presented in Table 2 below. Table 2 shows how common voluntary work in the different categories is, while Table 3 summarises the hours (mean) spent per week on the different activities in nursing homes and home services.

Hindrances to voluntary work
The respondents were asked to select the three most common hindrances to successful cooperation with volunteers. Table 4 shows that lack of volunteers was the most important barrier recorded by the managers from both HC and NH. Lack of coordination from the municipal care services was equally seen as a common hindrance by respondents from both groups.
Respondents from the HC scored poor flow of information as a hindrance more often than the respondents from the NH (p = 0.035). The same applies to low interest in the municipality, scored as an even greater hindrance by respondents from home care than the respondents from the nursing homes (p = 0.009).
Respondents from the NH scored cooperation overdependent on particular individuals as a more frequent hindrance than respondents from the HC (p =

Discussion
The three most commonly involved activities in voluntary work within NH and HC settings are cultural activities, social activities and visiting schemes.
However, the prevalence of voluntary work in long-term care is distributed differently. In our study, respondents reported that volunteers spent more time (measured as mean hours per week) in nursing homes compared to the home care sector. As for the variation between the two sectors, it can be assumed that service recipients in HC might have less demand for volunteers, as they are generally younger than residents in NH. However, it is known that recipients of HC have increasingly complex, high-care needs independent of their age, including psychiatric health problems and addiction (Førland & Folkestad, 2016;Hamran & Moe, 2012;Otnes, 2015). So younger reservice recipients do not necessarily equate to less demand for support and care.
The two sectors experienced an assortment of common hindrances. Most respondents reported lack of volunteers as a main barrier. The difficulties of initiating and recruiting volunteers in care is also evident in other Norway-and internationally-based studies (Andfossen, 2016;Bussell & Forbes, 2001). It is argued that a coordinator is needed to mobilize, recruit and assume the responsibility for the contribution from volunteers (Hillestad & Tessem, 2015).
Respondents from the HC reported low interest in the municipality as a more frequent barrier than the respondents from NH. This indicates that recruitment initiatives might be particularly low in this branch of long-term care. It may also reflect the complexity of the home context where voluntary work crosses between many boundaries: formal and informal, micro and macro, public and private as well as medical and social care (Burau et al., 2007). As an example, decisions are still somewhat unclear as to who should assume responsibility for the various needs of a home dweller and how tasks should be shared among the different providers (e.g. home care service, volunteers, informal carers). Knowledge is sparse regarding factors that influence the decision of who provides help and care to elderly people living at home (Hellström & Hallberg, 2004). Another factor that may potentially explain low interest in the community can be the volunteer's lack of willingness or ability to visit home dwellers with increasingly complex health conditions (Bing-Jonsson et al., 2016). Handling difficult situations with vulnerable home dwellers may prove to 170 NJSR -Nordic Journal of Social Research Vol. 12, 2021 be a demanding task for volunteers to take on, especially when they are operating on their own in individual homes without support from other volunteers or care staff (Solbjør et al., 2014;Tingvold & Olsvold, 2018).).
The respondents from the HC services reported poor flow of information as a more important barrier than respondents from NHs. Reforms over recent years have triggered changes in how home care staff carry out their work. Staff are directed increasingly towards serving a specific need of the home dweller (e.g., cleansing a wound, bringing medication, giving a bath) and do not have the same flexibility to consider various needs on the spot and place priority when entering the houses of the home dwellers (Vabø, 2012). Less time spent with home dwellers gives less time to observe the resident, register changing needs (Vabø, 2012) and communicate about psychosocial needs (Vik & Eide, 2012). A lack of procedures for how staff in home care can involve volunteers in providing care for lonely older people is missing, as well as knowledge about how this cooperation can be organised (Hoad, 2002;Rønning, 2011).
Confidentiality is also discussed as a hindrance in regards to the sharing of personal information, as staff are afraid of passing on sensitive information about home dwellers to volunteers (Øhrn, 2019). Furthermore, coordinators of voluntary work may be reluctant to send volunteers to home dwellers with complex or demanding care needs, such as mental illnesses, substance abuse and terminal illness (Tingvold & Olsvold, 2018). Coordinators may consider whether or not it is justifiable to send volunteers out to visit a service recipient with such challenging health and care needs. In a study, coordinators were concerned about those volunteers who visited care receivers in their homes; the volunteers had less opportunity to seek guidance and support in an unexpected event, as compared to volunteers in a nursing home with staff members present at all times (Tingvold & Olsvold, 2018).
Additionally, service recipients with complex health situations in both nursing homes and home care have changingand often unpredictabledays; this leads to changing opinions in terms of whether a volunteer should perform a visit or not (Tingvold & Skinner, 2019 of person-based dynamics and situational opportunities (Clary & Snyder, 1999 (Grabowski, 2006). In most countriesincluding Norwayinformal caregiving, and especially family caregiving, is a backbone in LTC. Their volume of caregiving is under substantial pressure for several reasons; the number of children per dependent elderly is decreasing, the labour market participation among women and older people is increasing and the professional competence required in LTC is expanding in addition to the uncertainty of the home dweller to accept contributions from volunteers. In the predominant way of narrating the potential of volunteerism, these patterns seem to be neglected. The realism of strengthening the role of volunteers in LTCespecially in the home care contextcan be debated and seen as wishful thinking as the challenges are quite obvious.

Strengths and limitations
The strength of the study lies in the new insight provided into healthcare