ILIVE Project Volunteer study. Developing international consensus for a European Core Curriculum for hospital end-of-life-care volunteer services, to train volunteers to support patients in the last weeks of life: A Delphi study

Background: Volunteers make a huge contribution to the health and wellbeing of the population and can improve satisfaction with care especially in the hospice setting. However, palliative and end-of-life-care volunteer services in the hospital setting are relatively uncommon. The iLIVE Volunteer Study, one of eight work-packages within the iLIVE Project, was tasked with developing a European Core Curriculum for End-of-Life-Care Volunteers in hospital. Aim: Establish an international consensus on the content of a European Core Curriculum for hospital end-of-life-care volunteer services which support patients in the last weeks of life. Design: Delphi Process comprising the following three stages: 1. Scoping review of literature into palliative care volunteers. 2. Two rounds of Delphi Questionnaire. 3. Nominal Group Meeting. Setting/participants: Sixty-six participants completed the Round 1 Delphi questionnaire; 75% (50/66) took part in Round 2. Seventeen participants attended the Nominal Group Meeting representing an international and multi-professional group including, clinicians, researchers and volunteer coordinators from the participating countries. Results: The scoping review identified 88 items for the Delphi questionnaire. Items encompassed organisational issues for implementation and topics for volunteer training. Three items were combined and one item added in Round 2. Following the Nominal Group Meeting 53/87 items reached consensus. Conclusion: Key items for volunteer training were agreed alongside items for implementation to embed the end-of-life-care volunteer service within the hospital. Recommendations for further research included in-depth assessment of the implementation and experiences of end-of-life-care volunteer services. The developed European Core Curriculum can be adapted to fit local cultural and organisational contexts.


Burbeck R Candy B
Low J Rees R BACKGROUND: Volunteers make a major contribution to palliative patient care, and qualitative studies have been undertaken to explore their involvement. With the aim of making connections between existing studies to derive enhanced meanings, we undertook a systematic review of these qualitative studies including synthesising the findings. We sought to uncover how the role of volunteers with direct contact with patients in specialist palliative care is understood by volunteers, patients, their families, and staff. METHODS: We searched for relevant literature that explored the role of the volunteer including electronic citation databases and reference lists of included studies, and also undertook hand searches of selected journals to find studies which met inclusion criteria. We quality appraised included studies, and synthesised study findings using a novel synthesis method, thematic synthesis. RESULTS: We found 12 relevant studies undertaken in both inpatient and home-care settings, with volunteers, volunteer coordinators, patients and families. Studies explored the role of general volunteers as opposed to those offering any professional skills. Three theme clusters were found: the distinctness of the volunteer role, the characteristics of the role, and the volunteer experience of the role. The first answers the involvement in day and bereavement services. Further research could focus on exploring their involvement in bereavement care. 5 Role ambiguity, role conflict, or burnout: are these areas of concern for Australian palliative care volunteers? Pilot study results. METHOD: Hospice volunteers (n = 120) were invited to participate in this pilot survey. Quantitative data were analyzed using descriptive statistics, while the free-text responses were analyzed using thematic content analysis. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Guidelines have been used to report this data.
RESULTS: A total of 97 participants completed the survey. The majority were middle-aged women who had been palliative care volunteers for more than 7 years and volunteered 14 hours/week (median). Participants reported low levels of role ambiguity (x = 8.4, standard deviation [SD] +/-3.0) and conflict (x = 9.8, SD +/-3.4) and described enjoying their volunteering and having no symptoms of burnout (76%).

ORGANISATIONAL/IMPLEMENTATION MOTIVATION TO BE A VOLUNTEER Use of motivation assessment tool as a selection criteria
A possible key to volunteer retention may be selecting prospective volunteers whose most important motivations for joining hospice are to help those in need; such volunteers may be more likely to remain active in the program longer.

Outcome Measure:
The authors encourage other researchers to use the IMHPCV as a tool for recruitment and retention.

Brown MV
The purpose of this phenomenological study was to explore the interpretation of stress, the appraisal of the stressors, as well as the top stressors experienced by hospice volunteers. Individual semi structured interviews were conducted with 15 hospice volunteers. The interviews were digitally recorded, transcribed, and analyzed, using qualitative research methods. Although the results indicated that the hospice volunteers did not perceive their work as stressful, 2 main themes regarding challenging experiences did emerge. Hospice-related issues and personal issues were of concern to the volunteers. In addition, the timing of the stressors revealed that the most stress was felt at the beginning of their volunteer services, which has implications for hospice volunteer coordinators as they support their volunteers in the field.
Main idea from this paper: Little research exists that describes the stresses of hospice volunteers. Often stress can be 'hidden'volunteers love their 'job' and altruistic motives mean they nay not describe their role as stressful despite elements causing some 'stress/distress'. The goal of this study was to examine the personality characteristics of hospice palliative care volunteers by measuring the so-called big five personality traits and 4 separate aspects of empathy. A total of 99 hospice palliative care volunteers completed the NEO Five-Factor Inventory (NEO-FFI) of Costa Jr and McCrae and the Interpersonal Reactivity Index (IRI) of Davis. The vast majority (84%) of the volunteers were females. Compared to the norms for adult females on the NEO-FFI, female hospice palliative care volunteers scored significantly higher on the traits of agreeableness, extraversion, and openness and significantly lower on the trait of neuroticism. On the empathy measure, female hospice palliative care volunteers scored significantly higher on the empathic concern and perspective taking subscales compared to the female norms, and significantly lower on the personal distress and fantasy subscales. The results of this study may have implications for the recruitment and retention of hospice palliative care volunteers.

ORGANISATIONAL/IMPLEMENTATION VOLUNTEER RECRUITMENT AND SELECTION Use of motivation assessment tool as a selection criteria
"Administering the NEO-FFI and IRI may help to reduce the costs (eg, time, effort, and money) that are associated with recruiting and training volunteers by screening out potentially unsuitable volunteers. There are, of course, other important considerations, besides personality characteristics, when it comes to volunteer selection, including a volunteer's motives for volunteering, involvement in other volunteer activities, work and life experiences, and past experience with death and disease." Two separate studies were conducted to better understand why so few middle-aged and older men volunteer in hospice palliative care; only about 10% of the patient/family care volunteers in New Brunswick's community-based hospice palliative care volunteer programs are men. In study 1, 15 (22%) of the 68 men who read a brief description about the kinds of things that hospice palliative care volunteers do expressed an interest in this type of volunteerism. The main reasons given for their lack of interest included ''being too busy'' and ''not being able to handle it emotionally.'' At least one third of the men who said ''No'' to becoming a hospice palliative care volunteer expressed an interest in 10 of 13 other common volunteer activities (eg, driving). In study 2, 59 men were presented with a list of 25 tasks that hospice palliative care volunteers might perform when providing emotional, social, practical, and administrative support. The men were asked to indicate which tasks they would be willing to perform if they were a hospice palliative care volunteer. The men were least willing to serve on the board of directors (28%), provide hands on patient care (38%), and work in the volunteer program's office (42%); they were most willing to talk to the patient (97%), share hobbies and interests with the patient (92%), listen to the patient's memories and life stories (90%), and provide friendship and companionship (88%). The results of these studies may have implications for the recruitment of male volunteers to work with dying patients and their families.

HOSPITAL BASED VOLUNTEERS Highly organised structure of hospitals impacts roles Issues of role boundaries in clinical environment
Challenges of providing hands on care Providing social and emotional support Being there and being present "hospital based programs primarily provide social and emotional support to hospitalized patients, as well as opportunities for family members to take a break and know that someone will be there with their loved one. However, because they are visiting patients in the hospital, union work rules generally prevent volunteers from doing much in the way of hands on patient care (eg, lifting patients, turning patients in bed, helping with feeding)" 1 advisors, academics, educators, and a volunteer supervisor, was asked to select palliative care education programs for health professionals and volunteers. The first step in achieving this mandate was to establish competencies for health professionals and volunteers caring for patients with life-limiting illness and their families and those specializing in palliative care.
METHODS: In 2015, a literature search for palliative care competencies and an environmental scan of related education programs were conducted. The Irish Palliative Care Competence Framework serves as the foundation of the Nova Scotia Palliative Care Competency Framework. Additional disciplines and competencies were added and any competencies not specific to palliative care were removed. To highlight interprofessional practice, the framework illustrates shared and discipline-specific competencies. Stakeholders were asked to validate the framework and map the competencies to educational programs. Numerous rounds of review refined the framework.
RESULTS: The framework includes competencies for 22 disciplines, 9 nursing specialties, and 4 physician specialties.
CONCLUSIONS: The framework, released in 2017, and the selection and implementation of education programs were a significant undertaking. The framework will support the implementation of the Nova Scotia Integrated Palliative Care Strategy, enhance the interprofessional nature of palliative care, and general list of 'competencies' set out in the framework: BACKGROUND: Palliative care is specialised health care to support people living with a terminal illness and their families. The involvement of volunteers can extend the range of activities offered by palliative care services, particularly for those living in the community. Activities undertaken by palliative care volunteers vary considerably but can be practical, social or emotional in nature. The types of training and support provided to these volunteers are likely to affect the volunteers' effectiveness in their role and influence the quality of care provided to palliative care clients and their families. Training and support can also have considerable resource implications for palliative care organisations, which makes it important to know how to provide this training and support as effectively as possible.

Principles
OBJECTIVES: To assess the effects of training and support strategies for palliative care volunteers on palliative care clients and their families, volunteers and service quality. SELECTION CRITERIA: Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before-and-after (CBA) studies and interrupted time series (ITS) studies of all formal training and support programs for palliative care volunteers. Programs or strategies in included studies were classified according to any stated or implied purpose: that is, whether they intended to build skills for the volunteer's role, to enhance their coping, or to maintain service standards.
DATA COLLECTION AND ANALYSIS: Two review authors screened 2614 citations identified through the electronic searches after duplicates were removed. The search of grey literature through websites yielded no additional titles. We identified 28 potentially relevant titles but found no studies eligible for inclusion.
MAIN RESULTS: We did not find any studies that assessed the effects of training and support strategies for palliative care volunteers that meet our inclusion criteria. The excluded studies suggest that trials in this area are possible.
AUTHORS' CONCLUSIONS: The use of palliative care volunteers is likely to continue, but there is an absence of evidence to show how best to train or support them whilst maintaining standards of care for palliative care patients and their families. Thirty-nine hospice palliative care volunteers completed a survey examining (a) their beliefs about end-of-life phenomena (EOLP), (b) the impact of EOLP on their lives, and (c) their perceived needs for training to respond to them. Forty-nine percent of the volunteers either had personally witnessed an EOLP in their volunteer work and/or had a patient or patient's family member report an EOLP to them. More than half of the volunteers strongly agreed or agreed that EOLP have influenced their religious beliefs and their spirituality in a positive way (53% and 59%, respectively). Eighty-nine percent of the volunteers indicated that they had never received any training about EOLP, and nearly all of the volunteers were interested in learning more about EOLP. After completing the survey, 59% of the volunteers shared stories about EOLP they had either personally witnessed or been told about. The most frequently reported experiences involved deathbed visions. The implications of these findings are discussed. "Since volunteers are more likely to commit to an activity that is personally satisfying, volunteer laypersons may constitute a reliable and cost-effective way to enhance advance care planning efforts and support individuals with palliative care needs."

Communication Skills:
 Listening Skills and responding to patient and family emotions  Discussing death and death anxiety provided layperson quotations related to layperson-to-peer communication associated with advance care planning (n = 4) or end-oflife conversations (n = 5). The studies were conducted in United Kingdom (n = 4) or United States settings (n = 5). The synthesis of layperson perspectives yielded five main domains: 1) layperson-to-peer communication, focusing on the experience of talking with peers, 2) layperson-to-peer interpersonal interactions, focusing on the entire interaction between the layperson and peers, excluding communication-related issues, 3) personal impact on the layperson, 4) layperson contributions, and 5) layperson training. Laypersons described using specific communication skills including the ability to build rapport, discuss sensitive issues, listen and allow silence, and respond to emotions. CONCLUSIONS: Published studies described experiences of trained laypersons in conversations with peers related to advance care planning or end-of-life situations. Based on these layperson perspectives related to communication, programs should next evaluate the potential impact of laypersons in meaningful conversations.

VOLUNTEER SUPPORT Self Care: Techniques and coping
Ongoing mentoring and support: include meetings over time, supervision Formal structured supervision with Feedback: identified as a learning need. The objectives of this study were to examine (1) the extent to which hospice palliative care volunteers are involved in program and patient/family advocacy, (2) volunteers' willingness to engage in program and patient/family advocacy, and (3) volunteers' perceived needs for training on how to be an effective advocate. Thirty-four hospice palliative care volunteers responded to the survey developed for this study. The majority of the volunteers surveyed consider themselves advocates for their programs and many of those, who have not already done so, would be willing to promote their program (eg, give a community presentation, talk to local media) if asked. Half of the volunteers were aware of unmet needs of the patients/families they supported, and just over one-third wanted to advocate on behalf of their patients/families but did not know what to do or where to go. Recommendations for volunteer training are made.

VOLUNTEER ROLE
Patient/Family Advocacy Issues: "Because of their position outside the family and healthcare professional roles, volunteers may become aware of patient/family needs that are not being met, and as a result, they have the potential to step in to advocate for those needs or to support the patient/family in advocating for themselves."

Community Engagement and Advocacy for Volunteer Programme:
"because of their experiences as volunteers (eg, seeing first hand the differences they can make in someone's life), volunteers are also in a position to be effective advocates for their volunteer program. This could include giving a presentation about their program in the community, participating in the training of new volunteers, talking to the local media, and being involved in fundraising events."

6
The liminal space palliative care volunteers occupy and their roles within it: a qualitative study.  (PC), positively influencing quality of care for seriously ill people and those close to them and providing a link to the community. However, it is not well understood where volunteers fit into PC provision or how to support them adequately. We therefore chose to describe volunteer roles across care settings through the perspective of those closely involved in the care of terminally ill people.
METHODS: A qualitative study was conducted using both focus groups with volunteers, nurses, psychologists and family VOLUNTEER ROLE Patient/Family Advocacy Issues: "Volunteers occupy a liminal space between the professional and the family domain, through which they notice and communicate patient needs missed by other caregivers."

Communication Skills
Fostering and building relationships "Volunteers represent a more approachable face of care, focused on psychological, social and existential care and building relationships."

VOLUNTEER SUPPORT
physicians and individual semistructured interviews with patients and family caregivers. Participants were recruited from hospital, home, day care and live-in services.
RESULTS: 79 people participated in the study. Two volunteer roles were identified. The first was 'being there' for the dying person. Volunteers represent a more approachable face of care, focused on psychological, social and existential care and building relationships. The second was the 'liaison' role. Volunteers occupy a liminal space between the professional and the family domain, through which they notice and communicate patient needs missed by other caregivers. Patient-volunteer matching was a facilitator for role performance; barriers were lack of communication opportunities with professional caregivers and lack of volunteer coordination.
CONCLUSION: Volunteers complement professional caregivers by (1) occupying a unique space between professionals, family and patients and fulfilling a liaison function and (2) being a unique face of care for patients. Healthcare services and policy can support volunteer role performance by ensuring frequent communication opportunities and volunteer coordination. A survey was conducted to examine the frequency, acceptability, and functions of humor between hospice palliative care volunteers and their patients, from the volunteers' perspective. Thirty-two volunteers completed the survey, which was developed for this study. The results revealed that most patients and volunteers initiated humor either "often" or "sometimes" in their interactions. Over half of the volunteers considered humor to be either "very important" or "extremely important" in their interactions with patients (42% and 13%, respectively), with the patient being the determining factor as to whether and when it is appropriate or not (ie, volunteers take their lead from their patients). Volunteers mentioned a number of functions that humor serves within their patient interactions (eg, to relieve tension, to foster relationships/connections, and to distract). Laughter and humor fulfills one of the main goals of hospice palliative care, namely, improving patients' overall quality of life.

VOLUNTEER ROLE Communication Skills; use of humour in patient/volunteer interactions:
"humour definitely has a place in hospice palliative care, with the patient being the determining factor as to whether and when it is appropriate or not (ie, volunteers must take their lead from, and be adept at, reading their patients)." METHODS: Multiple case study design (n = 8). Cases were end-of-life befriending services in home and community settings including UK-based hospices (n = 6), an acute hospital (n = 1) and a charity providing

VOLUNTEER ROLE: Communication Skills;
 building rapport, relationship building:  Discussion of sensitive issues "An agreeable relationship between patient and volunteer and a degree of relational chemistry appeared an important prerequisite for impact. In practical terms, the relational aspects of the volunteer visit were apparent in the opportunity provided for conversation. Conversation was the most common object of patient's appreciation." support to those with substance abuse issues (n = 1). Data collection incorporated qualitative thematic interviews, observation and documentary analysis. Framework analysis facilitated within and across case pattern matching.
RESULTS: Eighty-four people participated across eight sites (cases), including patients (n = 23), carers (n = 3), volunteers (n = 24) and staff (n = 34). Interview data are reported here. Two main forms of input were described-'being there' and 'doing for'. 'Being there' encapsulated the importance of companionship and the relational dynamic between volunteer and patient. 'Doing for' described the process of meeting social needs such as being able to leave the house with the volunteer. These had impacts on wellbeing with people describing feeling less lonely, isolated, depressed and/or anxious. CONCLUSION: Impacts from volunteer befriending or neighbour services may be achieved through volunteers taking a more practical/goal-based orientation to their role and/or taking a more relational and emotional orientation. Training of volunteers must equip them to be aware of these differing elements of the role and sensitive to when they may create most impact.
"Much attention has been given recently to concepts of community involvement in, and the importance of public health approaches to, palliative and end-of-life care [48]. Volunteer befriender services can be seen as part of a response to these calls." 3 9 To be a trained and supported volunteer in palliative care -a phenomenological study. BACKGROUND: It has been found that including volunteers in palliative care is a positive contribution to seriously ill patients. It is, however, recommended that the volunteers are trained and supported. The aim of this study was to describe a group of trained and supported volunteers' lived experiences as volunteers in palliative care within the community health care services.

BMC Palliative
METHODS: This study adopted a descriptive phenomenological approach featuring individual interviews with nine volunteers. The interviews were analysed using the descriptive phenomenological research method according to Giorgi.
RESULTS: Being a volunteer in palliative care was both a positive and meaningful experience. It was a privilege being able to help those in need, which yielded positive returns. As a volunteer, it was important to be present for the ill persons and to follow them in their various physical and psychical states, which also implied that the volunteer had to face and deal with challenging situations. However, volunteers stated it was crucial to possess knowledge and life experience, as well as a clarified role, and they stressed the importance of being followed up by a mentor.
CONCLUSIONS: The findings showed that trained and supported volunteers among seriously ill or dying people within the realm of community health care services play an independent and important role in the palliative care team. A coordinator in palliative care is especially suitable for training and supporting the volunteers.

Community Engagement and Advocacy for Volunteer Programme:
"To ensure that palliative care volunteers are available in the future, it is important to inform individuals about the benefits of volunteering in palliative care within public forums. Likewise, health care personnel have to be aware of the volunteers' roles in palliative care."

VOLUNTEER SUPPORT
Ongoing Support for volunteers "When volunteers experience their volunteering as meaningful, and when they receive recognition for performing voluntary tasks, they frequently wish to continue as volunteers.

ORGANISATIONAL/IMPLEMENTATION Recruitment and retention of volunteers
A higher number of 'Volunteer hours' is related to higher relative satisfaction with care.

VOLUNTEER SUPPORT
Ongoing support and mentoring for existing volunteers. Satisfaction with care was related to higher 'volunteer hours'supporting current volunteers may promote longevity within the service. patient week). Those hospice programs in the highest quartile of volunteer usage had higher overall satisfaction compared with those in the lowest-quartile usage of volunteers (75.8% reported excellent overall quality of care compared with 67.8% reporting excellent in the lowest quartile. After adjustment for hospice program characteristics, hospice programs in the highest quartile had highest overall rating of the quality of care (coefficient=0.06, 95% confidence interval=0.04, 0.09).
CONCLUSION: In this cross-sectional study, hospice programs with higher use of volunteers per patient day were associated with bereaved family member reports that the hospice program quality of care was excellent.

1
The use of reflective diaries in end of life training programmes: a study exploring the impact of selfreflection on the participants in a volunteer training programme. BACKGROUND: A training programme was developed and delivered to a cohort of volunteers who were preparing for a unique role to provide companionship to dying patients in the acute hospital setting. This comprehensive programme aimed to provide an opportunity for participants to fully understand the nature and responsibilities of the role, whilst also allowing sufficient time to assess the qualities and competencies of participants for their ongoing volunteering role. Participants completed reflective diaries throughout the training course to record their ongoing thoughts and feelings. The purpose 'BEING THERE' AND 'BEING PRESENT' WITH THE PATIENT spiritual and psychological components of what it means to provide a presence with another VOLUNTEER SUPPORT Self preservation and coping strategies Personal loss and bereavement

Self Awareness
Reflection and maintaining the emotional health and well being of the volunteering team.
Ellershaw J of this paper is to present a phenomenological analysis of these entries to understand participants' experiences, perceptions and motivations.
METHOD: The wider study was structured into three phases. Phase 1 was the delivery of a 12 week, bespoke training programme; Phase 2 involved a 26 week pilot implementation of the Care of the Dying Volunteer Service and Phase 3 was the research evaluation of the training and implementation which would inform the further development of the training programme. Selfreflection is a common component of End of Life training programmes and volunteers in this study completed a reflective diary after participation in each of the training sessions. A thematic analysis was undertaken to explore and understand the participants' experience, perceptions and motivations in relation to their participation in the training.
RESULTS: All 19 volunteers completed the reflective diaries. From a potential 228 diary entries over the 12 week training programme, 178 diary entries were submitted (78 %). The following key themes were identified: Dying Alone and the importance of being present, Personal loss and the reconstruction of meaning, Self-Awareness and Personal growth, Self-preservation and Coping strategies and group unity/cohesion.

CONCLUSIONS:
The participants in this study demonstrated that they were able to use the diaries as an appropriate medium for reflection. Their reflections were also instrumental in the ongoing revision and development of the training programme. Analysis of their entries illustrated that the diaries could provide the opportunity for a reappraisal of their world view and personal philosophy around death and dying. Further research is undoubtedly required, however this paper suggests that self-reflection in this way, supports preparation in honing the appropriate attitudes and qualities required to work in this role. METHOD: An online survey sent to 1,332 hospice homecare services for adults in Germany was conducted during the summer of 2012. We employed the SPSS 21 software package for statistical evaluation.
RESULTS: All training programs included selfreflection on personal spirituality as obligatory. The definitions of spirituality used in programs differ considerably. The task of defining training objectives is randomly delegated to a SPIRITUALITY Recognising spiritual diversity Being aware of religious/spiritual needs of patients and their families Supporting patients with diverse spiritual needs "This approach firmly rejects intentions to impose external standards of spirituality on recipients of hospice care. It also suggests a form of spiritual care that achieves expert management of the aspects of presence, listening, perception, acceptance, respect, and reaction." PRESENCE Being there and being with patients "spiritual care that achieves expert management of the aspects of presence, listening, perception, acceptance, respect, and reaction" supervisor, a trainer, or to the governing organization. More than half the institutions work in conjunction with an external trainer. These external trainers frequently have professional backgrounds in pastoral care/theology and/or in hospice/palliative care. While spiritual care receives great attention, the specific tasks it entails are rarely discussed. The response rate for our study was 25.0% (n = 332). Hospice palliative care volunteer work--being with dying persons and their often distraught family members--has the potential to take an emotional toll on volunteers. The aim of this review article is to examine the types of stressors hospice palliative care volunteers typically experience in their work and how they cope with them. The results of this literature review suggest that hospice palliative care volunteers do not generally perceive their volunteer work as highly stressful. Nonetheless, a number of potential stressors and challenges were identified in the VOLUNTEER SUPPORT Self-care information and strategies and personal resilience In Africa, the need for palliative care provision is escalating with an increasing number of people living with HIV/AIDS, coupled with rising cancer and AIDS-related cancer diagnoses. In Uganda there is a shortage of doctors, particularly in rural areas. To address this Hospice Africa Uganda developed a Community Volunteer Programme to train volunteers to help by providing support to patients in their own homes. The aim of this qualitative study was to evaluate the impact of the Community Volunteer Programme. Sixtyfour interviews, with patients (21), community volunteer workers (CVWs) (32), and the hospice clinical teams (11) were conducted, using semi-structured digitally recorded individual, group and focus group interviews, at the Hospice Africa Uganda sites. The results reported the value of the Community Volunteer Programme, including the impact on patients and families, and how the CVWs acted as a 'bridge to the hospice' in identifying patients. Developing financial challenges that are emerging which could potentially impact Health care professionals usually receive professional education in ethics, but the half million hospice volunteers in the United States may receive only brief training that is limited to confidentiality and the volunteer role. The purpose of this study was to explore ethical issues hospice volunteers confront in their work. Interviews with 39 hospice volunteers were conducted, audio recorded, transcribed, and analyzed using qualitative methods. Prominent themes were dilemmas about gifts, patient care and family concerns, issues related to volunteer roles and boundaries, and issues surrounding suicide and hastening death. Suggestions for training include discussions of ethics after initial training once volunteers had confronted ethical issues, with special emphasis on strategies for negotiating their uneasy role positioned between health care professional and friend.

ETHICAL ISSUES Boundary issues. Ethical issues and the volunteer role.
VOLUNTEER TRAINING AND SUPPORT Ongoing support and mentoring.
volunteer. French hospice volunteers scored significantly lower on 3 categories of motives on the IMHPCV compared to a sample of Canadian hospice palliative care volunteers (study 2), suggesting that cultural differences may be involved. No significant differences were found in levels of death anxiety or empathy between the 3 groups of respondents of the study. IMPLICATIONS FOR SCREENING OF POTENTIAL VOLS -DEATH ANXIETY AND COPING Copyright © The Author(s) 2014. Our present study aimed to describe the experience of volunteers trained in palliative care in the context of a primary care hospital. In particular, the difficulties and the benefits of this specific position were evaluated according to volunteers' own perceptions and words.

ORGANISAITONAL/IMPLEMENTATION
METHOD: We employed a qualitative method. Various aspects of the volunteer's role were explored by means of semistructured questions, addressing their activity, their motivations, and their feelings. Participants were volunteers (n = 19) trained in palliative care and working at a university hospital. After giving written consent, they completed the VOLUNTEER ROLE Role Definitions/boundaries "the position of volunteer was characterised as complex. This complexity was expressed in three main ways:  the difficulty to integrate and explain one's role within the healthcare team and with patients  the difficulties related to the necessity of constant adaptation to the shifting context of acute care wards (short hospitals stays, shifts in the team, lack of intimacy in the rooms)  the difficulty to define precisely and definitively the limits of the position of volunteer" Developing and maintaining relationships "volunteers emphasized the ability to listen to and empathise with patients…the quality of support was essential in their relationships with patients".

MONITORING AND ONGOING SUPERVISION
semistructured questionnaire at home. Content analysis was used to identify the main categories of answers and the principal themes reported by the volunteers.
RESULTS: The main difficulties were related to uncertainty of the context. As every situation is different, volunteers could not define their role once and for all. However, they derived great satisfaction from their activity. A supporting frame and a good balance between constraints and autonomy were facilitating factors. Besides, the complexity related to the context contributed to make the position valuable and challenging. SIGNIFICANCE OF RESULTS: Integrating a voluntary service in a primary care hospital is partly based on active participation of the volunteers in developing their position in a more adequate way. In return, this relative autonomy implies a rigorous and supportive attitude from the institution."

Regular contact with other volunteers Support from volunteer coordinators Opportunity for reflection and reflexivity
"…belonging to a well-defined group, with its rules, but also with the exchanges it allows, constituted a major criterion of satisfaction. The quality of the welcome, the support, and the user-friendliness of the group were often pointed out by volunteers as essential features."

ORGANISATIONAL/IMPLEMENTATION
Embedding the volunteer service within the structures of the organisation "The complexity and ever-changing characteristics of the context clearly made for elements hard to overcome. It was also the major source of frustrations. However, these difficulties were also perceived as a challenge, which when taken up contributed to the value of volunteering: It takes time to become integrated. (. . .) What I like most is the complicity and discussions I can have with the healthcare team. We help each other by exchanging our feelings and what we could do for the patient's well-being. It is often very constructive. (volunteer 18)"

VOLUNTEERING IN HOSPITAL SETTING
indicate that volunteers trained in palliative care have their place in acute and general care settings. The study constitutes a first contribution to better understand the potential benefits and specificities of volunteer work in this particular context.