Diversity & Equality in Health and Care Open Access

Keywords

Free clinics; Volunteers; Motivations; Outcomes; USA

Introduction

Volunteers provide a wide variety of essential services in health care settings, from patient care to administrative assistance. Many volunteers in the healthcare field are skillsbased volunteers, providing skilled services at hospitals or clinics in an effort to improve the quality of life of the individuals in those setting [1]. In the healthcare field, people tend to seek volunteer opportunities to gain work-related experiences [2]. More hospitals than ever before are utilizing volunteers for “profession and support services, governance and fund-raising” [2].

Free clinics provide an array of medical services at little or no cost to low-income, uninsured individuals in the United States (US) and often rely heavily on volunteers to provide services to vulnerable populations [3,4]. However, free clinics often experience uncertainty in funding sources and need to consistently fundraise to keep services and programs active [3]. While volunteers provide many services free clinics offer, there are few studies on volunteers’ experiences in this environment. The majority of studies on volunteering at free clinics have been conducted at student-run free clinics and focused on the impact of free clinic volunteer experiences on medical or health profession education [5,6]. More information about volunteering at free clinics, especially at non-student-run free clinics, is needed in order to better understand the types of experiences free clinic volunteers have, how they are utilized by these clinics and how free clinics can better train and equip their volunteers to improve patient outcomes. Thus, the purpose of this study is to explore volunteering experiences at a community free clinic.

Studying volunteerism from a sociological perspective focuses on volunteering as a social phenomenon, and seeks to bring into focus why individuals volunteer [7]. Volunteer participation is viewed through a socio-economic and cultural aspect [7]. The socio-economic aspect delves into the reasons for including volunteering into a lifestyle or excluding it from one’s lifestyle, while cultural aspects explore how different cultures view the importance of volunteering as viewed by society [7]. Volunteers are motivated by the opportunity to learn new skills, prepare for a future career, or become involved in their community, yet every individual has their own reason for volunteering and a unique way that they approach the volunteer site to gain different benefits [8].

Overview

This qualitative study was conducted at a free clinic located in the Intermountain West. The clinic serves uninsured individuals living below 150% of the federal poverty level and has been in operation since 2005. The clinic mainly provides routine health procedures and preventative care and is open five days a week. The clinic has approximately 75 patient visits a day. Six full-time staff and over 300 volunteers run the clinic. The roles filled by volunteers include physicians, registered nurses, interpreters, patient techs, x-ray technicians, physician assistants, patient assistance program, healthy loving educators, and those who work in the resource office. The patients of the clinic are from over 50 countries and speak various languages, making volunteer interpreters very important resources for patients and other volunteers at the clinic. The volunteer coordinator at the free clinic interviews individuals who are interested in volunteering. After the interview, new volunteers receive a first shift orientation providing a tour of the clinic and relevant training for their position. All new volunteers are required to complete HIPPA and Electronic Medical Record (EMR) training.

Study Procedure

The study was approved by the University of Utah Institutional Review Board (IRB). Data were collected from a series of focus groups which were held between September and November of 2016. The principal investigator of this study (AK) has collaborated with the clinic for education and research since May 2012. The research team members, working with the volunteer coordinator and clinic director, developed a focus group guide based on the clinic’s experiences and needs and literature (see Appendix). A one-page demographic questionnaire was developed to gather information about focus group participants (e.g. age, gender, years and months that a participant knows about the clinic). Participants of the study were current volunteers of the free clinic. All volunteers of the clinic are aged 18 or older.

Participants of the focus groups were recruited through fliers posted at the clinic, emails sent by the volunteer coordinator, and in-person requests by research team members on the day of each focus group. Consent was obtained from each participant. Each focus group was facilitated by the same research member for consistency, and the focus groups were audio recorded by two different devices. In addition to the facilitator, several other team members assisted the groups. The director, the volunteer coordinator, and other staff of the clinic were not present at any focus groups so that participants felt free to express their opinions about the clinic. During focus groups, a free lunch was served (approximately US$13-15/person). Participants received a $20 gift card upon their participation in a focus group.

Data analysis

The audio recordings of the focus groups were transcribed. The transcriptions were analyzed to ensure validity and reliability. Two of the research team members (HG and BG) developed initial codes separately based on the transcription of the first two groups. The third team member (AK) checked for agreement between the two coders and created the list of codes. The coders reviewed the first list of the codes before the actual analysis started. Using the finalized list of the codes, the transcripts were organized to identify themes and patterns within and across the groups independently by two study team members (HG and BG). AK explored discrepancies between the two members and reconciled the discrepancies. HG chose representative quotations to describe main results. Finally, all members of the study team agreed with the interpretations.

Results

Participant characteristics (From the demographic survey)

There were five focus groups held that included a total of twenty-eight total volunteers participated. The average volunteer’s tenure at the clinic was 8.24 months (SD=12.60). The characteristics of the participants (Table 1).

Beginning of volunteering

Participants discovered volunteer opportunities at the clinic through a variety of sources, including their university, community organizations or activities, personal contacts (e.g. family or friends) and the internet. Participants chose to volunteer at the clinic for various reasons. One of the most common reasons for volunteering at the free clinic was to gain experience in the medical field needed to apply for medical/ graduate schools. One participant planning to apply for medical schools stated, “Yeah, it was a super easy opportunity. You didn’t have to have a ton of experience. So it was a good way to a get your foot in the door somewhere and start building some experience.”

Table 1: Characteristics of participants frequencies, N=28.

Another common reason given for volunteering at the free clinic was to apply volunteers’ foreign language skills. One participant stated that: “...part of it is just an opportunity to[speak] Spanish, to be able to continue practicing, to talk with people.” Others stated that the clinic provided a convenient way to volunteer. They felt like they were wanted and valued by the clinic from the moment they applied, largely because of the quick turnaround from application to beginning volunteering at the clinic.

Orientation and training

A number of participants stated that they did not feel they received enough training before beginning their volunteer service. They voiced a need for more formal trainings and felt that having a designated volunteer trainer would be beneficial.

If we had one person giving the instruction, because I’ve had so many different people train me and everybody’s like, taught me in a different way and something different, which has been rad, because you get to learn so many different perspectives. But if [it] was a little bit more streamlined, more organized, then I think it would be uhm, more impactful the first time.

Participants pointed out that individuals training new volunteers should depend on the level of each volunteer’s prior experiences in a medical clinic environment. They also suggested that more experienced volunteers train less experienced volunteers in order to more quickly bring new volunteers up to speed with clinic practices. One participant said:

I guess it just depends on your, on your knowledge base, I guess...But I guess, for some of the other people that are volunteering that really have no patient care experience, it might be a little tough...Because I’m still fairly new myself. So, it might help to have somebody with, uh, pretty fluent in the whole operation to explain and know what’s really going on.

Participants acknowledged that there were challenges in providing adequate volunteer training at a free clinic setting due to the shortage of volunteers and the need of the patients. One participant stated:

And, in theory, volunteers actually are supposed to have three training sessions after the initial orientation. But it’s like, that’s the theory. Sometimes we’re short-staffed. And everybody’s like, “Oh, you’ve had one training session? You good at taking manual blood pressures. Go”!

Participants described several ways that they received training, including reading materials about the clinic and their duties as volunteers, and being mentored by a more experienced volunteer in the same area of skill. New volunteers sometimes went through formal training with staff to learn their job duties and were given checklists to ensure they knew the correct procedures. Some volunteers found the trainings to be informal and said they learned more through experience: “So the training I received? Uhm, it was fairly informal and a little hectic. The first three times I showed up for training, there was actually no one here to train me. So I kinda trained myself.”

Volunteers were asked about how adequately trained they felt they were when they began volunteering at the clinic. Many participants felt they had received adequate training to do the tasks required of them and felt confident in their abilities, while others only felt this way after gaining experience. Whatever their confidence level, many found that help was readily available if needed. Gaining hands-on experience at the clinic was described as a vital part of developing an understanding of what was expected of the volunteers. Training gave individuals an idea of what they needed to do, but the volunteers often felt unprepared until they had actually experienced what needed to be done: “And I, I learned more from doing than from being trained. But eventually, I got there.” Overall, volunteers expressed satisfaction with their orientation and training, although several participants felt they could have benefitted from more structured training and the designation of staff members as a volunteer trainer.

Positive experience

Volunteers expressed a number of positive experiences during their time at the clinic. Many found it personally rewarding to see patients’ health needs met: “There are sometimes when, when this clinic really helps people. And when I’ve gotten to be a part of that, I think it’s been really good for me.” Other participants described how volunteering at a free clinic was a rewarding experience. The clinic’s medical services are donated by local healthcare professionals. Some volunteers who were not professional medical care providers were impressed with how many local providers were willing to give medical care at the clinic without expectation of payment. For example, one participant said:

I think the most rewarding experiences I’ve had have been working directly with the, the health, the health care providers, and seeing really how much they, uh, care for the patients that come through the doors. Whereas the, the stigma with the healthcare system now is that, you know, the doctors just trying to see as many patients as they possibly can, get ‘em in and out the doors as fast as they can. But here, it’s not like that. Here the, the doctors and the physician’s assistants and nurses, they really take their time. They wanna understand, uh, what the patients are feeling. And that’s, that’s really cool to see.

Positive experiences involving learning about the clinic, gaining new skills, and the overall experience of being a volunteer were also expressed. Many volunteers also described the patients’ gratitude as an uplifting experience.

I think for me, as I said, it goes back to, like, those moments when you can tell that somebody is just so grateful for your service and for you being there. Uhm, you know, and we don’t know each of these people individually. We don’t know what they’ve been through. We don’t know what they’re currently going through. But, you can kind of feel it through their sincerity and through their gratitude that, like, to us, it may be just a volunteer opportunity, but for them, it’s something truly meaningful.

Negative experience

A few volunteers stated that they had no negative experiences during their duration of volunteering: “Difficult situation. Yeah. We haven’t had, I haven’t had any, any negative one.” However, some of the participants mentioned negative experiences. Unhappy patients and a stressful environment were listed as negative experiences by several volunteers.

I mean, like he said, sometimes you’ll call people and they’ll be angry. Or sometimes you’ll get, you’ll get people who come in, and sometimes the clinic’s not, doesn’t run as smoothly as some other clinics, because so much, so many people are volunteers and there are people who get impatient with that. And sometimes they’re kind of angry with you.

Potential miscommunications due to the language barrier between medical providers and patients were another source of negative experiences: “Language barrier. Like, I feel guilty when I can’t…it’s like, as soon as you grab them from the waiting room, you’re like, “Yep.” I feel really bad. But, um, yeah. That’s probably it.”

Not receiving enough training for tasks was also stated as a negative experience.

Probably the training at first. It’s just you feel, like, uhm, I don’t know, you kinda feel helpless. And so, like, I’m just standing here because I don’t know what to do. I’m supposed to be doing something, but I haven’t received the training, you know, enough training yet to do it. So, it kinda feels like you’re out of place.

Changes

Volunteers explained how their opinions changed over time in relation to their understanding/views/opinions of the underserved community served by the free clinic. Many of the participants described how they gained knowledge about the problems created by lack of medical insurance and access to medical care.

Before this, I don’t think I realized how much and how many people don’t have medical insurance. And seeing so many people come in on a daily basis, uh, shocked me at first. I was like, “Wow! There are these many people, just in this community alone, that don’t have medical insurance, and need the help.

Participants indicated that by volunteering at the clinic, they became more knowledgeable about underserved populations. One participant said:

I think one thing I’ve been really, uhm, intrigued by here is the wide variety of culture, cross section of population. It’s not just one; it doesn’t just represent one group of a certain kind of socioeconomic equal. It’s kind of all sorts, which has been really great to experience for me.

Several focus group participants explained how their time volunteering at the clinic impacted their viewpoint on inaccessibility of healthcare in the United States.

I feel like it’s been really eye-opening to, to see, uhm, you know how inaccessible health can be for some people. It’s…and like if there wasn’t clinics, like free clinics, then people would probably just constantly be in pain or they would, you know, have really severe health problems. And it’s really eye-opening to be able to like, recognize that, and then actually be able to help in some way.

One volunteer explained the breakdown of assumptions of who needed the services of a free clinic.

Well, the patient population isn’t what I thought it was. Uhm, I assumed it was a lot of unemployment situations. But actually, a number of the people that come through are, are, uhm, employed. And they don’t, they’re not offered health care or they fall into some sort of healthcare gap. So that’s helped me to go dig further and learn more about the healthcare system and the gaps, and why these people are falling into these gaps when they’re, they’re able-bodied, fully working. Uhm, why are they here, you know?

Participants also described how free clinics show the caring side of medical professionals, as represented by the volunteer healthcare providers at the clinic.

I think it’s nice knowing that there are places that they can go, uhm, if they don’t have insurance and, like, if they meet certain criteria. Although I’m not saying it’s, like, a perfect, but I think still there needs to more facilities where they can obtain that healthcare. Because here for example, I mean, it’s a great service that they provide here, but often times, there’s a wait list of two, three months, easy, uhm, before somebody can get in. And so, if they have, you know, more needs, that are more immediate needs, like, that’s still a long time to wait to be able to get that coverage.

Suggestion to the clinic

It was suggested that the clinic have a more structured volunteer training program. The volunteers go through a checklist, but it is implemented differently based on who conducts the training. Participants made it apparent that adding more structure to the training system would be beneficial.

Listening to kinda how they train some of the other departments, I think maybe normalizing it, at least resource, like having more of a system, and making sure that all of that gets done, instead of just kinda pairing someone with someone else, and then letting them train at their discretion.

Some participants felt that training the volunteers on a greater number of tasks would better assist the clinic in serving its clients, such as providing better training in clerical work. Volunteers were asked throughout their shifts to answer a ringing phone, or help out another volunteer by making copies, but were unsure of how to carry out the tasks.

I think just training some of the volunteers who are gonna to be near the desk on how to do some of those basic responsibilities. Like obviously, you’re not gonna expect them to know everything, but train them to answer the phone, train them how to transfer people, train them how to make copies, do faxes, uhm, how to schedule people.

Since there is a persistent shortage of volunteers, participants suggested the clinic advertise volunteer opportunities more widely in order to recruit additional volunteers.

I feel like maybe I would initiate like a recruiting system, maybe. Just because you can never have too many people to help and there is nothing wrong with, uh, helping somebody... The environment is, is, is healthy, because everybody there wants you to be there. Everybody there kinda needs you and because you play an important role, whether you are an interpreter, a phlebotomist, a nurse, whatever position you’re playing. And so, maybe just like a kind of recruitment system to kinda get the word out, uh, around, and see how many people we could get to come in and help even more.

Discussion

This study explored volunteering experiences at a nonstudent- run free clinic. There are three main findings. First, volunteers felt more aware of the experiences of the medically underserved after spending time at the free clinic. Volunteer opportunities such as this could be valuable for those entering the medical profession because of the exposure to an important and overlooked population. Second, free clinic volunteers need to be able to help in many different areas because of the nature of the free clinic setting. Being properly trained will increase volunteers’ comfort with the clinic and may improve volunteer retention. Third, connecting with patients and seeing them get their healthcare needs met was listed as one of the most positive parts of the volunteer experience.

The results of this study suggesting the potential contribution of volunteering at a free clinic to medical and health profession education is consistent with those of previous studies. Free clinics can expose medical students to opportunities to serve underserved populations [9]. Medical students who have experiences working for underserved populations are more likely to become primary care physicians and to serve underserved communities [9]. Free clinics also provide training opportunities to other students such as nursing students [10] and pharmacy students [11]. In addition, free clinics offer opportunities to students to collaborate with other professions [12].

While volunteers gain training opportunities through volunteering at a free clinic, they can make a wide range of contributions to free clinics and may volunteer longer if they receive proper training. Based on the input from focus group participants, one recommendation is to designate individuals at free clinics to carry out volunteer training in order to improve consistency. Previous studies on free clinic volunteers focus on educational outcomes of medical or health profession students [13,14]. Little is known about the contributions of free clinic volunteers beyond patient care and the strategies to develop effective training plans for free clinic volunteers. Future studies should evaluate training programs for free clinic volunteers.

The experiences of free clinic volunteering seem to be mostly positive. There are very few negative experiences expressed by the participants. The most rewarding experience among free clinic volunteers is meeting the health care needs of patients. Volunteering can enhance social well-being, life-satisfaction and self-esteem of volunteers [15,16]. Emphasizing benefits of volunteering beyond educational and professional benefits may help recruit volunteers with more diverse background and also retain volunteers.

While this study provided the information about volunteering at a free clinic, there are limitations. There was no participant who was a provider (e.g. a physician or nurse) due to their volunteer schedule. Lack of provider participants might have skewed the results. Some participants had volunteered at the clinic only for short term and might not have much knowledge/ experiences of volunteering at the clinic. Finally, this study was conducted at only one free clinic and had a very small sample size. Free clinics are all run differently and each has their own approach to the demographics that they serve. But since all free clinics serve underserved populations with limited social and financial resources, the challenges that free clinics face may be similar to each other [3].

Conclusion

Free clinics allow volunteers to gain educational and professional experiences while assisting in the provision of medical care for underserved populations. It is necessary to develop effective training programs for volunteers in order to maximize the benefits they can bring both to the clinic and the volunteers. One approach to improve training would be to designate a single person to administer trainings instead of relying on multiple trainers. The other way to better organize volunteer training may be to increase the volunteer management staff to distribute the responsibilities of the clinic's sole coordinator. Volunteering at free clinics benefits both the community and the volunteers personally as they develop greater understanding of issues facing underserved populations. Since free clinics rely on volunteers, further research on volunteering at free clinics is necessary to improve quality and quantity of free clinic volunteers. Particularly, future research should have a larger sample size and be in other health care facilities to contrast the data with the context.

Declarations of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval

The University of Utah Institutional Review Board (IRB) approved this study.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by the Sorenson Legacy Foundation (Akiko Kamimura) and the Undergraduate Research Opportunities Program at the University of Utah (Talon Harris).

Acknowledgement

The authors want to thank the patients who participated in this study and acknowledge the contribution of the staff of the Maliheh Free Clinic. In addition, we thank we thank Bianca Armenta and Mark Reviea for their help in focus groups or transcriptions.

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