Volunteering in Health Care Context: A Concept Analysis Using Rodger’s Evolutionary Approach

Background: Volunteering is a common concept used in various disciplines including in the health care context. Nursing plays a role in volunteering concept development. However, the use of volunteering concept is still interchangeable. The clear definition concept about volunteering will promote the improvement in healthcare system quality. Purpose: This study aimed to clarify the volunteering concept in the health care context using Rodger’s evolutionary concept analysis. Methods: This study used a literature review for collecting the exemplars. Researchers used articles published in 2010-2020 in ScienceDirect, PubMed, Web of Science, and Google Scholar. Articles were searched using OR and AND. The keywords and MeSH used were “Volunteering OR Volunteerism OR volunteers AND Health OR Care OR Nursing” in the title, abstract, and keyword articles. Inclusion criteria were full articles in English. Rodger’s evolutionary concept analysis was implemented in this study with six steps. Results: This study used 39 eligible articles analyzed by providing codes of each article and then classified them in attributes, antecedents, and consequences of concept. Five attributes of volunteering, namely, giving help freely, as long-term planned, as giving a benefit to another individual, group, or organization, as working at a formal organization, and as a long-life activity were found. Antecedents of volunteering include motivation, social demographic, and philanthropic behavior. The consequences of volunteering were consequences for volunteers, patients, and the health care system. Conclusion: Volunteering is a complex concept and many surrogate concepts have similar definitions. The attributes are still debatable and need to be explored. Also, the consequences of volunteering are still rarely discussed in a particular health care system context. Further studies need to analyze the measurement of volunteering development based on the nursing theory framework and explore the consequences of volunteering in the health care system related to the nursing care context.

In sociology and political context, many scholars stated that volunteering is associated with social activism (Stukas, Snyder, & Clary, 2016;Wilson, 2000). These two concepts are quite different. Social activism is oriented toward social change; however, volunteering focuses on helping with individual problems (Wilson, 2000). Furthermore, in the psychology context, volunteering is sometimes associated with altruism and philanthropic behavior, although some scholars consider this interchangeability concept (Alias & Ismail, 2015;Nothwehr & Rohlman, 2019). In the economic context, volunteering is a form of employment without payment and labor contracts (International Labour Organization, 2011). Mismatch naming and misuse concepts might make difficulties in developing research related to volunteering.
Volunteering is commonly utilized in health care context. Volunteering is an integral part of the health services system and needs special attention (Jenkinson et al., 2013;Pilayon & Nuntaboot, 2017;Singh, Cumming, Mohajer, & Negin, 2016). Many studies revealed that volunteering effectively improves the quality of health services (Jenkinson et al., 2013;Singh et al., 2016). Furthermore, volunteering can improve volunteers' and patients' health status in the health care context (Hsiao et al., 2020;Papa, Cutuli, Principi, & Schere, 2019;Poulin, 2014;Stukas, Hoye, Nicholson, Brown, & Aisbett, 2016). Thus, it is necessary to explain the concept of volunteering in the health care context and become the foundation for further research in instrument development.
Concept analysis is an essential strategy for clarifying concepts that are still ambiguous and vagueness (Rodgers & Knafl, 2000). Also, concept analysis can help explain the antecedents, attributes, and consequences of a concept, making it easier for researchers or scholars to develop research or understand a concept in daily practice implication (Paley, 1996). Although there is limited nursing theory as the conceptual framework, the concept of volunteering needs to be developed from research to practice in nursing (Witucki Brown et al., 2011). Volunteering is close to the nursing context, especially in the concept of altruism and community participation model. Altruism becomes a foundation in the caring process, and community participation is a nursing care strategy of increasing the quality of health care systems (Smith, 1995;Stukas et al., 2014).
In surrogate terms, the analysis process used no further reduction in analyzing and synthesizing articles. Moreover, this procedure is more flexible than in the antecedents, attributes, and consequences analysis. A cross-disciplinary comparison is also performed to see the existing surrogate terms related to volunteering. In the exemplar of the concept, the authors illustrated the existing themes in the antecedents, attributes, and consequences of volunteering in a particular case to ease the reader from understanding the volunteering concept. The authors then analyzed the concept's implication based on existing theory or framework after finding surrogate terms and themes in antecedents, attributes, and consequences of volunteering.

Surrogate terms and the related concept
The use of the concept of volunteering and volunteerism is sometimes interchangeable. However, some literature explains that volunteerism is a behavior, whereas volunteering is real activism (Hustinx et al., 2010). The things that become essential terms in volunteering and volunteerism are the free acts without coercion and no explicit reward . Also, volunteering development is related to helping each other in a formal context, and it is a proactive rather than reactive activity (Wilson, 2000).
Volunteering is related to many concepts, such as social activism, altruism, philanthropic behavior, and helping behavior Wilson, 2000). Those concepts have similarities, but they have different attributes. Moreover, social support is also related to volunteering. Social support is a foundation concept and related to volunteering (Kumar, Calvo, Avendano, Sivaramakrishnan, & Berkman, 2012). Social support refers to the availability of helping relationships and the quality of those relationships. However, social support has a broad meaning and has a multidimensional meaning and needs to analyze in a specific context (Hether, Murphy, & Valente, 2014;Pedro, Rocha, & Nascimento, 2008).
Volunteering in the health care context can be implemented in a home-based, communitybased, and hospital-based settings (Read, 2014;Siabani, Driscoll, Davidson, & Leeder, 2016;Singh et al., 2016). Most of the article explains that volunteering in community settings is more feasible in the implementation (Jenkinson et al., 2013;Tulloch et al., 2015;Yansaneh et al., 2014).

Attributes, antecedents, and consequences of the concept Attributes
Volunteering has many definitions and dimensions and depends on the setting of the volunteering activity. In the health care context, there are five definitions related to the attributes of volunteering.

Volunteering is giving help freely
Volunteering is a form of unpaid social activity (Kobayashi, Sugihara, Fukaya, & Liang, 2019). However, it is not a form of slavery. High motivation from individuals in providing help to others makes volunteers do not need remuneration (South, Purcell, Branney, Gamsu, & White, 2014). Given freely can also be interpreted that someone only wants to help without a will. Thus, volunteering does not depend on a particular religion, age, social status, or ethnicity.

Volunteering is long term planned
Volunteering is a systematic process of providing help to others. This needs long term planning and commitment from volunteering members (Söderhamn, Landmark, Aasgaard, Eide, & Söderhamn, 2012). Volunteering is not a spontaneous or active activity, but volunteering is a reactive activity that starts from a plan (Alias & Ismail, 2015). In the health care context, volunteering must have a plan of action in providing health services.

Volunteering is giving a benefit to another individual, group, or organization
Volunteers have to give a benefit to individuals, groups, or organizations (Wilson, 2000). In other words, volunteering must be a positive benefit for people. Volunteering is not an activity that violates law or crime. However, volunteering is sometimes related to political movements but focuses on people. If volunteering conduct in a political or economic movement, it is referred to as the definition of activism (Gonella et al., 2019). In the health care context, the benefit of volunteering is correlated to health status and health system.

Volunteering is working in a formal organization
Some articles illustrate that volunteering must be under formal organizations (Alfes et al., 2017;Shen & Khosla, 2016). Formal organization refers to a non-government organization or government organization. Developed countries, such as the United States and the United Kingdom, have many non-governmental organizations (NGOs) managing volunteering in the health system. However, other countries such as Thailand, Myanmar and Taiwan, volunteering can be organized by the government or volunteer groups (NGOs) (Gau, Buettnerr, Usher, & Stewart, 2013;Pilayon & Nuntaboot, 2017;Watt et al., 2016).

Volunteering is a prolonged life activity
Volunteering is different from employment. Volunteering is a prolonged life activity (Nothwehr & Rohlman, 2019). People can be involved in volunteering activities without time and age restrictions. It makes volunteering a social movement for all groups. In the health care context, everyone can become a volunteer. However, they have to go through some training for volunteering in several advanced illness conditions such as cancer, stroke, or diabetes mellitus. Volunteering is given freely (Kobayashi et al., 2019); (Papa et al., 2019); (Söderhamn et al., 2012) Volunteering is a long-term planned (Söderhamn et al., 2012); (Studer, 2016) Volunteering is gives a benefit to another individual, group, or organization (Gonella et al., 2019) Volunteering is working in formal organization (Alfes, Antunes, & Shantz, 2017); (Jenkinson et al., 2013); (Söderhamn et al., 2012) Volunteering is a prolonged life activity (Nothwehr & (Showa et al., 2016); Consequences for the patient: gain the cognitive abilities, be a support system, decrease loneliness. Increase self-care management (Dowling, 2019); (Kim & Konrath, 2017); (Siabani et al., 2016); (Van Zon et al., 2016) Consequences for health care services/system: facing an increasing demand for informal care in addition to professional health care, helping nurses to maintain professional boundaries, increasing access to essential health services, reduced treatment burden, increasing hospital quality (Cherven et al., 2020); (Leon et al., 2015); (Pesut et al., 2014); (Steunenberg, van der Mast, Strijbos, Inouye, & Schuurmans, 2016); (Tulloch et al., 2015); (Yansaneh et al., 2014); motivation. The internal motivation to help someone is essential in improving volunteering activity (Gonella et al., 2019;. Also, self-growth is an internal motivation in volunteering activity (Hurst et al., 2019). External motivation is still debatable in the concept of volunteering. Volunteering emphasizes free paid, but some literature states that paid altruism is needed for volunteering in improving the quality of service (Ormel et al., 2019). On the other hand, South et al. (2014) explained that payment in altruistic behavior or volunteering would lead to financial conflicts.

Social demography status
Social demography status influences volunteering activities. Some social demographics that influence volunteering are gender, age, occupancy, cultural background, and religion. Gender is a factor that influences volunteering. The results showed that women have higher motivation and altruistic behavior than men (Afari-Asiedu et al., 2018;. Gender not only encourages volunteering but also how they work. Gender will affect the caring process in patients (Wilson, 2000).
Age also influences someone to do volunteer activities. Volunteering usually tends during the transition from adolescence to young adulthood (Wilson, 2000). However, older people also make it possible to become a volunteer. Older people desire to help others and always want to be useful to others (Komp et al., 2012).
Religion influences someone to do volunteering activities. Some religions believe that by helping others, someone will get something useful from their God (Vähäkangas, 2014). Volunteering activities are also sometimes carried out by religious organizations (McDougle et al., 2014). Besides religion, the cultural background also influences a person to do volunteer. Some cultures give positive impulses to help others (Jack et al., 2011).

Philanthropic behavior
Philanthropic behavior is the antecedent of volunteering. In philanthropic behavior, there are two concepts, namely donation, and volunteering. Individuals who have philanthropic behavior make these individuals active as volunteers (Alias & Ismail, 2015).

Consequences
Consequences are everything that happens after the concept exists. Volunteering in the health context has three dimensions of Consequences, namely, consequences for volunteers, Consequences for patients, Consequences for health care services/systems.

Consequences for volunteers
Volunteering can improve the health status of individuals who carry out volunteering activities. Literature review results obtained by volunteering, volunteers can change selfperception, increase life satisfaction, decrease stress and depression, prevent poor selfrated health (Fegan & Cook, 2012;Hsiao et al., 2020;Papa et  Consequences for patients Volunteering in the health care context is involved in one group of patients and various types of patients. A literature review found that volunteering could apply in patients with cancer, dementia, schizophrenia, or patients with stroke. In particular, volunteering can gain cognitive abilities, support patients, decrease loneliness, and increase self-care management (Dowling, 2019;Siabani et al., 2016;Van Zon, Kirby, & Anderson, 2016).

Consequences for health care services/systems
Volunteering can increase demand for informal care in addition to professional health care, help nurses to maintain professional boundaries, increasing access to essential health services, reduced treatment burden, increasing hospital quality (Cherven et al., 2020;Leon et al., 2015;Steunenberg et al., 2016;Tulloch et al., 2015;Yansaneh et al., 2014).  (45), a private employee, wanted to give his time to help others. He chose to become a volunteer in hospice care. At first, Peter was confused about the activities and competencies required to become a volunteer. Finally, Peter asked one of the nongovernment organizations (NGOs) engaged in the humanitarian sector in his area. Eventually, he found it. Peter was asked to fill out forms and be interviewed regarding his experience and abilities. Peter was asked to participate in the training first and was given a volunteering program from hospice care. However, Peter was not in a contract and could resign at any time. In the team, Peter met many volunteers with various motivations, backgrounds, and ages. Peter met other volunteers who have behavior to help others and have much money to be donated for social activity. Another volunteer explained that he wanted to get a salary from the volunteering process, although it is only for daily needs. Peter felt that his stress level was decreasing after working as a volunteer. Furthermore, Peter also made observations related to other volunteers after one year of work. Peter revealed that they felt more meaningful in facing life after working as volunteers. From the patients' perspectives, they said that they got a sufficient support system from volunteers in their treatment process. The patient did not feel loneliness anymore. The health care system in his area also changed to be more effective related to transition care of patients after NGOs and volunteers helped improve the quality of caring for patients in hospice care. However, there is no specific assessment for measuring volunteering activity and correlation with the health care system. This exemplar describes the attributes, antecedents, and consequences of volunteering. From this exemplar, we can identify that volunteering in the healthcare context is an effort to help others freely, long-term planned, giving benefits, and working in a formal organization, namely NGOs. Peter also had the motivation to help people. This exemplar describes the antecedent of volunteering, namely, internal motivation. Other volunteers met Peter described that social demography, philanthropic behavior and external motivation also was antecedents of volunteering. After working for one year, Peter got experience and change of stress level, and other volunteers also feels more meaningful. Furthermore, patients also explained that not feeling lonely and got a support system during this volunteering program. This exemplar showed the consequence of volunteering, namely the consequences for volunteers and the patient. Becoming more effective in transitional care is the consequence of volunteering in a health care system.

DISCUSSION
This study aimed to describe the concept of volunteering more clearly and distinguish it from related concepts. The literature review revealed that volunteering has distinct attributes, antecedents, and consequences with other concepts. The researchers used Rodger's evolutionary concept analysis to see the concept of volunteering with the literature review approach so that the study results can explain details about the concept of volunteering. Practically, volunteering was illustrated in an exemplar of the concept and made it clear to explain the concept's component. Volunteering has specific antecedents that include motivational factors, social demographics, and philanthropic behavior. In attribute, volunteering has a uniqueness that distinguishes it from other concepts such as altruism, philanthropy, helping behavior or social activism. In the healthcare context, volunteering also has specific consequences for volunteers themselves, patients, and the health care system (see Figure 2).
We found five attribute concepts of volunteering from eight articles. However, several attributes are still debatable and need to be explored in further research. First, the claim that volunteering is giving freely is still debatable. According to Ormel et al. (2019), although it is biased, volunteering requires incentives to increase volunteers' motivation. The exemplar of the concept described that one of the volunteers want to get a salary from volunteering activity as his motivation. This phenomenon also appears in the concept of volunteering. Therefore, the relationship between motivation and incentives for volunteers needs to be explored with an interpretive approach, especially in the healthcare context. Second, volunteering is working in a formal organization that still needs to be discussed and explained in further research. According to Whittaker et al. (2015), in a review on informal volunteerism in emergencies and disasters, they explained that informal volunteers who are not supervised by a formal organization are included in volunteering activities. However, informal volunteering can only be used in specific settings, such as disaster and emergency conditions. This attribute can also be the foundation for developing volunteering instruments specific to the health care context. Previous research only explained the burden of volunteering and not comprehensively about volunteering's attributes (Gau et al., 2014). This instrument's development helps health care providers, especially nurses, assess and evaluate the volunteers' readiness or perception in the process of volunteering activity. Nurses' role in this situation becomes essential because of the relationship between altruism and the nursing profession. Nurses can apply altruism or helping behavior in every caring activity (Alavi, Zargam-Boroujeni, Yousefy, & Bahrami, 2017). Furthermore, altruism is a core conceptual aspect of Watson's human caring theory (Watson, 2007). Therefore, nursing has a role in developing the instrument for assessing volunteer activity based on nursing theory.
Motivation, social demography status, and philanthropic behavior are the antecedents of volunteering. Those antecedents were explained in Ko et al. (2004), although not all attributes have been proven empirically. Ko et al. (2004) used a theory of planned behavior to predict volunteering in care for SARS patients in Taiwan. Self-efficacy, attitude, and working in the hospital are attributes of volunteering. Self-efficacy and attitude are a form of internal motivation from a volunteer in doing volunteering activities. Philanthropic behavior and social demographics as an antecedent may be able to be explained by social support theory. In Surrogate terms, social support theory becomes the theoretical underpinnings of volunteering, which can be influenced by social demographics and motivation (Aranda et al., 2019). Philanthropic behavior is a different concept from volunteering, although several papers mention those correlations. In social phenomena, several people who have behavior in donating their money for helping others sometimes want to be volunteers. Those conditions could be classified as philanthropic behavior (Hyánek & Hladká, 2013). It was illustrated in the exemplar of the concept. Therefore, the relationship between these two concepts still requires exploring comprehensively.
The consequences of volunteering are divided into three: the consequences for volunteers, patients, and the healthcare system. Consequences in volunteers and patients are clearly described in several papers, and the impacts of volunteering have been empirically proven. Furthermore, an exemplar of the concept explained the consequence in volunteers and patients clearly. However, the consequences of volunteering in the health care system are still rarely described in a particular nursing care context. An exemplar of concept provided an example that volunteering can mediate the continuity care process for patients from the hospital to hospice care. This exemplar can be the foundation for further research development. Simultaneously, volunteering in health care systems becomes a solution to solve accessibility care in rural areas (Yansaneh et al., 2014). Volunteers become pivotal in improving the quality of health services at either in the macro-level or micro-level healthcare system through community participation.
Community participation is part of community involvement in the health care system (Meleis, 1992;Sawyer, 1995). Community participation is needed in improving the quality of health systems, especially in rural areas (Meleis, 1992). Community health nurses have a responsibility to increase community participation (Melo & Alves, 2019). Moreover, community participation is one of the nursing care models that can be applied at the community level (Chalmers & Knstajanson, 1989). One of the strategies in community participation is volunteering activity (Attah & Anam, 2017). Thus, the synergy between nurses and volunteers may become a key strategy in improving nursing care quality in the health care system. Nurses play a role as a leader in volunteering regarding community participation in nursing care models. In a further study, nurses may explore the consequences of volunteering in either macro-level or micro-level healthcare systems related to community participation strategy in the nursing context.

CONCLUSION
Volunteering is a complex concept, and many surrogate concepts have similar definitions. Volunteering defines giving help freely, as long-term planned, as giving a benefit to another individual, group, or organization, working at a formal organization, as a prolonged life activity. However, this attribute is still debatable and needs to be explored. Also, the consequences of volunteering are still rarely discussed regarding consequences in the health care system related nursing care context. The pivotal role of nurses in the concept of volunteering is to develop volunteering measurement based on nursing theory and as a leader of volunteering activities.