USE OF NONPROFESSIONAL VOLUNTEERS WITH PREGNANT TEENAGERS PEGGY B. SMITH, Ph.D.
Baylor College of Medicine aottslon, Texas AUDRINE L. SCALES, R.N.
Jefferson Davis Hospital Houston, Texas ABSTRACT The future funding needs of perinatal programs for teenagers should motivate adolescent clinics to make creative use of nonprofessional volunteers. When adequately trained and supervised, volunteers can perform meaningful tasks vHth high-risk teenage patients. In this program, volunteer involvement not only has extended the staff's capacity to counsel effectively and to educate pregnant adolescents but also has augmented the program's effectiveness by providing rewards to reinforce patient compliance with nutrition and weight control. This paper proyides some guidelines to medical professionals who want to improve the volunteer efforts of other adolescent pregnancy programs. Such perinatal se~'vices must begin to capitalize on the resources of the volunteer sector if such programs are to continue and eventually expand to meet the needs of the pregnant teenager.
Pregnancy Prevention Act and Title X of the Public Health Service Act may seriously limit available funds for staffing teenage pregnancy programs. It is hoped that the limitation of funds for such programs will not force the closing of adolescent clinics but will, instead, stimulate creative strategies to meet the counselling and service needs of the pregnant adolescent with minimum expense. The purposes of this paper are to help medical personnel identify alternative sources of manpower among nonprofessionals and to suggest ways of cultivating volunteer interest and effectively managing volunteer participation in perinatal programs for pregnant teenagers. The use of volunteers in medical and social programs is not new. Private agencies, especially nonprofit agencies, have traditionally incorporated volunteers into their organizations. The role of such volunteers was primarily to raise funds, transport clients, and provide clerical skills and nonspecialized services such as cleaning and cooking) More recently, sensitive social problems such as adolescent sexuality, pregnancy, contraceptive education, and counselling requiring special expertise have received public attention and have attracted volunteer involvement. This paper describes volunteer activities that occurred from 1974 to 1980 in the Goldfarb Adult Development Clinic, a perinatal program for pregnant adolescents, under the auspices of the Obstetrics and Gynecology Department of Baylor College of Medicine.
INTRODUCTION The adverse consequences of adolescent pregnancy have been well documented.1 Through empirical techniques, various disciplines have clearly substantiated the gamut of negative outcomes for teenagers who become pregnant. 2 Special services and intervention strategies 3 are often recommended to mitigate the more undesirable situations associated with adolescent motherhood. Such comprehensive programs seem to improve the outcome of these high-risk pregnancies? Continued federal funding for these needed support services may not be forthcoming. Possible recisions and future reductions in Title VI of tke Adolescent
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DESCRIPTION OF PROGRAM The Goldfarb Adult Development Clinic, a comprehensive psychosocial program for pregnant teenagers, was established in 1968 as a result of a Rockefeller Foundation grant to explore the antecedent factors associated with adolescent pregnancy. Classes and individual counselling on health-related matters are provided twice daily to antepartum and postpartum teenagers. From the inception of the project the staff was acutely aware of the counselling, educational, and motivational needs of the perinatal adolescent. The clinic seemed to be one of the few resources available from
18 which teenagers could obtain information on human reproduction, birth control, and baby care. The sensitive nature of the subject matter and the nontechnical reading level of the teenage patient often necessitated individual instruction, education, and counselling. The time required for such specialized techniques, however, was more than available nurses could provide. A local women's group and several college students, concerned over the growing adolescent pregnancy problem, informally expressed interest in clinic participation. Volunteer placement was originally initiated to meet the teaching demands created by the large numbers of pregnant adolescents seeking perinatal care in the hospital. VOLUNTEER SCREENING AND TRAINING Although participation was on a self-assigned voluntary basis, care was taken to guarantee that placement in a public maternity hospital serving large numbers of pregnant adolescents would be beneficial for both the patients and the volunteers. Subjective factors such as flexibility, acceptance of divergent life-styles, and psychological comfort with persons of different ethnic and racial heritages were considered. After the first year of volunteer participation, additional orientation was implemented by allowing potential volunteers the opportunity to" rehearse their future activities with individuals who had worked in the clinic during the past year. This system allowed the veteran volunteer to share on-the-job insights and firsthand responsibilities with a potential worker before a commitment to the project was made. After the initial screening and orientation were completed, an in-service day was scheduled during which all phases of the program were explained by professionals affiliated with different disciplines in the hospital. The purposes of the in-service day were to provide basic background on the issues surrounding adolescent pregnancy and to familiarize volunteers with the key personnel in the health-care system and with hospital rules and clinic procedures. VOLUNTEER ASSIGNMENTS The selection of volunteer tasks took various factors into account. The background Of the volunteer was an important consideration. Most of the volunteers could be grouped in two categories: 1) educated women who, while lacking formal pediatric or obstetrical training, had all been pregnant, received prenatal care, and were responsible for children, and 2) college students who had academic backgrounds but lacked pregnancy experience. These limitations were of concern to the staff because during routine patient educa-
tion and counselling (the proposed areas of volunteer involvement) health and emotional problems were often detected that required intervention skills beyond the scope of the volunteers' expertise. Volunteer scheduling was also considered. Paraprofessionals were usually available only in the morning, a time when the hospital routine was crowded with primary care activities. These problems were resolved through the assignment of a supervisor responsible for the daily administration of the clinic and the postpartum floor as well as for the coordination of the educational classes for the adolescents. The nurse coordinator was able to provide sensitive guidance and direction to the volunteers so that the volunteer was not placed in a situation for which she was untrained. The resource role of the nurse coordinator was continually stressed during placement orientation and during the daily activity of the volunteer. All volunteers were instructed to ask the nurse when in doubt. Once the supervisory mechanism was established, the clinic jobs were clarified and delineated. Three primary educational and counselling activities were selected for the volunteers. The first job was bedside counselling. Before entering the postpartum ward each volunteer checked with the coordinator to receive a brief history of each patient. Although all the hospitalized patients were adolescents, some had more complicated problems. The types of information and counselling approaches for each patient would therefore depend on her particular situation. In this activity each volunteer was responsible for explaining to each patient the basics of anatomy and physiology, contracep-. tion, and elementary baby care. The volunteer also discussed community resources with each patient according to individual needs, and reviewed a packet of information with each patient at the bedside. The packet contained information on immunizations, preventive health care, venereal disease, postpartum exercises, baby care, and a variety of other perinatal concerns. The postpartum floor also had a group of antepartum teenagers hospitalized because of conditions such as multiple births, diabetes, toxemia, and placenta previa. Since hospital fire codes prohibited televisions and radios in the rooms, the sojourn was monotonous, and adolescent patients occasionally left the ward against medical orders. This problem motivated the volunteers to create an activity entitled "bedside crafts." Twice a week volunteers would teach the hospitalized antepartum patients to make articles for themselves or for their babies. Materials and activities were cleared by the head nurse for safety before being introduced to the patient. A basket of items ready to
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19 assemble was kept with the coordinator so that patients could initiate activities at bedside. Volunteers also were available to participate in the group classes on perinatal care, scheduled twice daily on the adolescent floor. The most popular topics selected by the volunteers were the baby care and child development segments. An annotated curriculum routinely used in the program was shared with the volunteer to assist her in her presentation. Before teaching the class, each candidate would sit in during a regular presentation made by the staff. During the volunteer's first presentation, the coordinating nurse would remain in the classroom to assure quality control and to give psychological and informational support. Two auxiliary phases of the volunteer placement allowed women to participate in the clinic from their homes. A group of volunteers met one evening a week to make gifts for the adolescent girls--items that would be useful to the new mother once she returned home, such as mobiles, baby record books, diaper shirts, and crib toys. The items were delivered to the clinic quarterly and were used as rewards in the antepartum program to motivate the patients to monitor their nutritional intake and weight gain. Each pregnant teenager who ate from the four food groups and gained less than two pounds a week selected a gift of her choice. Another volunteer helped to gather teen-oriented magazines for the clinic. These magazines were passed out on the postpartum floor and during the clinic as the patients waited to see the doctor. The flexibility of these two activities appealed to women who were sincerely interested in the clinic but were unable to participate during the regular workday. PITFALLS OF v o L U N T E E R INVOLVEMENT During the six years of ongoing volunteer placement programs, nursing staff and patients have had positive experiences in utilizing volunteer participation. The good working relationship is attributed to program administration planning, which attempted to identify possible weaknesses in the volunteer staff before they came to light. Three areas of potential problems were identified. The first area involved staff reaction to the volunteer placement. Staff acceptance of the volunteer is crucial. Administration was aware that postpartum volunteers initially could be perceived as psychologically threatening and their involvement could be interpreted as a possible staff replacement rather than an extension. The volunteers on the floor could be seen as an informal monitor for program administration. There were also some pragmatic problems associated with staff reactions to volunteers. While volunteers can perform meaningful functions, their initial
orientation means extra time and work for the paid staff. Nevertheless, the volunteers were warmly received. To maximize this reception, the supervisory staff was involved in all phases of volunteer incorporation. Interpretation of the volunteers' role as well as staff perception of the volunteers' tasks were solicited before formalized c'ommitment of the volunteer. The supervisory staff was given veto power over the types of activities and the types of individuals for whom they had responsibility. Another potential weakness was ambiguity in the expectations of the volunteers. After the volunteers actually become involved in the project the personal expectations may change. To avoid this problem, volunteer expectations were clarified in writing before program placement. Clarification took the form of a job description, which was kept on file in the administrative office and was publicized in the volunteer organization's newsletter. For student volunteers a contract was drawn up between the student's supervising instructor and the administration of the clinic. Both the job descriptions and contracts were reviewed routinely to be sure that no change in expectations had occurred. A final area of anticipated weakness involved the maintenance of positive community relations. The program administration was acutely aware that community volunteers are key elements in the continuation of community acceptance and involvement in the program. Conversely, volunteers who became either disenchanted or disapproving of the operations of the clinic could severely limit positive community relations. In an attempt to neutralize such effects or intervene before such negative feelings occurred, each placement group chose a chairperson who would act as an ombudsman to clarify any potential problem. This individual also was of utmost importance in case a volunteer was inappropriately placed. The removal of such a volunteer could be accomplished graciously through the ombudsman. EVALUATING THE UTILITY OF VOLUNTEERS As in other assessments of health care delivery and educational programs, the primary purpose of evaluation is to facilitate rational decision making. The emphasis on its contribution to decision making probably is the key component of evaluation that sets it apart from basic research? Evaluating volunteer utilization is a valuable activity. For the coordinators of volunteer placements, evaluation can identify elements that can be extremely helpful in improving the volunteer programs and in achieving greater effectiveness. Despite the benefits of evaluation, however, careful and comprehensive assessment of volunteerutilization
20 m a y become expensive and difficult to implement with limited paid staff; it can actually act as a constraint in the delivery of direct service. One way to overcome this cost obstacle is to implement a variety of informal methods that can indicate whether or not the use of volunteers affects the outcome of pregnancy in the adolescent. While these techniques lack statistical rigor, they can provide useful information. The fiscal in-kind monetary value of volunteers can tell us something about their usefulness. F o r instance, in the program for adolescents, $200 worth of volunteer time per week was donated to the program. Such a figure can be persuasive to individuals concerned about overhead and cost-effectiveness ratios. Another way of ascertaining the utility of volunteers is to calculate the factor of staff extender to reach more patients. Volunteers used in the program al-
lowed the staff to cover two postpartum floors instead of one; a conservative estimate is that about 600 additional adolescent patients were served. It is to be hoped that reaching more individuals with information will increase the number of teenage mothers who develop effective parenting skills. Another informal evaluative measure is to ascertain the volunteers' satisfaction from participating in the program. After completing a one year placement, each volunteer was asked to fill out anonymously a onepage questionnaire, providing feedback to the clinic on ways of meeting more effectively the needs of volunteers in their work with the perinatal clients. The volunteers who participated in t h e program unanimously felt that their activities were worthwhile. The only criticism reflected a need for more operational information prior to placement.
4. Smith PB, Wait RB, Mumford DM, Nenney SW, Hollins BT. The medical impact of an antepartum program for pregnant adolescents: A statistical analysis. Am I Pub Health 1978; 68:169. 5. Roth RA. Vohmteers in Child Abuse and Neglect Pro. grams. Contract Number HEW 105-76-1136 for National Center on Child Abuse and Neglect. U.S. Children's Bureau, Administration for Children, Youth, and Families. 6. Gorry GA, Smith PB. Evaluating sex education programs. 1 Sex Educ Ther 1980. In press.
1. Smith PB, Mumford DM. Adolescent Pregnancy: Perspectives [or the Health Pro[essional. Boston, Massachusetts: G. K. Hall and Company, 1980. 2. Baldwin W, Cain V. Children of teenage parents. Faro Plan Perspect 1980; 12:34. 3. Furstenberg FF Jr. Unplanned Parenthood: The Social Consequences o[ Teenage Childbearing. New York: The Free Press, 1976; 224.
PATIENT COUNSELLING AND HEALTH EDUCATION