Recognition of factors affecting the use of volunteer clinical forces in hospitals in Tehran: A qualitative study.

INTRODUCTION: Volunteers are valuable human resources for service-providing organizations. Health system requires their participation and cooperation in all sectors to achieve more success. The present study was conducted to recognize factors influencing the use of volunteer clinical forces (VCFs) in Tehran hospitals from 2018 to 2020.
METHODS: This is a qualitative study, based on grounded theory approach, and was done through semi-structured interviews. The studied population included the experts, managers of hospitals, and high-ranking managers in the Ministry of Health, Iranian Red Crescent Organization, and health nongovernmental organizations (NGOs). Nineteen persons were selected by purposeful sampling method and interviewed. The achieved data were analyzed by content analysis method.
RESULTS: The results showed that using VCFs in Tehran's hospitals was affected by eight following factors: organizational, legal, policy-making, economic, social, security, personal, and cultural dimensions. These findings illustrated the necessity of making changes in the structures, the rules, and the culture of health system to fit the bases with new approaches.
CONCLUSION: VCFs amplify the quality and structure of service providing for patients in hospitals. The focus of policymakers and high-ranking managers in health system is on accelerating their use permanently and legally. Developing health-centered NGOs facilitates the access to VCF, lessens nonclinical loads of hospitals, and improves the organization of human forces. The experiences and knowledge of VCFs cause to develop hospitals' resilience, develop social participation, and improve social capitals in medical field. Copyright:

Introduction

Volunteering service is a sociocultural phenomenon. The volunteers include three main forces (conventional staff, volunteers, and customers) and are known as valuable human resources. The organizations providing social services can conduct their programs in a limited range without experienced volunteers. Volunteering activities are defined as a considerable benefit for organizations.[12] Volunteer is a person working without receiving any wages, for example, in schools, churches, and hospitals for a definite period of time. They are not included similar people and have different personal and occupational skills or experiences. Wilson and Musick's study showed that volunteering work has three characteristics: productive work needed human capital, mass behavior related to social capital, and ethical activity which is dependent on cultural capital.

Reinforcement of volunteer forces' motivation is one of the key elements in developing social participation and social capital. The impact of external motivation overweighs the internal one in volunteers, and there is bilateral and reinforcing relationship between happiness feeling and volunteer activities in charity affairs.[2345]

Hospitals are the main units of providing services in health system with a considerable number of forces in general and specialized levels. Using volunteer forces can save remarkably hospitals' costs, increase the quality of services, and increase satisfaction of patients. Humanitarian-aid organizations and hospitals can bring about a large number of services by managing efficiently the use of volunteer forces. However, lack of respecting them as a valuable capital is one of the barriers against organizations' success.[5678910]

Metz stated that the services provided by volunteers seem to be productive, flexible, and sincere. Although it seems that some duties can be done by other persons, relative benefit of a defined action depends on conducting that action by an employee or a volunteer.[11] Turner et al. stated that the estimated value of an episode of time specified by a volunteer, for performing a health program, is about 60–90 dollars.[12] In England's Health System, 78,000 volunteers provide 13 million hours of services. In addition, hospitals gained 11 pounds out of investing just one pound for every volunteer force.[1314]

Health system requires absorbing further cooperation and commitment in all sectors and levels. Meanwhile, volunteering activities of health-centered forces provide some opportunities for socializing and lead to occupational improvement and personal development.[1516] One of the major prerequisites of permanent development and effective participation is continuous, regular, and disciplinary participation of people in different fields. General interest activity is one of the main indicators of social capitals. Francis Fukuyama defines social capital as the ability of people to cooperate and participate. The theories of social capital emphasize the presence of individuals in societies and activities of volunteer institutions.[171819] In Singapore, nongovernmental organizations (NGOs) and civil institutions are providing heath-centered services free of charge in hospitals or even in patients' houses.[20]

In Iran, 85% of hospitalization services were provided by governmental sector. The perceived shortages of patients in care and supportive domains are mostly caused by not only lack of suitable indicator of human forces but also lack of appropriate human communication in hospitals.[2122] The National Program for People Participation and Intersectoral Cooperation in Health System is a comprehensive operation to achieve health goals through using capabilities and enhancing community participation. This is designed to do by promoting the participation of governmental and nongovernmental departments through effective intersectoral cooperation. The aim of this cooperation includes developing healthy and productive life as the main part of policies associated to 20-year Islamic Republic's Vision and also Health Reform Plan. This massive program emphasizes using forces contributing in health system.[23]

In Iran, different organizations are interested to encourage volunteers involving in their activities. Some examples of this tendency are as follows: using health mediators in hospitals and volunteering program called “Salamat Yar” (Health Assistant) which was designed by reciprocal cooperation of the Ministry of Health and Iranian Red Crescent Organization.[21] Using volunteer clinical forces (VCFs) has been done in critical conditions and in an emotional manner with disorganized design and based on personal tastes of managers. However, no research has been conducted with regard to this issue yet. Using these specialized forces in hospitals is not effective without recognizing the dimensions and factors related to their appropriate, permanent, and legal use. This research has been conducted, for the first time, to recognize the factors contributing in using VCF in Tehran's hospitals.

Methods

This is a qualitative research conducted through content analysis from 2018 to 2020 to recognize the factors contributing the use of VCF in Tehran's hospitals. The reason of selection of qualitative research was the qualification of this sort of study in collecting and organizing huge amount of data with high level of variety, achieving deep knowledge of participants and assisting to extract communication patterns and trends.[2425] The selection of grounded theory was due to the capability of this method in extracting human's experiences and this opinion that there are some points in life experiences which are possible to be studied. Grounded theory is a systematic and qualitative process for making a theory directly out of inputs extracted and analyzed regularly.[2627]

The studied population included the officials of Hospital Management Office in the Ministry of Health, bosses and managers of hospitals and nursing offices having volunteer forces, the officials of health NGOs, and hospital volunteer forces and the officials of Volunteering Deputy in Iran Red Crescent Organization. They were selected by purposeful sampling method and 19 cases were face-to-face interviewed. The inclusion criteria of the present investigation included the tendency of participants to take part in the study, having at least 5 years of official management work history, or hospital voluntary activity.

The participants were selected based on the purposeful sampling method. The sample size was determined according to the achieved data. Therefore, the participants were selected with the most amount of enriched information, and they could present their information appropriately to the researcher. The interviews were continued up to reaching to the data saturation level.

Semi-structured interviews were used to collect the data. The interviews were done in a place in which the participants felt to be relaxed and could state their experiences. Guiding questions were used during the interviews. These questions were provided by reviewing the literature and the ideas of specialists in this field [Table 1].

Table 1

The guidance of semi-structured interview

I am the PhD candidate student of Health Management in Iran University of Medical Sciences. My study title is “the design of a pattern to use Volunteer Clinical Forces (VCF) in Tehran’s hospitals.” Hence, I follow this goal through this aim. Before interview, it is necessary to notice following points
1. This is a research interview and is solely related to collecting data of present thesis. The format and goal of this interview is absolutely different from ordinary journalistic interviews
2. Based on your permission, the content of your statements, questions, and answers will be kept to transcribe and insert the data into data analysis software
3. You can continue interview as far as you like. Your statements are surely kept confidential. You are given a “participant code” which only research team know that who’s this code is. In all analyses, you are mentioned just by your code
4. First, I apologize you for interrupting your words or asking additional description with regard to the mentioned issues
Research’s questions
1. Please describe your professional activities briefly.
2. As a high-ranking health manager, what is your idea about using VCF in hospitals?
3. What are the dimensions and modifiers of using VCFs in hospitals?
4. What are the present patterns for using VCFs? In your opinion, which one of them is more practical?
5. In your opinion, in what hospital sectors VCFs can be more effective?
6. What are your suggestions to manage more efficiently VCFs and keep and promote their motivation?
7. In your opinion, do NGOs have the capacity to use VCFs permanently?
8. As a manager, what are your concerns in using VCFs in hospitals?
9. Respecting your participation, please provide your possible suggestions with regard to using VCFs in hospitals?

VCF=Volunteer clinical force

The duration of interviews was between 45 and 90 min. The participants' statements were recorded by a recorder after informing them and receiving their consent. The achieved data were analyzed through content analysis method. Content analysis has qualitative and quantitative approach.[2829] Data coding was done by two researchers. For increasing trustworthiness of the study, Lincoln and Guba Four-Dimensions criteria including credibility, transferability, dependability, and conformability was used.[3031]

The questions of interviews were as follows: “What is your idea about using VCFs in hospital?,”, “What characteristics should VCFs have?,” and “What expectations do you have with regard to them?” The rest of the questions and descriptions are noted in Table 1.

The goals of the study were explained to the participants in respect of ethical considerations. They were asked to complete informed consent form and had their right to leave the study whenever they decided.

Results

The present study was done by the participation of 19 participants. The achieved data showed that 47.4% of the participants were male [Table 2]. The main factors contributing the use of VCFs in Tehran's hospitals included eight major dimensions and 47 subthemes [Shape 1].

Table 2

The demographic information of the participants

Organization	Sex, frequency (%)		Frequency sum (%)
	Male	Female
The Ministry of Health and Medical Education	1 (5.3)	4 (21.0)	5 (26.3)
Red Crescent of Islamic Republic of Iran	1 (5.3)	1 (5.3)	2 (10.4)
Governmental and nongovernmental hospitals	2 (10.5)	3 (15.8)	5 (26.3)
Health NGOs	4 (21.0)	0 (0)	4 (21.0)
Volunteer forces	1 (5.3)	2 (10.5)	3 (15.9)
Sum	9 (47.4)	10 (52.6)	19 (100)

Shape 1

Dimensions impacting the use of volunteer clinical forces in Tehran's hospitals

Organizational dimension

Based on the ideas of the studied participants, extracted organizational dimension had five subthemes: organizational culture, organizational structure, organizational relations, organizational processes, and organizational management method. For example, some of the opinions of the participants are reported here: “Basically, the hospitals need this dialog and handling the volunteering dialog in hospitals is very difficult.” “We have a basic debate: perhaps, insufficient maturity in health systems of management field,” “We always need to have volunteer clinical forces in our systems: Whether the operational manager, high-ranking manager, or staff,” “Please doctors quit management systems of hospitals and universities and let others be hospital or university managers, a person majoring in Management,” “Because VCFs are not included in organizational chart, it should be tackled basically.” And this is a professional matter: If it is aimed to do like volunteer, an NGO has to do it. An NGO having its own identity, personality, and protocols. Hospital audiences should be NGO rather than a person” [Shape 2].

Shape 2

Subthemes of organizational dimension related to using volunteer clinical forces in hospitals

Legal dimension

The factors influencing the use of VCFs in Tehran's hospitals can be included in five subthemes: lack of advanced upstream rules and documents related to VCFs, lack of providing the bases of individual and organizational rules of these forces, removing legal barriers of affairs related to VCFs, the management of insurance affairs, and providing rule of NGOs in health field.

Some of the statements of the participants are narrated as follows: “Volunteering work in Iran has no discipline,” “The most important issue for volunteering issue, especially in health field, is that we have no definite rule, we have no upstream rule.” “In Ministry of Health, there was no rule which supports a surgeon professor working voluntarily.” “Our first concern is that legal barriers would be removed.” “Where is it as routine that there is a volunteer in an NGO and we should pay his/her insurance?!” “One of the criteria for a volunteer can be this point that he/she should be screened from scientific, ethical, and communicative aspects. Hospital is a complex environment with different people in different levels and the possibility of corruption is high over there.” “And the guy comes into the system, if he/she does any fault, how the legal support of this fault is?” [Shape 3].

Shape 3

Subthemes of legal dimension of using volunteer clinical forces in hospital

Policy-making dimension

Based on interviews, the factors contributing policy-making in using VCFs in Tehran's hospitals are included in the following subthemes: increasing health system resilience by using VCFs in the form of NGO, the complexity of health system policy-making process, the necessity of providing the policies related to VCFs, implementing routine policies, the evaluation and reviewing the policies, using previous policy-making experiences, and justifying and lobbying with political powerful people.

The instances of the participants' statements related to this dimension are as follows: “one of the most important of our limitations in health system is the lack of people's participation in providing services.” “Due to conflict of interests, there is no promise on volunteering work in Ministry of Health.” “We got that they do not want to let anyone come into the system,” Our job was mostly to do lobby and justify the politicians and members of parliament, city council members, and municipality,” “I believe that volunteering work should be included in social sector of every university” [Shape 4].

Shape 4

Subthemes of policy-making dimension in using volunteer clinical forces in hospital

Economic dimension

Based on the beliefs of participants in the present study, economic factors affecting the use of VCFs in hospitals are included the following items: The assessment of the cost–benefit/effectiveness of VCFs, financial transparency of intermediary organizations, the emphasis on financial transparency of volunteering affairs, the necessity of specifying budget for conducting volunteering programs in hospitals, and consideration of financial model in the pattern of using VCFs.

The statements of the participants with regard to this dimension are narrated exactly as follows: “The hospital tells me that I rely on you, last year I did 1000-h volunteering work and I saved this hour/cost. I made better the people's condition,” “It is right that we should not pay for volunteer forces as routine, but it does not mean that the program is without any cost.” “VCFs can create capacities, increase hospital's income, and decrease unnecessary referrals to hospitals,” “I mean, the budget is the main matter in this respect. What sort of measure you want to do, you need its necessary budget.” “There are some socially basic services which affect so much cost decrease and relapsing to the hospital.” “The volunteering work process is not free and a system should take the responsibility” [Shape 5].

Shape 5

Subthemes related to economic dimension in using volunteer clinical forces in hospital

Social dimension

The issues related to social dimension impacting the use of VCFs in hospitals were as follows based on interviewees' beliefs: Increasing requirement of society to volunteer services, the existence of social potentialities, regarding new style of social life, the importance of specifying social privilege for VCFs, the importance of social positive valuing, organizing health field NGO, the activity of VCFs as taking social responsibilities, reinforcing social support through VCFs, the annual occurrence of crises in the country, the impact of VCFs on developing social capital, and its impact on social attitude improvement to the health system.

There are some examples of the participants' statements related to this dimension: “Now, public attitude is against health system…Those ones provide services inefficiently…don't pay tax, they treat badly…Their system is very tough. They don't take care of patients.” “In many countries, one part of person's physical and cognitive power is what they do for society.” “There are some socially basic services which affect facilitating the processes and increasing satisfaction so much.” “Social solidarity comes to my mind is about VCFs.” “Socially volunteering activities is a part of social capital in the country.” “Social intervention is done among individuals and the social value of this deed should be improved” [Shape 6].

Shape 6

Subthemes of social dimension in using volunteer clinical forces in hospital

Security dimension

Based on the beliefs of participants in the present study, security factors affecting the use of VCFs in Tehran's hospitals are included the following three subthemes: “The natural sensitivity of health field, the sensitivity of health field toward other fields in recruitment of forces, and the lack of anticipation of security considerations in the health system structure.”

The statements of the participants with regard to this dimension are narrated exactly as follows: “The presence of volunteer forces in systems has some advantages in addition to its own considerations.” “From security point of view, it is also justifiable because it can be misused.” “Keep in your mind that, for every sort of recruitment pattern, The Ministry of Health is a little tough…and it is right.” “They have right because it is health field and you cannot open the door and let any volunteer comes into.” “In respect of security, since no structure is defined for them and they don't want to have any information leakage, they don't let them enter into” [Shape 7].

Shape 7

Subthemes of security dimension in using volunteer clinical forces in hospital

Personal dimension

Based on the conducted interviews in the present study, personal factors affecting the use of volunteer clinical personnel in Tehran's hospitals are included the following issues: psychological characteristics of VCFs, focusing on purpose, general capabilities, scientific and experimental experiences, ritual differences, and characteristics.

There are some examples of the participants' statements related to this dimension: “I believe that…some people want to help and they get involved beyond organizational frameworks and based on humanity and their own personality.” “Life expectancy increases in these volunteers.” “Those ones doing volunteer activities have no limitation for themselves and say, for example, the time work is over, or transportation service left…This is not my duty or… I work in this framework only.” “Even age is important: There is a case in which the staff cannot ask a volunteer to do something which is difficult in his age” [Shape 8].

Shape 8

Subthemes of personal dimension in using volunteer clinical forces in hospital

Cultural dimension

Based on the conducted interviews in the present study, cultural factors affecting the use of volunteer clinical personnel in Tehran's hospitals are included the following issues: The presence of cultural context in country for volunteering activities, the necessity to provide general culture building, emphasis on scientific approach in culturalization for VCFs, the existence of subculture called giving over difficult duties to VCFs, and culturalization through radio and TV.

There are some examples of the participants' statements narrated exactly: “The issue of people participation is very highlighted in Iran.” “I have seen VCFs in TV programs and haven't seen it scientifically and academically.” “Because it is a new issue especially in hospitals, it faces big problems at the first stages.” “By a scientific structure and methodological knowledge, volunteering basis has to be forms and deliver it to hospitals completely.” “We have a lot of capacities which can help us.” “Volunteer forces bring new culture.” “Culturalization should be done for this issue especially through TV and radio programs.” “It is important that it is publicized in virtual network and the relation with people got formed.” “We can show their importance through Instagram practically.” “We can ask them to do some responsibilities such as education, consultation, awareness making, and culturalization based on hospitals' social mission” [Shape 9].

Shape 9

Subthemes of cultural dimension in using volunteer clinical forces in hospital

Discussion

In the present study, eight main factors affecting the use of VCFs in Tehran's hospitals were recognized. They included organizational, policymaking, economic, social, security, personal, and cultural dimensions by 47 subthemes.

Volunteers and employees provide different human and intellectual resources for organizations. The perception of personal differences, routes of their communication and understanding their activity process cause to create friendly organizational environment.

The changes in NGOs' and hospitals' structures should be made to use clinical forces in health system. This leads to enhance patients' satisfaction and makes it possible to use physical, intellectual, ad cooperative manners of these forces for compensating the permanent shortage in clinical forces, especially in hospitals.

This is consistent with the findings of Handy and Srinivasan and Studer and Von. They stated that the presence of VCFs in organizational processes related to decision-making and headquartering can improve the relation between employees and VCFs. It also accelerates the involvement of these forces in the operational body of organization.[3233]

The most important characteristic of an organization affecting the recruitment of VCFs is the goal of organization. These goals establish different types of organization cultures. Besides, the behavior of volunteers differ in accordance with their understanding of organization's mission and goals.[34] The appropriateness of organization's structures for conducting volunteering activities leads to stabilize and improve the activities of volunteers.[35] Encouraging, respecting, and involving the volunteer forces require a thoughtful approach in organization management and can reinforce organizational culture: Andam et al. stated in their study that acknowledgment can impact the persistence of volunteers' activity up to 71%.[3637]

The participants in the present study expressed the lack of experience in using volunteer forces in hospitals and the immaturity in nongovenmental institutions related to health field. This result was found in the study by Nekoui Moghadam (2017). The involvement of volunteers is mostly seen in governmental branch of health filed in Iran, whereas NGOs have considerable success in this field in other countries.[38]

The participants in the present research emphasized the importance of using the graduates of Management major in hospitals as managers rather than physicians. The findings of some investigations showed that there was no any reliable assessment in studying positive impact of physicians in operating hospitals in comparison with the graduates of Management major. Based on the experiences of the participants in the present study, the viewpoints of the graduates in Management major was more open and susceptible to attract participation, rather than the physicians passing just some educational courses.[394041]

The present research illustrated the possibility of retraining the VCFs and directing them to work more effectively. Wu et al. came to this result that education can demonstrate the process of organization for volunteers and facilitate the achievement of organization's goals.[35]

The lack of upstream rules and documents in VCFs domain in Iran leads to establish of their legally personal and organizational bases and hospitals prefer not to interfere in their affairs. These disciplines can prevent from losing the rights of the patients, volunteers, and hospitals. Removing legal obstacles and unclear insurance problems of the volunteers can be led NGOs to work more efficiently. Singer demonstrated in his study that “volunteering cooperation” for general services and governmental sectors is a common activity which is done voluntarily by the staff in governmental and Nonprofit Organizations (NPOs) out of their scheduled work time.[42] Gilliland stated that the court called the volunteer firemen received wage per hour as the employee and deserved them to receive the least amount of wage. The reason of this deduction was that they were permitted to work and tolerate the workload.[43] In Iran, some limited rules are established with regard to volunteers in few organizations such as Red Crescent Organization and also in the situations in which the public and governmental institutions require their help. Iranian legal system has no tendency to develop the range of government's civil responsibility toward volunteers.[44]

Xu stated that ethically personal resources shape socially personal resources. Ethical resources of civil society are very important for success in volunteering organizations. Personal, social, and political capitals are influencing factors impacting civil society.[45]

Thomsen and Jensen (2020) stated in their investigation that volunteers' involvement in providing public services is the key element of policymaking for governments around the world.[46] The experts in this study assessed the present complexity of health system, policy-making process, implementing the policies, and the necessity of evaluating and revising the policies related to VCF.

However, it seems that previous valuable experiences in limited use of VCFs should be assessed in the following instances: the use of clinical forces in the Iraq–Iran War, Muslim Physicians without Borders, and Nursing Volunteering National Team in Crisis.

Motivating volunteers and believing their practice among high-ranking officials of the Ministry of Health can facilitate their use by health field NGOs. In Australia, NGOs are major responsible for providing citizens' welfare. Therefore, the presence of volunteers in policy-making related to service provision causes to increase the flexibility against accidents and resilience of health system.[3747]

Developing use of volunteer forces in health system is known as “labor without wage” but with economic value. This sort of working is defined as an investment in human and economic resources. Furthermore, volunteering work is considered as an alternative to reduce costs.[4748] Handy stated in his study that >2 million volunteering pieces of work per hour was done annually, and some factors such as productivity, production, and business bases impact the need to use volunteers.[49] He stated that the use of volunteers in hospitals had long history in the North America and hospitals may use them more to increase the quality of services and lessen costs. Moreover, they prefer to use professional managers for increasing the efficacy of volunteers. This research showed that 6.84 dollars of investing in volunteer-related affairs leads to receive back 684% of interest in civil affairs and society involvement. This consequently results in new values.[50]

Based on the research findings, growing need of society to volunteering services and promoting positive attitude of society for volunteering affairs, especially in recent years, have led to improve the importance of volunteering working in hospitals. This was in line with the results of Ripamonti et al. They stated that the activity of VCFs in hospitals represents the increase of social commitment considerably.[51] VCFs provide medical and supportive services, and they consider their activities as the social responsibility.[52] Acknowledging the participants and the volunteering organizations and also giving them any sorts of encouraging materials such as medal or formal certificates for doing volunteering activities can change volunteering to a unique social process and lead to provide social support for VCFs.[35]

The use of intermediary organizations and organizing NGOs in health filed was in line with the studies by Wellens and Jegers and Newton et al. They stated that supporting volunteers is a main source for nonprofitable organizations for using the time and capitals allocated to education and selecting new volunteers as much as possible. They also declared that NGOs make all their effort to respond logically to the needs of stakeholders, the board of directors, and volunteers and also achieve their organizational goals.[5354] In addition, the preference of using intermediary organizations and NGOs in health field as the sources of developing social responsibility and social capital was all emphasized in the present study.

The importance of health field and the necessity of exact recruitment of clinical employed forces in hospitals were two considerable issues focused by the participants of this investigation. This is accompanied with the findings of Benjamin et al. They concluded that individuals' health-related information is one of the most critical parts of their owning. The access to their data is permitted when their life is in danger. Hence, it is a serious challenge for hospitals to protect privacy of their clients. It is expected that the highest level of confidentiality is practiced in this matter.[55]

The security limitations of health structure and the possibility of misusing the hospital atmosphere as a complex system were the other beliefs extracted from the participants' statements in the present study. This highlights the role of intermediary and NGOs as the facilitators. This is consistent with the findings of the Kim et al. and Auger. They stated that private territory is a universal value and the providers of health services should protect patients' private territory. Misusing the information related to patients' health can cause serious problems.[5657]

One significant point associated to hospitals' security is that hospitals are more concerned of protecting their patients physically and mentally, rather than regarding technological aspects of their treatment. However, digitizing the data related to health and disease leads to fundamental changes in clinical, operational, and trading models.[5859]

One of the data-making sources related to health is hospital so that a huge amount of data are gathered by accumulating the individual data of patients. These data are so important in succeeding health organizations. Meanwhile, data associated to care have remarkable capacity for improving the patients' health outcomes, cost decline, and also lifestyle promotion. Nevertheless, security concern related to data reservation and private territory can be removed if these issues are tackled sufficiently.[59] This result is in line with the findings of Dinev et al.: perceived effectiveness from informational observing mechanisms impact patients trust, and they also affect the concerns related to private territory in hospitals. According to the experiences of the experts, this issue is more significant in hospitals using VCFs.[60]

The natural identity of volunteers' roles has been regarded by social scientists who follow the process of volunteering commitment and the psychological outcomes of volunteering affairs. The findings of the present study stated that the motivation of seeking and doing volunteering clinical work is affected by psychological and emotional aspects of individuals' characteristics and their personality. This is in line with the beliefs of scientists in psychological domain such as Alfred Toffler. He believed that the main source of humans' sufferings is the nihilistic crisis and volunteering work can satisfy their needs to perceive the meaning of life through a well-being sense made by doing good deeds.[61] Psychologists believe that volunteering makes deeper the aim and meaning of life and clarifies the identity of different roles of people for others. This is in line with the findings of Read. He concluded that volunteering in hospitals creates opportunities for self-evaluation. The authors also believe that volunteering is the reflex of individuals' personality.[6263]

Based on the expert's opinions, the recognition of important characteristics of volunteers including VCFs is so significant for hospitals. Wu et al. showed the same findings in their study: VCFs have various roles in their daily and professional life. Positive interpersonal interactions and a smooth shift of working can increase the personal effectiveness of volunteers.[35]

The other aspect of findings in the present investigation is the importance of personal, sexual, and age bracket characteristics in providing volunteering services. The experts believed that males and single people were more volunteers rather than females and married people according to former pattern of Iranian previous trading system. However, Calcutt (2020) stated that females show more human-friendly values and males and younger volunteers illustrate more tendency to do individual-based and self-centered activities.[37]

The reason of this disproportionate situation between Iran and other societies is something beyond personal and cultural differences: Limited experience in using VCFs in Iran has reported only in critical and abnormal conditions. There is no experience of using them independently in usual situation in a regular and designed form. Therefore, it is not possible to judge their performance in this condition in advance.

Overgaard stated that in societies with suitable cultural context for volunteering working, people respect each other. Receiving professional care from volunteers seems to be more suitable rather than employed staff.[47] This is in line with the present study's results: The presence of cultural context and scientific approach for volunteer working can recover public viewpoint about health and medical services providers. This can also modify the subculture upon which volunteers should do the harder duties. Empirical point of view and use of culture building in mass media especially TV and radio programs impact public culture related to volunteering. It, subsequently, affects volunteering clinical domain and provides this capacity to health system of the country. This result is accompanied by the findings of Nekoui Moghadam et al. (2017). They stated that if culture building is done by mass media with regard to volunteering measures, the use and preservation of health forces seem to be easier and faster.[31]

The strong points of this research included using qualitative method and interview as the instrument of the study. The interviews were conducted by the participation of a wide variety of stakeholders such as the deputy or advisor of minister and high-ranking officials in the main health departments of governmental and nongovernmental hospitals and also clinical forces having history of volunteering work. This leads to create empirical approach with regard to the modifiers and dimensions of VCFs in hospitals.

The limitations of the present study were that the interviewed experts worked or lived in Tehran province. Regarding the cultural variation in Iran and the impact of social and cultural aspects on the use of VCFs, this factor limits the generalization of the study's results for all parts of the country.

Using these workforces in Tehran's hospitals is new and has been neglected in the process of supplying professionally clinical forces. The present investigation leads to reveal the potentialities of hospitals and health field as an important determinant in social domain.

It was also tried to ask different questions with the same directed approach and based on the interviewed individuals' positions. It can be known as an innovation in this research. The present study can be the pioneer of the following studies to use VCFs in hospitals. Moreover, it can challenge the viewpoints in the field of doing social responsibilities of health field. This can direct the policymakers and stakeholders to consider this issue more and provide the context of developing services for the clients and patients.

Conclusion

Based on the findings, the focus of policymakers and health system's high-ranking managers to facilitate the use of volunteer clinical staff permanently and legally in hospitals can lead to reinforce the structure of services provided for patients and lessen the irregularities in intersectoral cooperation. This can also result to further and deeper participation of the main stakeholders and increase the social participation and social capital, especially in the treatment field. In addition, it leads to use more effectively the capacities of VCFs.

Iranian health system suffers from the shortage of clinical forces and coclinical staff. This can provide opportunity for volunteering forces in the country to provide their clinical services in different forms (volunteer camps and giving services in deprived regions of the country). It cannot be done now operationally due to the lack of upstream documents and instructions and also inconsistency between health systems' sectors and insurances. All these irregularities lead to decline their participation considerably because they do not find proper context to involve systematically.

Meanwhile, the managers and officials of the medical centers have basic challenges with VCFs and are concerned of the legal aspects of their activities in hospitals and health centers. It is suggested using them practically in the form of pilot programs, and simultaneously, the legal principles of their use would be provided. The risks of their use can be covered by insurances. Mass media can be pivotally important in publicize their activities as NGOs. These NGOs can be defined as the cores of forming and developing social capital and social responsibility. Their activities can be improved, and their services provided for the elderly and patients are possible to be enhanced.

Suggestions for the next studies

It is suggested conducting the research to investigate cost-effectiveness and cost–benefit of using VCFs in Iran's hospitals. Furthermore, it is recommended that comprehensive studies are done to provide domestic pattern for using VCFs in hospitals.

Financial support and sponsorship

Grant number by Iran University of Medical Sciences (IUMS) is: IUMS/SHMIS_1396.9321532003.

Conflicts of interest

There are no conflicts of interest.