Introduction
The number of older adults is increasing worldwide, with the share of the world’s population aged over 65 projected to increase from 9 per cent in 2020 to 16 per cent by 2050 (United Nations, Department of Economic and Social Affairs 2019). In line with global trends, the number of Australians aged 65 and over is growing and expected to reach 25 per cent of the nation’s population by 2055 (Commonwealth of Australia 2015). Owing to increased longevity and a concomitant rise in age-related physiological and neurological conditions, a greater number of older adults will require support in the future. Some of these older adults will require long-term care in settings such as nursing homes (World Health Organization 2015). In Australia, nursing homes (or residential aged care facilities) currently provide long-term care to approximately 178,000 older adults (Australian Institute of Health and Welfare 2024).
While community-dwelling older Australians generally experience positive mental health, those residing in nursing home settings are more likely to experience psychological distress and poorer quality of life (Atkins et al. Reference Atkins, Naismith, Luscombe and Hickie2013). Moving into a nursing home is often characterised by the loss of one’s personal possessions and proximity to family, friends and community, and difficulties in engaging in valued activities (Davison et al. Reference Davison, Camões-Costa and Clark2019; Lee et al. Reference Lee, Simpson and Froggatt2013; Lloyd et al. Reference Lloyd, Calnan, Cameron, Seymour and Smith2014; Paddock et al. Reference Paddock, Brown Wilson, Walshe and Todd2019). Residents may feel a reduced sense of autonomy and independence as they adopt new daily routines that are largely dictated by organisational pressures rather than personal preferences (Ludlow et al. Reference Ludlow, Churruca, Mumford, Ellis and Braithwaite2020; Paddock et al. Reference Paddock, Brown Wilson, Walshe and Todd2019). Despite the shared living arrangement, there may be limited opportunity for meaningful interaction with others (Barbosa Neves et al. Reference Barbosa Neves, Sanders and Kokanović2019), and impaired cognitive and physical health may make it challenging to form new relationships (Grenade and Boldy Reference Grenade and Boldy2008). Demands on staff to provide clinical and task-oriented care may limit their opportunity to get to know their residents on a close personal level (Ludlow et al. Reference Ludlow, Churruca, Mumford, Ellis and Braithwaite2020; Oppert et al. Reference Oppert, O’Keeffe and Duong2018). This has led some scholars to suggest that older adults may become ‘de-storied’, as their individual narratives are not acknowledged or supported (Bohlmeijer et al. Reference Bohlmeijer, Westerhof, Randall, Tromp and Kenyon2011: 368). Taken together, older adults in nursing homes commonly report feeling disconnected from their sense of self, meaning and purpose, and their identity (Heliker and Scholler-Jaquish Reference Heliker and Scholler-Jaquish2006; Lee et al. Reference Lee, Simpson and Froggatt2013; Lloyd et al. Reference Lloyd, Calnan, Cameron, Seymour and Smith2014; Paddock et al. Reference Paddock, Brown Wilson, Walshe and Todd2019; Saunders and Heliker Reference Saunders and Heliker2008).
Activities that involve reminiscence and the sharing of life stories have been shown to improve a range of mental health outcomes for older adults in nursing homes, including life satisfaction, self-esteem (Housden Reference Housden2012; Menn et al. Reference Menn, Corsten, Lauer and Wallace2020), maintenance of identity, quality of relationships (Doran et al. Reference Doran, Noonan and Doody2019; Thompson Reference Thompson2011), social isolation and depression (Franck et al. Reference Franck, Molyneux and Parkinson2016). Reminiscence, defined as the ‘recall of experienced episodes from one’s past’ (Webster et al. Reference Webster, Bohlmeijer and Westerhof2010: 528), may promote positive mental health outcomes in a number of ways – it may encourage older adults to feel more confident in their ability to cope with challenging circumstances, foster a sense of self-mastery, improve mood through the recollection of pleasant memories and strengthen ego integrity, as well as acceptance and integration of past experiences(Bhar Reference Bhar2015; Webster et al. Reference Webster, Bohlmeijer and Westerhof2010). Tangible artefacts, such as books, collages and memory boxes, are often created as products of such biographical approaches to record, retain and share stories with others.
The use of multimedia technology is becoming increasingly common for sharing life stories (Thompson Reference Thompson2011). With the proliferation of hand-held devices such as phones and tablets, digital stories can be created with ease and shared with others. As with traditional reminiscence and life story activities, digital storytelling enables older adults to feel heard and to express their emotions and their identity (Fiddian-Green et al. Reference Fiddian-Green, Kim, Gubrium, Larkey and Peterson2019). Some evidence has shown that collaborating with older adults to produce digital stories in various ways can stimulate memories (O’Philbin Reference O’Philbin2019; Subramaniam and Woods Reference Subramaniam and Woods2016), engender positive emotions (Critten and Kucirkova Reference Critten and Kucirkova2019; Damianakis et al. Reference Damianakis, Crete-Nishihata, Smith, Baecker and Marziali2010; Hausknecht et al. Reference Hausknecht, Vanchu-Orosco and Kaufman2019; Subramaniam and Woods Reference Subramaniam and Woods2016), improve the quality of relationships with family members and caregivers (Damianakis et al. Reference Damianakis, Crete-Nishihata, Smith, Baecker and Marziali2010; Subramaniam and Woods Reference Subramaniam and Woods2016), increase social and community connectedness (Capstick et al. Reference Capstick, Ludwin, Chatwin and Walters2016; Hausknecht et al. Reference Hausknecht, Vanchu-Orosco and Kaufman2019; Sehrawat et al. Reference Sehrawat, Jones, Orlando, Bowers and Rubins2017) and foster a sense of self and identity (Capstick et al. Reference Capstick, Ludwin, Chatwin and Walters2016; Critten and Kucirkova Reference Critten and Kucirkova2019; Damianakis et al. Reference Damianakis, Crete-Nishihata, Smith, Baecker and Marziali2010). Such studies describe digital storytelling projects primarily conducted with older adults in the UK (Capstick et al. Reference Capstick, Ludwin, Chatwin and Walters2016; Critten and Kucirkova Reference Critten and Kucirkova2019; O’Philbin Reference O’Philbin2019; Subramaniam and Woods Reference Subramaniam and Woods2016), Canada (Damianakis et al. Reference Damianakis, Crete-Nishihata, Smith, Baecker and Marziali2010; Hausknecht et al. Reference Hausknecht, Vanchu-Orosco and Kaufman2019) and the United States (Sehrawat et al. Reference Sehrawat, Jones, Orlando, Bowers and Rubins2017).
The current study
Given the promising potential of digital storytelling activities to support the mental health of older adults in nursing homes (e.g. Damianakis et al. Reference Damianakis, Crete-Nishihata, Smith, Baecker and Marziali2010; O’Philbin Reference O’Philbin2019; Subramaniam and Woods Reference Subramaniam and Woods2016), it is necessary to gain an understanding of the processes that underscore implementing digital storytelling activities in nursing homes. A small number of existing studies have evaluated challenges associated with delivering digital storytelling with older adults living with dementia in particular (e.g. Smith et al. Reference Smith, Crete-Nishihata, Damianakis, Baecker and Marziali2009; Stenhouse et al. Reference Stenhouse, Tait, Hardy and Sumner2013). Investigating processes associated with implementing such activities for nursing home residents without a diagnosis of dementia is important. Process evaluations explore how a programme is implemented and received in practice, which can assist in facilitating adaptive implementation. Such information can be used to refine and improve the implementation of such programmes in future (Fonteyn and Bauer-Wu Reference Fonteyn and Bauer-Wu2005; Oakley et al. Reference Oakley, Strange, Bonell, Allen and Stephenson2006). This may be particularly important when programmes involve implementation across several settings and involve several stakeholder groups (Oakley et al. Reference Oakley, Strange, Bonell, Allen and Stephenson2006). Further, such evaluations are important as there is the potential for implementation to produce negative effects for participants, such as sadness and frustration (O’Philbin Reference O’Philbin2019; Smith et al. Reference Smith, Crete-Nishihata, Damianakis, Baecker and Marziali2009). Conducting such an evaluation of the Digital Stories programme to explore specific context-related enablers and barriers is important to produce knowledge that may assist in wider dissemination of the programme in other contexts.
The current study is a qualitative process evaluation exploring the barriers and facilitators to implementing a volunteer-led digital storytelling programme in nursing homes in metropolitan Melbourne, Victoria in 2018 and 2019. The study explored the perspectives of volunteers who were responsible for delivering the digital storytelling programme. Perspectives of nursing home residents and staff who assisted with programme implementation, are reported elsewhere. It is crucial that volunteers’ perspectives are explored and that their feedback is considered in future programme development, as they are responsible for programme execution at the micro level. The current study sought to address the following research questions:
(1) What enabled the implementation of the Digital Stories programme from the perspective of the programme volunteers?
(2) What hindered the implementation of the Digital Stories programme from the perspective of the programme volunteers?
(3) What suggestions do the programme volunteers make to improve the Digital Stories programme?
Methods
Design
A qualitative study design was used for the evaluation, which was conducted alongside the implementation of the Digital Stories programme over three iterations from mid 2018 to late 2019. The sample size for the evaluation was constrained by the size of the participant pool; a limited number of volunteers were involved in the programme. Interviews were conducted with a sample of volunteers who delivered the programme, in order to gain their unique perspectives as those responsible for the day-to-day implementation of the programme.
The Digital Stories programme
The Digital Stories programme connected volunteers with residents of nursing homes to help residents feel acknowledged, valued and less isolated. Residents were matched with a volunteer. The volunteer met with their matched resident weekly for one to two hours on a one-to-one basis over approximately five months. Volunteers encouraged the resident to reminisce and worked with the resident to create a film lasting three to five minutes about the ‘essence’ – that is, the values, personal qualities and identity – of the resident.
Volunteers were provided training throughout the programme. The first training session was three hours in length and was held one to two weeks before volunteers were introduced to the residents. This session covered the basics of understanding the nursing home environment and communicating with older people. Ongoing group training sessions were held weekly for approximately 90 minutes and involved education on a range of topics including engaging older people in reminiscence, the benefits of storytelling, choosing the story to be told, skills in writing the script and technical procedures involved in producing the digital story (i.e. script writing, sourcing audiovisual materials and using video editing software). Each session was held as a group session involving all volunteers and both co-facilitators. Training sessions also served as an opportunity for debriefing and supervision regarding experiences with residents.
Volunteers were recruited from the psychology and nursing undergraduate populations at the university and the wider university network (e.g. attendees of the ageing seminar series, which is open to the general population). Residents were recommended to the programme by key staff members of nursing homes. Residents were required to be at least 65 years old, to be socially isolated and to have sufficient cognitive ability to participate in the programme.
Programme facilitators were responsible for programme oversight (recruitment of volunteers, nursing homes and residents, and volunteer education and training). The programme was facilitated by the first author (JS) and a colleague (RC) who has extensive experience in facilitating volunteer programmes in nursing homes.
Participants
Individuals who volunteered to deliver the programme in nursing homes between June 2018 and December 2019 were eligible for the study. Twenty-four volunteers were invited to participate in the study, of which 12 consented to the study, seven from the 2018 cohort and five from the 2019 cohort. Volunteers knew others from their cohort as they attended the training groups. The remaining volunteers did not respond to invitations to participate. Reasons for non-response are unknown. No participants dropped out.
The 12 participants volunteered in the Digital Stories programme in five nursing homes in south-eastern metropolitan Melbourne, Victoria: four were not-for-profit homes (two were religion-based and two were non-religion-based) and one was a for-profit home.
Procedure
Participants were interviewed by phone (n = 3) or face-to-face (n = 9) from August 2019 to April 2020 using a semi-structured interview schedule. They were asked three questions: What enabled you to deliver the Digital Stories programme? What were, or could have been, barriers to delivering the Digital Stories programme? Do you have any suggestions for improving the Digital Stories programme?
All interviews were recorded using an audio device. The interview duration ranged from 6 m 44s to 23 m 24s. Interviews were conducted by the first author, a PhD candidate conducting a broader evaluation of the impact of the Digital Stories programme for residents in nursing homes. The interviewer was known to the participants, as she co-facilitated group training sessions. No repeat interviews were conducted.
Data analysis and reporting
Interview data were analysed using thematic analysis. As defined by Braun and Clarke (Reference Braun and Clarke2006), thematic analysis is a method for identifying, analysing and reporting patterns or themes within a dataset. For the present study, the researchers applied an inductive approach to the analysis, in which the themes are driven by the data, rather than a deductive approach, in which a predetermined theory guides the process of coding and the creation of themes (Braun and Clarke Reference Braun and Clarke2006). Thematic analysis was conducted following the six-phase process articulated by Braun and Clarke (Reference Braun and Clarke2020): (1) data familiarisation and writing familiarisation notes; (2) systematic data coding; (3) generating initial themes; (4) developing and reviewing themes; (5) refining, defining and naming themes; and (6) writing the report. This process was recursive, meaning that the researchers did not move through the phases in a strictly linear fashion (Braun and Clarke Reference Braun and Clarke2006). The researchers’ engagement with the six-phase process is described next.
The first author who conducted the interviews listened to and transcribed the audio recordings verbatim. Once the interviews were transcribed, the researcher read the transcripts several times in order to become familiar with the data. The author produced written memos throughout the process as potential patterns in the data developed, in order to remain aware of researcher bias (Williams and Morrow Reference Williams and Morrow2009).
The transcriptions were analysed using qualitative data analysis software (Quirkos 2021). The researcher conducted data coding by highlighting data extracts and grouping them into codes. Throughout this process, the researcher met with the two co-investigators to discuss decisions regarding the naming and grouping of codes to reach consensus. After reaching consensus, the initial codes were renamed, collapsed or separated into new codes following review by the researchers. An audit trail of code generation was regularly maintained, and several iterations of coding trees were kept, in order to increase the trustworthiness of the analysis (Nowell et al. Reference Nowell, Norris, White and Moules2017).
After coding, the codes were considered for possible generation of themes. Thematic maps were used to aid in the development of themes to visually represent patterns and linkages throughout the data (Braun and Clarke Reference Braun and Clarke2006). Peer debriefing with the co-investigators was conducted to examine the overarching patterns and reach consensus on the defining themes, to enhance the credibility of the findings (Nowell et al. Reference Nowell, Norris, White and Moules2017).
Reporting of the evaluation adhered to the guidelines specified by the consolidated criteria for reporting qualitative research (COREQ; Tong et al. Reference Tong, Sainsbury and Craig2007; see supplementary file). Findings were organised around the research topics: (1) enablers of implementation, (2) barriers to implementation and (3) suggestions for future implementation (Guest et al. Reference Guest, MacQueen, Namey, Guest, MacQueen and Namey2014). Due to the participants providing only limited implementation suggestions, the data were insufficient to allow any theme to emerge. These suggestions were reported without thematic analysis being applied. Only interview data pertaining to the research questions are analysed and reported in this article.
Findings
The individual characteristics of the volunteers are presented in Table 1. Volunteers were all female and aged between 21 and 70 years. Most of them were undergraduate students at the time of their participation in the study.
Table 1. Participant characteristics
Note: 1 = for-profit providers, 2 and 4 = not-for-profit providers operated by a religious organisation, 3 and 5 = not-for-profit providers operated by community-based organisations.
* This participant volunteered in the programme twice.
Findings were organised by the three research questions of this study. The main themes and sub-themes generated will be presented in turn(Table 2). Additional participant suggestions to better facilitate programme implementation are also reported. Quotations from volunteers are presented to support each theme. Pseudonyms are used to name volunteers and residents to maintain anonymity. For clarity, residents who were participants of the programme are referred to as ‘residents’ henceforth; the term ‘participants’ refers to volunteers who participated in this evaluation study.
Table 2. Major themes and sub-themes pertaining to the enablers for and barriers to implementing the Digital Stories programme
Enablers for implementing the Digital Stories programme
Volunteers were invited to share their perspectives on the factors that enabled them to implement the programme. All participants identified various elements of the programme protocol that enabled them in their delivery (n = 12). Many participants also identified specific skills and characteristics required of themselves in order to successfully implement the programme (n = 6). A smaller number discussed that the support they received from staff at the nursing home assisted in their ability to deliver the programme (n = 2). Thus, three overarching themes were constructed: features of the programme, skills and characteristics of the volunteer, and support from nursing home staff. Within these three themes, specific sub-themes were further explored.
Theme 1: Features of the programme
In the Digital Stories programme, volunteers are provided with a manual for delivering the one-to-one digital storytelling programme with a resident in a nursing home they are paired with and attend regular education and training with their peers and programme facilitators at the university. Across all interviews, participants identified various elements of the programme itself when they were asked to discuss what enabled them to implement the Digital Stories programme. Sharon commented broadly that the structured protocol provided by the programme aided in her success: ‘We had plenty of information about the process and I think it’s quite a well organised programme, it’s like, “go in and get to know them first”, so you do give time to build the rapport which is important and before you sort of say, “well while you’re there now you’ve gotta start looking for the real stuff”.’
All participants identified at least one specific feature of the programme that enabled them to deliver the programme successfully. Three sub-themes were generated: support from peers and facilitators, education and training, and sharing an end goal with the resident.
As part of the scheduled training, volunteers have the opportunity to debrief regarding their experience within the weekly session and can seek support from peers and facilitators during this time. Most participants (n = 9) highlighted the importance of both formal and informal support provided by facilitators and their peers throughout the programme:
Feeling like I was sharing in an experience and part of a programme was actually really beneficial … I was able to sort of recognise, you know, when I’d had successes or challenges just by the nature of finding out about their experiences. (Veronica)
I must admit I’m sort of at times unsure of myself … so the support I got from all of you, and the cohesion and love and support that the group had for each other, was really what enabled me to do it. (Susan)
Practical support from peers, particularly in relation to producing the digital story, was recognised by Veronica who shared: ‘I witnessed that in our group [that there were technological barriers], … but students who couldn’t do that, I saw other students step in to help.’ Kathryn also noted that the group was ‘really helpful to bounce ideas around’.
Almost half of the participants (n = 5) identified the importance of the education and training provided in the training for the role.
Yeah, learning that skill to just sit and listen and pick up on the, on the interesting things that they’re saying and picking up on some of the training that you guys gave us, especially at the start … I thought that was really good. (Janelle)
[The facilitators] did such a good job of preparing, and all the booklet that kind of guided us, um, so, I think without that it would be quite difficult and I probably would’ve been a lot more lost structurally. (Cindy)
Two participants reported that the shared end goal of producing a digital story assisted them in forming relationships with the resident, which may have otherwise been challenging: ‘having an end goal in mind gave me more motivation to go rather than just sit there, maybe I would’ve felt a little bit listless, sitting with Alma’ (Amy). For Veronica, the benefit to the resident in having a shared end goal was noticeable in the nature of their relationship following the conclusion of the formal programme: ‘Now that we don’t actually have that shared interest of creating the story, I’ve noticed that the visits are more challenging. It was actually really nice to have an incentive to work together and collaborate, and I think that the resident felt that sense of collaborating in something.’ Overall, participants identified that support from peers and facilitators, education and training provided, and having a shared end goal with the resident enabled their implementation of the digital storytelling project.
Theme 2: Skills and characteristics of the volunteer
Half of the sample described various characteristics and personal qualities related to the way that they approached their role. For example, Susan articulated the importance of approaching the role with a balance between personal investment and maintaining appropriate boundaries:
I went to Arthur’s 100th, and yeah, the family is just lovely. We don’t over-contact each other but we intend to be in contact … you have to think very carefully about, as a volunteer, that you don’t overdo your role too. There is a distance there that there is, sort of a professionalism as a volunteer, that needs to be maintained … that you don’t try and be one of the family. (Susan)
Two specific sub-themes were identified: the ability to be adaptable to residents’ needs and the importance of personal investment. First, participants (n = 4) described that the ability to be adaptable to residents’ needs was crucial in establishing and developing a relationship with the residents and progressing through the programme.
My ability to really sit back and listen to the resident without pushing too much of my own idea or my own direction onto them, where I wanted the story to go … I think that really helped. (Cindy)
Just before he turned 100 there were a few issues that came up, but it didn’t matter that I didn’t know all of them, because I was able to support him in my own way, and just listen to what he wanted and go with what he needed at the time … you needed to meet him on that level. (Susan)
Second, three participants identified that a level of personal investment was necessary to fulfil the role. The participants felt they needed to be personally motivated to make a commitment to the cause. For example, Grace spoke of her investment in the goals of the programme as a motivator to build the confidence necessary to implement the programme:
I had to like, really build a lot of confidence at first probably, cos I was – oh I still am – a little bit shy … I think what really pushed me was like, knowing that I’d be able to help someone … so I was really motivated to help Donald with that process of actually realising he’s, like, lived a really, really good life, instead of being like, upset that he hasn’t achieved something.
In summary, participants felt that the personal qualities of being adaptable to residents’ needs and being intrinsically motivated to support residents in their role assisted them to implement the programme.
Theme 3: Support from nursing home staff
Two participants discussed the importance of having support from the nursing home they were volunteering in. Specific sub-themes included practical support and emotional support. First, Sharon highlighted that the nursing home provided practical support when she needed to source materials for the digital story:
I got lucky when I wanted – Jean doesn’t have many photos, she hardly kept any photos of her life when she moved in cos she’s quite an organised kind of person so she got rid of them all – so when I had asked the facility for some copies of some photos from her time there, they were really fast, within a day I had them.
Veronica recounted what occurred when the resident she was paired with unexpectedly died during the programme: ‘My resident passed away, and I felt, you know I did have a call, and that was very supportive, and so I felt that, yeah there was a lot of support about that.’ Practical and emotional support from the nursing home staff felt particularly important for this small number of volunteers.
Barriers to implementing the Digital Stories programme
Participants were asked for their perspectives regarding barriers to implementing the programme. A wide range of responses were provided; most volunteers (n = 9) discussed individual traits of the residents that served as a barrier to implementation. A few reported that elements of the prescribed programme protocol were limiting (n = 3), and a smaller number discussed tensions associated with choosing the narrative to be told in the residents’ digital stories (n = 2). Thus, three overarching themes were identified (i.e. individual traits of the residents, limitations associated with the prescribed protocol, managing perspectives regarding what stories are told).
Theme 1: Individual traits of the residents
Individual traits are the most salient theme identified when exploring barriers to implementation. The residents’ traits, such as cognitive ability, emotional capacity and cultural background, were related to the capacity of residents to fully engage in the programme as expected. For example, Sophie described the challenges she faced when communicating with a resident who experienced poor physical health: ‘It was very hard for her to engage in a conversation for a long period of time before she lost her breath or got tired … it was hard for her – psychologically, she wanted to talk.’ Amy discussed her experience with a resident from a culturally and linguistically diverse (CALD) background and the impact of this on delivering the programme: ‘I think because Alma was slightly more hesitant of me and coming from a collectivist culture that could be a bit of a barrier sometimes, trying to engage a personal narrative … I would be reflecting her strengths in an individualised way … and maybe at times she felt uncomfortable with that.’
Some common threads emerged and three sub-themes were generated: cognitive capacity, emotional capacity and humility. Four participants identified that residents’ cognitive capacity, especially impairments in autobiographical and short-term memory, hindered them from participating in particular components of the programme with the volunteer, such as using specific prompts for reminiscence around life events. Cindy and Madison spoke of the challenges that cognitive impairment posed to the residents and to meeting the aims of the programme:
Especially if there’s memory problems, I think that having specific questions can be a limitation cos it kind of reminds them of those memory problems rather than letting them speak freely about what they do remember. (Cindy)
At some point she did have trouble remembering things, … maybe that’s also why she didn’t really want to talk too much about it [specific past events]. … Memory problems didn’t seem to come up until we had started, I guess that may have been a bit of a barrier for the story side of it. (Madison)
Susan identified that residents’ short-term memory impairments could be addressed by being patient and understanding how best to prompt the resident’s memory: ‘He’s got short-term memory [loss], but he now can remember me quite well, if I give him time, because he doesn’t see that well, but I give him a bit of time and say “it’s your biographer here” and not use my name; he then has the context and we can go straight into where we left off.’
Residents’ emotional capacity, as cited by a small number of participants (n = 2), had implications for their participation. Janelle and Melissa identified that some residents might have memories that are difficult to revisit:
There are a lot of sensitive things in people’s lives they don’t want to talk about, and you have to have a, a feeling to be able to know where to, where to keep, keep, being interested in a certain topic and where to just let it go and move on, cos it might be something they don’t want to revisit. (Janelle)
I think maybe at times it could’ve been a bit confronting, because you spent so long of your life just not really diving into like deep topics with people and suddenly you’re introduced to someone and now you have to start talking about your life and although it’s completely voluntary, it’s, maybe, she sensed umm, at times like … a bit of pressure to sort of reveal things. (Melissa)
Apart from cognitive and emotional capacity, some participants (n = 4) identified that a barrier to engagement in the programme was residents’ humility. As Kimberley expressed it, ‘that initial fear that their story may not be interesting enough’ served as a barrier to achieving the end goal of the programme in creating a digital story. Two participants reported that the residents felt that they were ‘boring’, with Kathryn recalling that the resident queried several times in the early stages of the programme, ‘Oh, are you sure I’m not boring you?’. Overall, individual resident differences related to capacity (both cognitive and emotional) and humility were central to this theme.
Theme 2: Limitations associated with the prescribed protocol
While some expressed that the manualised nature of the programme enabled effective implementation, three participants were consistent in suggesting that applying the manualised programme too rigidly led to barriers in successful implementation=. Susan felt that the Digital Stories programme ‘shouldn’t be so rules bound’:
[F]acilities and institutions and programmes have a lot umm, kind of, political agendas, and things like that, and I think that that kind of stops you from being able to explore it as holistically. So if … you get a by-line of you must do this, this, this, this, it’s um, sometimes a bit constricting, and you become part of what all the kind of nursing protocols are. … Being able to work from the psychological aspect had freedoms inherent in it, because you weren’t administering stuff, the client wasn’t a patient in that strict sense of the word, it was a digital story.
The remaining two participants identified specific limitations associated with taking an overly prescribed approach to reminiscence – Cindy found that, for the resident, ‘questions that were too specific could be quite limiting and didn’t lead to extended answers … I felt that kind of hindered her ability to kind of talk about things.’ Sophie reported that the resident perceived the meetings as an ‘interview … and because she thought it was an interview that made it a bit superficial, that she had limits to what she could say’. For these participants, applying the protocol too strictly or formally appeared to limit their capacity to explore the residents’ stories in a meaningful way.
Theme 3: Managing perspectives regarding what stories are told
While this final theme was discussed by only two participants, it featured prominently in their interviews. Both volunteers discussed experiencing tensions associated with choosing what information to include in the digital story. For Veronica, this tension resulted from upholding the wishes of the resident in the context of managing the expectations of family members:
My resident was quite adamant that she didn’t want the, her family, really interfering in that process … you’ve got to keep in mind about how they’re going to receive this, and um, at the same time, respecting the autonomy of the participant … she was quite assertive about telling her own story … I think it was more about leaving her, the stories of her children, out, that the story was her own story.
For Janelle, this tension came about as a result of recognising that the story she personally felt deserved to be told may not have been the same story the resident wanted to be told:
Does he think that it’s OK for me to put this in a digital story or does he think that it’s, you know like, not important? Like, I think that it’s important, but maybe he doesn’t … I asked him multiple times whether he thinks it’s OK to use this story and use these photos because I felt like maybe he didn’t, so I feel like that maybe was a barrier.
In both instances, participants realised the need to be faithful to the stories told by the residents themselves and their own wishes for what was included in and omitted from the story.
Additional suggestions to better facilitate the programme
In addition to commenting on barriers and facilitators, participants were asked to provide suggestions for future programme implementation. Specific suggestions were offered by five participants. While many participants emphasised the importance of peer support during the training sessions, two participants raised the need to ensure that there is a careful balance between providing structured education and opportunities to debrief and share weekly experiences.
The earlier ones [training sessions] were really useful because you gave us a lot of training, and the later ones were still useful but I think they were more about, like, just everyone going through their experiences of that week … sometimes it just felt a bit long, like maybe it should’ve been an hour, not an hour and a half. (Janelle)
Some weeks you spend more time talking about the weekly experiences than is ideal, umm but you know that’s part of it. (Sharon)
Despite participants having a basic level of proficiency in the use of computers, some may not have the necessary skills to use video editing software efficiently. Two participants made suggestions around providing more specific support in this area.
The support was very good with the Friday night sessions, maybe, technological, it might have just been our group, so perhaps – when you’ve got younger students, like you don’t want to go through that because it might bore them – but maybe just a session on how to put it together, just to alleviate some of the stress that people have with that. (Veronica)
Maybe just get like a, someone professional, … just, to give us techniques on editing, because like just the little things can make a big difference and like we can take that on board for like other things, if we wanna make like our own family video or anything, even for like just one of the seminars just get like an IT person or I don’t know, yeah, um, yeah because I struggled with that, I’m not a very good computer person. (Sophie)
One participant, Grace, suggested that volunteer and resident pairs could meet each other in a group meeting before commencing the programme to enhance wider community connectedness: ‘I’ve got one idea – umm, for everyone to be introduced all together maybe, like in the different facilities, so you have like a little team where everyone sees each other first … it’s not one on one it’s more like everyone that’s partnered together all in the same room talking to each other.’ Overall, while a few suggestions were made, they appeared to be primarily associated with the training and support provided throughout the programme, with only Grace making a suggestion with regards to how the meeting with residents is approached.
Discussion
The purpose of the current study was to investigate volunteers’ accounts of the enablers of, barriers to and improvements to implementing the Digital Stories programme in nursing homes. Developing an understanding of the processes that supported and hindered programme implementation was expected to improve future delivery of the programme and to assist in interpreting programme efficacy. With regard to enablers of programme implementation, thematic analysis produced three overarching themes: skills and characteristics of the volunteers (e.g. the ability to be adaptable to residents’ needs), specific features of the programme (e.g. having a shared end goal with the resident) and support from the nursing home staff (e.g. emotional support). With regard to barriers to implementation, overarching themes were: individual traits of the residents (e.g. capacity for engagement), limitations associated with the prescribed protocol, and managing perspectives regarding what story is told. Volunteers also made suggestions for future programme development, primarily related to education and training. Salient findings associated with enablers of and barriers to implementation will be discussed in turn next, before turning to the implications, strengths and limitations of the evaluation.
With respect to enablers, all volunteers identified features of the programme that enabled successful implementation. Most of them emphasised the importance of ongoing support and specific education and training. Given that volunteers in the Digital Stories programme were not required to have any formal education in counselling or any age-related studies, training was anticipated to play a pivotal role in the programme delivery. The importance of support from peers, facilitators and nursing homes has also been reported in other studies. In a review of volunteering in dementia care, volunteers who prematurely resigned from their roles reported a lack of opportunity to debrief about their experiences (Hurst et al. Reference Hurst, Coyne, Kellett and Needham2019). Volunteers working with older adults interviewed by Same et al. (Reference Same, McBride, Liddelow, Mullan and Harris2020) expressed a similar need to feel supported and heard by the organisation they were volunteering with, and also spoke highly of specific instances of individual support they received. Previous research has reported positive outcomes for befriending schemes when volunteers were formally trained (Charlesworth et al. Reference Charlesworth, Shepstone, Wilson, Thalanany, Mugford and Poland2008). A review of studies of volunteers in dementia care showed that ensuring that volunteers are adequately trained and provided with a clear and specific description of their role and activities reduces the likelihood of burnout and emotional distress (Hurst et al. Reference Hurst, Coyne, Kellett and Needham2019). Alignment was found between the opinions expressed by volunteers in the present study and those expressed by staff members who participated in the programme, with staff identifying the importance of having a supportive team within the facility who understood the programme and could provide practical and emotional support to volunteers.
Some volunteers expressed that the collaborative nature of the programme, by which both volunteers and residents held a shared goal to produce a digital story, partly enabled the success of the programme. It is well known that goal collaboration is crucial in forming a therapeutic working alliance, which plays an important role in engendering positive outcomes between health professionals and clients (Horvath et al. Reference Horvath, Del Re, Flückiger and Symonds2011; Horvath and Greenberg Reference Horvath and Greenberg1989). Although the current programme was not designed to constitute therapy or counselling, its success appeared to rely partly on the agreement of the goal between residents and volunteers.
Furthermore, many volunteers also identified personal qualities and skills that were required on their behalf in order to successfully deliver the programme, including the ability to be adaptable to the needs of the residents and a degree of personal investment. When working with older adults, the ability to make modifications in line with their specific cognitive and physical needs is important in producing successful outcomes (Bhar et al. Reference Bhar, Silver, Campbell, Lawson, O’Brien and Rehm2015; Fearn Reference Fearn2021; Rehm et al. Reference Rehm, Stargatt, Willison, Reser and Bhar2017). Sentiments regarding personal investment expressed by our volunteers are consistent with those in previous studies; volunteers in aged and dementia care become involved and persist in the role for a number of reasons, including altruism and the desire to make a positive change, as well as personal development with regard to, for example, confidence and self-esteem (Fearn Reference Fearn2021; Hurst et al. Reference Hurst, Coyne, Kellett and Needham2019; McHugh et al. Reference McHugh, Lee, Aspell, Connolly, Lawlor and Brennan2016; Same et al. Reference Same, McBride, Liddelow, Mullan and Harris2020).
With respect to barriers to implementation, volunteers mainly identified characteristics of the residents that made delivery challenging, frequently citing capacity in the context of memory impairment and emotional capacity for engagement. These issues are echoed in previous research; Pennington and Knight (Reference Pennington and Knight2008) interviewed volunteers of a befriending programme for isolated community-dwelling older adults and identified that impaired memory was a barrier to building rapport. In a series of exploratory case studies, befrienders in nursing homes identified that issues with short-term memory resulted in having to re-establish rapport upon every visit, making it challenging to form an enduring friendship (Stephens et al. Reference Stephens, Simpson, Holmes, Collins, Silver and Bhar2016). Housden et al. (Reference Housden2012)argued that facilitators of reminiscence programmes must be appropriately trained to recognise when the activity may create risk of emotional harm, particularly for older adults with experiences of trauma or unresolved past conflicts.
Some volunteers expressed challenges associated with telling stories that were faithful to the residents’ lived experiences, while managing the expectations of family members and their own perceptions of what constituted a story worth telling. Such findings are common in digital storytelling literature. Researchers have documented tensions associated with deciding whether to include emotionally sensitive content (Smith et al. Reference Smith, Crete-Nishihata, Damianakis, Baecker and Marziali2009; Waycott et al. Reference Waycott, Davis, Warr, Edmonds and Taylor2017), the challenges faced by ‘holding the threads’ when the older adults have difficulty with articulating their personal narrative (Stenhouse et al. Reference Stenhouse, Tait, Hardy and Sumner2013) and managing the power relations inherent in producing stories on behalf of those with traditionally marginalised voices (Manchester and Facer Reference Manchester and Facer2015; Stenhouse and Tait Reference Stenhouse, Tait, Hardy and Sumner2018; Waycott et al. Reference Waycott, Davis, Warr, Edmonds and Taylor2017).
Beyond the overarching themes generated, some volunteers made noteworthy comments regarding individual resident qualities, such as cultural background, that may play a role in successful implementation. There is evidence to show that there are important cross-cultural differences in the ways people view their life stories and engage in reminiscence (Swann and Bosson Reference Swann, Bosson, Fiske, Gilbert and Lindzey2010; Webster et al. Reference Webster, Bohlmeijer and Westerhof2010). In the present study, cultural differences were pertinent to the aim of telling a story about an individual person who may identify with a collectivist way of being, where the needs of the group are more salient than the needs of the individual. Indeed, similar studies of digital storytelling projects have taken place in Western, individualistic nations (Capstick et al. Reference Capstick, Ludwin, Chatwin and Walters2016; Critten and Kucirkova Reference Critten and Kucirkova2019; Damianakis et al. Reference Damianakis, Crete-Nishihata, Smith, Baecker and Marziali2010; Hausknecht et al. Reference Hausknecht, Vanchu-Orosco and Kaufman2019; O’Philbin Reference O’Philbin2019; Sehrawat et al. Reference Sehrawat, Jones, Orlando, Bowers and Rubins2017; Subramaniam and Woods Reference Subramaniam and Woods2016). Further investigation is required, with a larger and more diverse sample of participants, to ascertain the impact of such individual differences on implementation.
Implications for digital storytelling practice
Firstly, while many volunteers expressed similar opinions regarding implementation, some variation in findings emerged, such as how taking a prescriptive approach hindered rapport development for some but assisted in providing meaning and purpose to the visits for others; further, providing ample time for debriefing in group sessions was regarded as crucial by some but excessive by those who felt that they did not need it. For future implementation, programme facilitators should ensure that delivery of the programme (including providing training, instruction and support to volunteers) is itself flexible enough without making facilitation overly onerous.
Secondly, given that most volunteers reported that individual traits of the residents (such as cognitive and emotional capacity) were barriers to successful implementation, facilitators must carefully select residents in the recruitment stage of the project with regards to such traits. A more thorough screening process could be adopted, in which facilitators collaborate closely with nursing home staff to increase the likelihood that the programme is offered only to residents who have the capacity to participate fully.
Thirdly, the training and education provided (which was identified as an enabler by almost half of the volunteers) could be enhanced to include greater emphasis on the challenges articulated by volunteers in the current study, such as those associated with resident capacity for participation and managing ethical conflicts regarding what stories are told. Given that most volunteers identified that formal and informal support from facilitators and peers was important, educational content should be balanced with the opportunity to provide support on specific issues as they arise, both during and outside of formal training sessions.
Lastly, some volunteers indicated that their personal qualities, such as personal investment, adaptability, and ability to listen well, enabled them to implement the programme. This highlights the importance of ensuring that volunteers are thoughtfully recruited, on the basis of such qualities and skills, for future projects.
Strengths and limitations
The present study sought to qualitatively evaluate the implementation of a novel digital storytelling programme, intended to improve relationships and social connectedness, and encourage a sense of self and identity, among nursing home residents. Findings from interviews with volunteers directly responsible for delivering the programme contribute to an emerging body of literature interested in developing novel approaches to supporting the psychosocial health of older adults in nursing homes. Themes emerging from interviews in the present study provide specific areas of focus for improving the implementation of future digital storytelling programmes.
There are two salient limitations in the present study. First, stakeholders beyond programme volunteers were not included in this process evaluation, including both nursing home staff who assisted with implementation and, importantly, residents who participated in the programme. Staff and residents may hold different views from those of programme volunteers with regard to enabling and limiting factors. While some findings were presented as a point of comparison in the present study, these perspectives on the programme are reported elsewhere. Second, only 50 per cent of programme volunteers participated in the study. It is unknown whether the 12 volunteers who did not participate held different views compared to the volunteers who participated in the study.
Conclusion
These findings contribute to the small but growing body of research interested in the process of digital storytelling with older adult participants (e.g. Smith et al. Reference Smith, Crete-Nishihata, Damianakis, Baecker and Marziali2009; Stenhouse et al. Reference Stenhouse, Tait, Hardy and Sumner2013). Given the capacity for digital storytelling activities to support the personal values and self-views of older adults in nursing homes, the present study explored the factors that support or block implementation of such activities by volunteers. It is well documented that stigma exists around working with older adults and there is a lack of training opportunities for such work, particularly in the psychology and nursing disciplines (Bhar and Silver Reference Bhar and Silver2014; Stargatt Reference Stargatt2017; Wells et al. Reference Wells, Foreman, Gething and Petralia2004). As a result, it is imperative for volunteers to be supported to work with older people and gain knowledge of the experiences of ageing, to increase the workforce who specialise in age-related fields in future. For this reason, it is critical that volunteers have positive experiences of implementing such programmes and that their feedback is considered in future programme development.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0144686X24000424.
Acknowledgements
The authors acknowledge the work of Rebecca Collins, for co-facilitating the Digital Stories programme with the first author.
Author contributions
All authors made a substantial contribution to the study and the paper: JS, SB and MT planned the study; JS collected data, conducted data analysis and wrote the paper; MT and SB supervised the data analysis, then reviewed and revised the paper.
Financial support
The first author was supported by a Swinburne University Postgraduate Research Award (2017). The digital storytelling project was support by a grant from Arcare Family Foundation (2019).
Competing interests
The authors declare none.
Ethical standards
Ethical approval was obtained through the Swinburne University of Technology Human Research Ethics Committee (2019/843).
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