Original Article To be Truly Alive: Motivation Among Prison Inmate Hospice Volunteers and the Transformative Process of End-of-Life Peer Care Service American Journal of Hospice & Palliative Medicine® 2014, Vol. 31(7) 735-748 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113506035 ajhpm.sagepub.com Kristin G. Cloyes, PhD, MN, RN1, Susan J. Rosenkranz, MA2, Dawn Wold, MN, BSN, RN-BC3, Patricia H. Berry, PhD, RN, FAAN, CHPCN1, and Katherine P. Supiano, PhD LCSW FT1 Abstract Some US prisons are meeting the growing need for end-of-life care through inmate volunteer programs, yet knowledge of the motivations of inmate caregivers is underdeveloped. This study explored the motivations of inmate hospice volunteers from across Louisiana State (n ¼ 75) through an open-ended survey, a grounded theory approach to analysis, and comparison of responses by experience level and gender. Participants expressed complex motivations; Inter-related themes on personal growth, social responsibility and ethical service to vulnerable peers suggested that inmate caregivers experience an underlying process of personal and social transformation, from hospice as a source of positive self-identity to peer-caregiving as a foundation for community. Better understanding of inmate caregiver motivations and processes will help prisons devise effective and sustainable end of life peer-care programs. Keywords prison hospice, end of life, hospice volunteer, peer-care Introduction The US prison population is aging at a rapid rate; aging prisoners have become the fastest growing demographic group in state and federal prisons.1 In 2012, Human Rights Watch reported that the number of US prisoners older than the age of 65 grew 94 times faster than any other group and the entire prison population combined between 2007 and 2010.2 Moreover, prison inmates are unhealthier, experiencing more comorbidity, long-term chronic illness, and age-related disability than their same age, community-dwelling counterparts.3,4 Prisoners have higher rates of heart disease, respiratory disease,3,5-8 and infectious disease including hepatitis and human immunodeficiency virus/AIDS3,4,9,10 and significantly higher rates of cancer—and more aggressive forms of cancer—than the US population as a whole.11,12 Thus, in prison, chronological age does not necessarily equal the health age.1 Many prison systems, when tallying the number of aging inmates, have adjusted their cutoff points for elderly status downward as far as age 50 to reflect the relatively poor health status of the men and women in their institutions.1,2 Exponential growth in the number of aging inmates, increased chronic long-term illnesses, increasing physical and mental disability, and high rates of cancer—coupled with more than 30 years of determinate and lengthy sentencing practices—has added up to a fact that a rapidly growing number of US inmates will die in prison from age-related and longterm chronic illness.2 Therefore, the need for adequate endof-life (EOL) care for dying inmates has emerged as a critical issue for correctional health care and public health.13 Correctional health providers witness this need first hand, as they are challenged to add geriatric, hospice, and palliative care nursing expertise to the list of competencies necessary to perform their work.4,14 A number of US prisons are meeting the growing need by implementing prison-based hospice and palliative care programs. A 2011 report published in this journal identified 69 1 College of Nursing, University of Utah, Salt Lake City, UT, USA Oregon Health and Sciences University, Portland, OR, USA 3 Mercy Medical Center, Dyersville, IA, USA 2 Corresponding Author: Kristin G. Cloyes, PhD, MN, RN, University of Utah College of Nursing, 10 South 2000 East, Salt Lake City, UT 84112, USA. Email: kristin.cloyes@nurs.utah.edu Downloaded from ajh.sagepub.com by guest on March 5, 2015 American Journal of Hospice & Palliative Medicine® 31(7) 736 hospice programs in operation in US prisons.15 Among these are prisons that have implemented innovative peer care programs in which inmate hospice volunteers provide extensive EOL care across a number of domains, including physical, psychological, social, and spiritual, for fellow inmates. In these programs, inmate volunteers receive focused training and engage in ongoing activities to provide direct patient care and social and emotional support for fellow inmates requiring EOL care.16,17 Volunteers receive no compensation for their time or service, and their volunteer activities are not considered in decisions made about their correctional status (ie, parole). The utilization of inmate volunteers within such peer care models may allow systems to provide more extensive EOL care than is possible under current correctional healthstaffing models alone,18 especially considering ongoing issues related to a shortage of nursing and medical staff willing to work in correctional settings19 and providing adequate training and education for correctional health workers and officers to address the emerging need for geriatric and EOL expertise.4,20 Despite the development of innovative volunteer programs in prisons throughout the United States, few health science studies document essential components and outcomes of prison hospice programs, including factors related to peer caregiving in prison hospice and palliative care.13 Of particular interest are how the characteristics and activities of inmate hospice volunteers may contribute to the sustainability and success of prison hospice and EOL programs, whether and how volunteer peer caregiving leads to better outcomes for patients and programs, and the effects of providing peer care service on the inmate volunteers themselves. This study investigates the involvement of inmates in peer care hospice delivery by exploring the beliefs and attitudes of inmate volunteer caregivers. We focused on inmate hospice volunteers’ understanding of hospice and EOL care, their motivations for volunteering their time and service to provide EOL care for their peers, and what being a hospice volunteer means to them. Purpose The study reported here presents the results of a survey we conducted with a cohort of inmates from across the state of Louisiana who were participating as inmate hospice volunteers in 5 different Louisiana prisons. The purpose of this qualitative study was to describe and explore the beliefs and attitudes of inmate volunteer hospice caregivers including their understanding of hospice care, their motivations for volunteering, and what hospice peer caregiving means to them. The central methodological framework of the study was grounded theory, an interpretive approach to developing social theory or models that can be explored in future studies using a variety of methods. Based on this, we sought to explore how qualitative patterns in the inmate hospice volunteer responses suggested underlying social processes that both shape and are shaped by participants’ perceptions and experiences. All study activities, including those detailed in this report, were conducted with the approval of our University’s institutional review board (IRB) for the protection of humans and the Louisiana State Department of Public Safety and Corrections. Site The Louisiana State Penitentiary at Angola (LSP) has one of the longest running formal prison hospice programs in the United States, in continuous operation since 1998, and often visited by representatives of other state prison systems who are interested in learning from LSP’s history and example. Although the LSP Prison Hospice Program has been the subject of popular media and documentary, no health science research has been conducted in their program. We have been engaged in field research at LSP in their Prison Hospice Program since August 2011, conducting medical record reviews, in-depth interviews with inmate hospice volunteers, medical and nursing staff, and corrections officers, and observing activities related to the program and its interface with the treatment unit and the institution as a whole. Sample Methods Study Purpose and Background This study is part of a larger program of ethnographic community-based research aimed at documenting key components and processes that contribute to the sustainability of effective prison hospice and palliative care programs. In previous studies, we have documented patient outcomes for 1 long-running prison hospice program as benchmarked by comparison with community hospice and palliative care patients17 and have described how inmate hospice volunteers experience grief and bereavement in relation to their EOL caregiving, including how they cope with multiple losses, and how these processes they describe differ in substantial ways from normative frameworks presented in the professional literature on grief and bereavement.21 As part of our ongoing research, we attended the first Louisiana Prison Hospice Conference, March 13 to 16, 2012, sponsored by the Louisiana Department of Public Safety and Corrections and the Louisiana-Mississippi Hospice and Palliative Care Organization with the support of LSP staff and administrators. When we began our field research at LSP in August 2011 this conference was not yet planned. As its development provided an additional opportunity to collect salient data from a range of inmate hospice volunteers across Louisiana State, we quickly sought and secured approval from LSP administrators and our University’s IRB to conduct the survey during the conference. The conference, held in the LSP chapel and visitors reception area, included plenary and workshop sessions designed to introduce less experienced volunteers to core concepts in Downloaded from ajh.sagepub.com by guest on March 5, 2015 Cloyes et al 737 Table 1. Inmate Hospice Volunteer Activities. a Patient care prison hospice volunteer activities Symptom assessment (ie, pain, oxygenation, mental status, and comfort) Support or perform ADLs (ie, hygiene, bathing, toileting, transfers, and eating) Check and maintain skin integrity (ie, turning, inspection, and wound care) Nonphramacologic symptom management (ie, positioning, breathing control, and massage) Cleaning, regulating and maintaining bedside environment Documentation of patient care Communication with nursing and medical staff and other hospice IDT members Companionship, social and emotional support Patient advocacy Interaction with patients’ friends and family Sitting vigil (ie, 24 hour 1:1 care during final 72 hours of patient life) Postmortem care and preparation of the body for viewing and burial Nonpatient care prison hospice volunteer service activitiesa Participate in decision making related to EOL volunteer activities Encourage and vet suitable volunteer applicants Training new volunteers Program fundraising; soliciting donations for patients from prison social clubs Peer mentoring; grief and bereavement support Hospice outreach and education with inmates in general population a Data and verification concerning these activities were collected by the research team through on-site observation of the inmate volunteers and staff of the LSP Prison Hospice Program during the course of the study, and through discussion with staff and volunteers in other Louisiana prison hospice programs. EOL care and to allow attendees to learn from their more experienced counterparts. Our research team presented the results of our initial patient outcomes study there first,17 and otherwise attended as participant observers. Also in attendance were 121 inmate volunteers from 5 Louisiana prisons, including the Louisiana Correctional Institute for Women. Given the emergent nature of this opportunity, while we were able to secure permission from LSP administration to conduct the survey during the conference, we were not able, within the time frame, to secure permission from the 4 other participating prisons to collect any additional demographic data from the participants. Therefore, we cannot report demographic descriptions for the entire sample. Providing a demographic description of the LSP volunteers (n ¼ 36) who make up 47% of the survey sample, however, may help provide additional context. The average age of LSP hospice volunteers was 48 years (range 27-71 years). The duration of their current incarceration (n ¼ 35, 1 unreported) ranged from 3 to 36 years with 4 volunteers incarcerated for 5 years or less, 5 incarceration for 6 to 10 years, 8 for 11 to 15 years, and 18 incarcerate for more than 15 years. Thirty volunteers were African American and 6 were white. It is important to note that the role of prison hospice volunteers in the LSP Prison Hospice Program and in other prison hospices across Louisiana State is very different from the role of hospice volunteers in most community-based hospice programs. Inmate volunteers are responsible for providing direct patient care. Table 1 presents a list of the activities in which Louisiana inmate hospice volunteers typically engage. Items on this table were identified through review of program policy and training materials and interviews with staff and inmates and verified through direct observation during our field work. Data Collection The data presented here were collected during this conference via a survey distributed to all inmate attendees. Of the potential 121 respondents, 75 returned the survey for a response rate of 62%. Eighteen (24%) respondents were women, and all women attending the conference were beginner hospice volunteers with less than 2 years’ experience; 25 (33%) respondents were men with less than 2 years of volunteer experience; 32 (43%) respondents were men with more than 2 years of volunteer experience. The conference organizers planned concurrent sessions for the participants by experience level. They decided— based on the input of prison hospice health care staff and inmate volunteers—that 2 years’ experience marked a practical cutoff line between inmate hospice volunteers in the initial phase of learning to care for patients and those with a more advanced skill and knowledge base. At the opening session of the conference, we introduced the research team to conference attendees and explained our ongoing research. While the LSP inmate volunteers were familiar with us and our project, attendees coming from outside LSP were not. We explained the purpose of the survey as collecting information from a wider range of volunteers about their beliefs, attitudes, and values regarding hospice and the volunteer role. We explained that we were primarily interested in learning about their point of view, since theirs was a unique perspective and area of expertise on providing EOL care in prison. The survey consisted of 3 open-ended questions: 1. 2. 3. What is hospice care? Why are you a hospice volunteer? What does being a hospice volunteer mean for you? What is the most important thing for people to know and understand about prison hospice and your volunteer work? Surveys were color coded and distributed based on gender and level of experience. Volunteers with less than 2 years’ experience providing direct EOL patient care were labeled as beginners, and those with 2 or more years’ volunteer service as experienced. Space was left for participants to write their response to each question. We distributed the surveys to all participants during the opening session, emphasized that participating in the study by completing and returning the survey was voluntary, that any decision they made about participation would have no impact on their status as prisoners or volunteers, and that we would have no way of tracking who participated Downloaded from ajh.sagepub.com by guest on March 5, 2015 American Journal of Hospice & Palliative Medicine® 31(7) 738 and who did not. We instructed potential participants not to write their names or other identifying information on the surveys. They had until the end of the conference (3 days later) to return them, either directly to us if they felt comfortable doing so, or to an envelope we placed at the back of the main meeting room at the beginning of each conference day, and collected at the end. All respondents answered all the 3 questions. Although some responses were brief (a phrase or incomplete sentence), the majority consisted of several sentences or a paragraph. In several cases, respondents appended pages of notebook paper to have more space to write. We did not collect demographic, incarceration, or institution-related data for respondents, in order to protect their privacy and the confidentiality of their responses. As mentioned earlier, we did, however, color code and distributed the survey forms by gender and level of experience (more or less than 2 years’ experience), so we could compare responses on these variables. Analysis We aggregated all completed survey responses question number, gender, and experience level and transcribed these responses into word documents, resulting in 9 files for coding and comparative analysis that we imported into NVivo 9. Following grounded theory methods for inductive and constant comparative analysis22 3 team members performed an initial phase of line-by-line in vivo coding. Next, all 3 team members performed line-by-line process coding.22,23 In vivo and process coding were chosen as initial phases of coding, because we wanted to (1) give primacy to the actual words of the participants given their unique status, situation, and knowledge and (2) examine the actions and concepts being described by the participants both in content (what they said) and in style (how they said it, what they appeared to accomplish by saying it that way). Using both in vivo and process codes we coded at the level of phrases, so each line of text often had more than 1 code assigned and multiple codes could be assigned to the same phrase or passage. We proceeded with the same coding methods for each document and set of question responses. After all 3 coders completed in vivo and inductive coding for each set of question responses, we exported codes into excel spreadsheets and met to review and compare coding. We had nearly total overlap for our in vivo coding for each question set. We discussed the meanings of the process codes and assessed degree of consensus, paying particular attention to the small number of process codes that did not appear across all 3 coders’ files and either integrated these codes into other process codes we decided were similar or added them as new codes and recoded the data with them. We also began to group codes by similarity of concept or action, and to collapse more specific codes into higher order categories. We repeated this process for each survey question. Throughout coding, we each also made analytic notes that were also exported and reviewed, paying particular attention to coding differences in gender and experience level. Once in vivo and process-coding phases were complete for all questions and groups, we met and reviewed a set of emergent categories that summarized data content and patterns submitted by each coder and compared these across all 3 coders, questions, and groups. Because of the remarkable similarity of the categories developed by each coder, we needed to make only minor adjustments to arrive at our final coding scheme based on these emergent themes (presented in Figure 1 and described in results). Finally, in addition to qualitative analysis of conceptual patterns, emergent categories, and themes, we counted the number of participants whose responses were coded as falling within the most frequent concepts for each question and compared the ratios of responses by group to examine whether there were gender- or experience-based differences. Results Our data analysis demonstrated 2 levels of information in the data—the actual responses of the volunteers or how they answered each question and the underlying concepts and processes that seemed to shape these responses, based on close examination of patterns and characteristics of the responses themselves. This represents 2 interdependent layers of meaning important to grounded theory analysis22 (1) a content level that describes what is said; (2) a conceptual or thematic level that describes the underlying processes and actions that shape the responses and explain what they accomplish in the context of becoming, or being, an inmate hospice volunteer. Descriptive Summary of Volunteer Responses The concepts that arose most frequently in the volunteers’ responses to each question are presented in Tables 2 to 4. The values in each table represent the percentage of responses in total, and by gender and experience level, within each distinct conceptual category. As seen in Tables 2 to 4, there were significant differences in response based on gender and experience. Here, we present a qualitative summary of participant responses to each question and highlight significant differences between respondents based on gender and length of caregiving experience. What is Hospice Care?. The following emerged as the most frequently recurring concepts arising in response to the question ‘‘What is hospice care?’’, in order of frequency: (1) patientcentered physical, mental, emotional and spiritual care; (2) EOL care to ensure quality of life and ease of transition; (3) unconditional support, service, and respect for others; and (4) a social and moral responsibility toward those who are dying and who need help, which must be freely given. Although the question could be interpreted by the respondents as simply a request for a definition of hospice, nearly all respondents also went on to add a second part to their answer in which, in every case, the respondent expanded on their definition of hospice care by adding either a statement of their own philosophy or a variation in the definition that spoke to the Downloaded from ajh.sagepub.com by guest on March 5, 2015 Cloyes et al 739 Figure 1. Transformative process of prison inmate hospice volunteer service. Table 2. Most Frequent Participant Responses to Survey Question 1 by Concept: ‘‘What is Hospice Care?’’ Number of participants with responses in each category by experience and gender Response category and examples Patient-centered care of physical, emotional, and spiritual needs: Helping them and being there for them in each and every way, mentally, physically, and spiritually (Male volunteer, <2 years). End-of-life care for quality of life and transition support: Hospice care is a system put in place to ensure the comfort and quality of life for people who are terminally ill (female volunteer, <2 years) Unconditional service and respect for others: People caring for people with love and respect and without a doubt, an open heart (Male volunteer, >2 years) A social responsibility for service that should be freely given: Hospice care is caring people who care for people without pay or any desire for recognition or pats on the back (Male volunteer, >2 years) Number of participants responding in categorya <2 years (n ¼ 43) >2 years (n ¼ 32) Male (n ¼ 57) Female (n ¼ 18) 49; 65% 29: 68% 20; 63% 38; 67% 11; 61% 42; 56% 24; 56% 18; 56% 34; 63% 6; 33% 36; 48% 18; 42% 18; 56% 29; 51% 7; 39% 36; 48% 15; 35% 21; 66%b 32; 56% 4; 22%b a As the units of coding were phrases or sentences expressing 1 distinct concept, participants could have responses coded in more than one category because of the open-ended nature of the survey questions. b There were significant differences in the proportion of respondents in each group with responses in these categories. Note that differences in this category are linked because all women in the sample were in the group that had <2 years of volunteer experience. Downloaded from ajh.sagepub.com by guest on March 5, 2015 American Journal of Hospice & Palliative Medicine® 31(7) 740 Table 3. Most Frequent Participant Responses to Survey Question 2 by Concept: ‘‘Why are You a Hospice Volunteer? What Does Being a Hospice Volunteer Mean for You?’’ Number of participants with responses in each category by experience and gender Response category and examples Number of participants responding in categorya <2 years (n ¼ 43) >2 years (n ¼ 32) Male (n ¼ 57) Female (n ¼ 18) 37; 49% 25; 58% 12; 38% 23; 40% 14; 78%b 19; 25% 11; 26% 8; 25% 16; 28% 3; 17% 18; 24% 10; 23% 8; 25% 15; 26% 3; 17% 18; 24% 9; 21% 9; 28% 13; 23% 5; 28% 16; 21% 12; 28% 4; 12.5% 10; 18% 6; 33% To provide help and comfort to those who need it most: It means giving my all to someone who cannot help themselves (female volunteer, <2 years). To express my true nature and capacity to care: It means a great deal to show compassion. Compassion is in many of us (male volunteer, >2 years) Because God has called me to this work: Being a volunteer for me is a privilege, an honor given to me by a loving Father because he trusts me to do my best (male volunteer, <2 years) To give back to my community and repay a debt: My mother died when I wasn’t there for her and I would like to give back to someone now (female volunteer, <2 years) To give the end-of-life care I want for myself and my family: I needed and wanted to be there for others that someone would be there for me (male volunteer, >2 years) a As the units of coding were phrases or sentences expressing 1 distinct concept, participants could have responses coded in more than 1 category because of the open-ended nature of the survey questions. b There was a significant difference in the proportion of men and women responding in this category. Table 4. Most Frequent Participant Responses to Survey Question 3 by Concept: ‘‘What Should People Know and Understand about Prison Hospice and Your Volunteer Work?’’ Number of participants with responses in each category by experience and gender Male Female Number of participants <2 years >2 years responding in categorya (n ¼ 43) (n ¼ 32) (n ¼ 57) (n ¼ 18) Response category and examples We are expressing authentic compassion: ‘‘That when we do the work it’s from our hearts and because we actually do care.’’ (Male volunteer, <2 years) Hospice confirms shared humanity in prison and with the outside world: ‘‘At the end of the day, whether you are incarcerated or free, you will die. How you die depends on others if you are unable to help yourself.’’ (Male volunteer, >2 years) Volunteering leads to personal change and redemption: ‘‘Hospice changed my life. I never realized the well of compassion within me was depthless. It made me recreate myself as a person.’’ (Male volunteer, <2 years) Hospice connects us intimately to each other and we become family: ‘‘These people are part of our family, and we take care of one another.’’ (Female volunteer,<2 years) Providing quality end-of-life care is a social responsibility: ‘‘Coming to an understanding that life is not all about us, that we must begin to care for others as we ourselves may want to be cared for.’’ (Male volunteer, >2 years) 20; 27% 16; 37%b 4; 20% 19; 33%b 19; 25% 8; 19% 11; 34% 15; 26% 4; 22% 13; 17% 7; 16% 6; 19% 10; 18% 3; 17% 12; 16% 12; 100% 0; 0%b 7; 39%b 5; 7% 5; 12% 5; 9% 7; 22% 10; 18% 1; 5% 2; 11% a As the units of coding were phrases or sentences expressing 1 distinct concept, participants could have responses coded in more than 1 category because of the open-ended nature of the survey questions. b There were significant differences in the proportion of respondents in each group with responses in these categories. Significant differences by experience level and gender are linked because all women in the sample had <2 years of volunteer experience. specific context of prison hospice and their position as inmates providing care to their peers. Inductive analysis combined with a z-test comparison of the ratio of responses in each volunteer group showed that there was consistency across responses with Downloaded from ajh.sagepub.com by guest on March 5, 2015 Cloyes et al 741 one exception. A significantly higher proportion of the experienced volunteers saw hospice care as a social or a moral obligation and responsibility (z ¼ 2.2223, P < .05). The women and men beginner volunteers described hospice as a way for prisoners to demonstrate that they are still people. The women and the more experienced men noted that hospice provided a way to give of oneself to those for whom they care. Male beginners described hospice as leaving a legacy and saw hospice caregiving as a ‘‘spiritual and moral duty.’’ Female beginners described hospice as being mindful of others and a way of stretching oneself (1 respondent described this as ‘‘doing things you normally wouldn’t, things you find gross’’). The experienced men depicted hospice as a calling from God and a way of showing God’s love (‘‘It is a God given privilege to exemplify His nature and character to someone who is making their transition into eternity’’; ‘‘a special gift from God’’; ‘‘Hospice care is the ministry of presence’’). This group also described hospice as a way of paying it forward (‘‘giving to another as you’d want when you find yourself in the same place’’) and said that hospice was a space where they could show their compassion for others. Why are You a Hospice Volunteer? What does this Mean for You?. For the majority of respondents, this was the question that evoked the longest and most involved responses. Again, inductive analysis and comparison of the ratio of responses in each volunteer group using z-tests showed that there was considerable consistency across men and women and more and less experienced volunteers in how they responded to this question. The following emerged as the most frequently recurring concepts arising in response to the question ‘‘Why are you a volunteer’’, in order of frequency (1) to provide help and comfort to those who need it most; 2) to express my true nature and capacity to care; (3) because God has called me to this work and/or given me the ability to do this; (4) to give back to my community and repay my debts; and (5) to provide the EOL care that I would want for myself or my family. The z-tests of differences in numbers of participants responding in each group within these categories showed no significant differences between the volunteer groups with one notable exception, a higher proportion of women than men responded that a central motivation was to provide help and comfort for others (z ¼ 2.8269, P < .05). This finding supported comparative qualitative analysis of expressed motivation. While all 3 groups talked about how being a hospice volunteer and providing peer care enhances their sense of self-worth, the women wrote more about how they obtain personal satisfaction and even enjoyment through helping hospice patients: I’m a hospice volunteer because it gives me joy at the end of the day to know that I made a difference in someone else’s life. Being a volunteer means that I’m a peculiar individual. It takes a peculiar and unique person to do what hospice volunteer do. (Female volunteer, beginner) More than the majority of male volunteers, their responses centered on ideas of connectedness and the emotional implications of their service, for example, that volunteering alleviates loneliness for patients and volunteers, that hospice encourages volunteers to stay open in heart and mind, and that prison hospice creates close connections with other people: Prison Hospice is a lot different from free world hospice. One, because we are with these people 24/7. So we become like family, really close. We often tend to help all around care for even those whom may not need. To me it’s not about receiving. It’s about giving love, peace and comfort to our sister’s. Majority of these people have no family. We are the family. We all need love, we are still human. (Female volunteer, beginner) Although there were no statistically significant differences among the men based on experience, qualitative analysis of all the responses (not only the most frequent) suggested several compelling points of contrast. Unlike the experienced men, male beginners expressed how volunteering was a way to gain respect from other prisoners and from staff. For example, one volunteer noted that, because he was a hospice volunteer, medical staff would take him more seriously when he had his own health concerns: ‘‘I want the medical staff to listen to me when I say that I am not well.’’ Male beginners also noted that volunteering was a way for them to use skills from their work on the outside, connecting their current hospice volunteer status to their work before they were incarcerated. In contrast, none of the experienced men made these kinds of references. They tended more to characterize their volunteer service as a social obligation or duty. In fact, the idea that volunteering to gain the positive recognition or approval of others was not a legitimate or correct motivation came up several times in their responses and is exemplified in this quote: To help someone that needs it and can’t help themselves in any way. To give of my time without a need to be applauded or given certificates. To love others known and unknown just because it’s the right thing to do. (Male volunteer, beginner) Men in the more experienced group also wrote how hospice created a safe space for them to be more fully human and to show their emotional and spiritual side. These comments expressed an awareness of how the social norms and stereotypes that govern prison culture also constrain the full expression of humanity, whereas hospice and peer care provide a chance to ‘‘take off the mask.’’ As one experienced male volunteer eloquently put it, ‘‘In this setting, largely driven by a false sense of toughness, it forces one take the mask off and confront humanity in the most noble way.’’ What is the Most Important Thing for People to Know and Understand about Prison Hospice Inmate Volunteers? The following concepts emerged as most frequently recurring across all responses to question 3, ‘‘What should people know and understand about prison hospice and your volunteer work?’’ Downloaded from ajh.sagepub.com by guest on March 5, 2015 American Journal of Hospice & Palliative Medicine® 31(7) 742 (1) Hospice volunteering is a way to express authentic compassion that is truly within us; (2) hospice confirms our shared humanity with each other and the free world; and (3) volunteering and giving of yourself, especially when to do so is difficult or demanding, leads to personal change and redemption; (4) hospice provides a safe place to make and keep close connections with others, and to become family; and (5) providing reliable, high-quality, patient-centered EOL care should be a shared social responsibility. Within the most frequent response category, there were significant differences based on both gender and experience. A significantly higher proportion of less experienced men volunteers (and thus men overall, as all the women had less than 2 years’ experience) responded that being a volunteer was a way to express compassion, empathy, and caring that is both authentic and part of who they really are (z ¼ 2.3933, P < .05). This finding resonates with our field work, including in-depth interviews with inmate volunteers and staff who report that prison hospice creates a safe space within the overall hypermasculine context of men’s’ prisons in which volunteers can let down their guard, be themselves, and engage in positive and compassionate interactions with other men. That we are family in here. These are my brothers with whom I will live out my life. There is a certain desire to be there for family that superseded all other desires. Thus, volunteering in the hospice program is merely an innate desire. (Male volunteer, beginner) Moreover, the responses in this category of authentic compassion also frequently included references to being a hospice volunteer ‘‘for the right reasons.’’ These reasons included having ‘‘a heart’’ for hospice work and volunteer service, ‘‘really caring,’’ and being motivated by the patients’ needs and best interests. Several volunteers contrasted being an inmate volunteer to professional care providers such as physicians, nurses, and nursing assistants in terms of authenticity: We really do care. Not for compensation, whether freedom or monetary gain. We care because these are human lives, and one day we may very likely face these same situations of dying in prison. (Male volunteer, beginner) Also, a significantly higher proportion of less experienced volunteers (z ¼ 3.2606, P < .05) responded that hospice was a means to establish personal and family connections with others while incarcerated. No experienced volunteer responses were coded as falling within this response category despite it being the fourth most frequently recurring concept in response to question 3. Our qualitative findings suggest that this is because the more experienced volunteers describe how prison hospice should be about the patients and the needs of the larger community and not about themselves. Experienced volunteers were the only group that described prison hospice as being necessarily and thoroughly ‘‘patient centered in ways that might not be possible in other settings because of the need to maintain ‘professional boundaries’: Prison hospice is patient specific. Whatever the patient needs we do our best to provide. Hospice prisoners are different from the general prison population, the loving care they receive are second to none. As a volunteer, I am committed to the integrity of both the program and the patient. (Male volunteer, experienced) Experienced volunteers described how serving others—especially the provision of intimate 1:1 care leading up to and at the time of death—pushes them beyond their comfort zone and forces them to confront their own issues and then set these aside to focus on the needs of the patient. For experienced volunteers, ‘‘Prison hospice is not about you. It’s about the patient.’’ Finally, not captured in the comparison of most frequent responses is the qualitative finding that the experienced men talked more about the dying process and philosophical connections between the process of caring for the dying and the process of transforming self and community. This included their beliefs that dying is a natural and transformative human process for both patients and volunteers, allowing both to focus on the important things in life such as caring, compassion, family, friends and values. Thematic Analysis of Volunteer Responses After descriptive summary of the responses to each question, our analysis developed emergent themes, derived from the descriptive summaries, and comparative analysis of the in vivo and process coding.23 This analysis reflected overall conceptual patterns in these data and noted differences based on experience and gender. We identified 9 unique themes that, while interrelated, encompassed different aspects of being a hospice volunteer and described differing levels of influence or engagement ranging from the highly personal to the more community oriented. Transforming Personal Identity (‘‘Changing myself’’). This category describes volunteers’ recognition of personal growth or change in perspective of self or humanity. This was expressed across all responses but occurred more frequently in the responses of women and men beginners. Volunteers discussed hospice volunteering as a way to show themselves, other inmates, and the free world that they have matured personally through the work of caring for others. For example, a male beginner volunteer wrote: Hospice changed my life. I never realized the well of compassion within me was depthless. It made me recreate myself as a person. The things that never took priority before slowly lost importance. Now I live my life in a way that at the end will leave me with comfort that I did all I could to make the world a better place. (Male volunteer, beginner) Volunteers, and men more often, also noted that such an opportunity to define or remake oneself may not have been available to them before. In this respect, hospice presents a unique space within the prison system for the process of Downloaded from ajh.sagepub.com by guest on March 5, 2015 Cloyes et al 743 constructing a new identity that is protected from cultural pressures around masculinity, as illustrated in this response: Hospice care is an opportunity for guys in prison (CAREGIVERS) (emphasis in original) to prove themselves that their heart has softened up from all the he/she hatred, selfishness, and ambiguous characteristics. Hospice is to show that your heart is open to caring despite the judgmental aspect/racial barriers, the genders and the character. (Male volunteer, beginner) The men discussed how hospice caused them to shed stereotypical masculine roles. Many expressed the idea of hospice as a safe space to repair themselves—a space not only for patients to heal, but also for the volunteers to heal: Living a criminal life, I recognize that I’ve been selfish. Being a volunteer allows me to be selfless. It also humbles me to place someone’s care before mine . . . I see myself now as a respective part of my community–someone who is making a positive difference. (Male volunteer, experienced) For volunteers, hospice work is described as a transformative and life-affirming experience. Expressing True Self (‘‘This is who I really am’’). This encompassed identifying as a person who has remade himself or herself and the idea of working to one’s potential. Unlike the idea of change, hospice work was described as an opportunity to show who the volunteer really is, a person capable of caring for others and providing unconditional love, something the inmate was unable to do in other situations. For many, this was described as a chance to demonstrate their selflessness. Volunteering provides an opportunity for men and women to enact their authentic desire to show caring and compassion for other people: We do what we do simply because it’s who we are—kind, caring, compassionate men. The fact we’re in prison doesn’t change that. Unfortunately, society deems us otherwise simply because of our poor choice (for more than half the population anyway—first offenders). Yet we are now defined by that crime, even though it isn’t who we are! (Male volunteer, experienced) Another facet of the idea of expressing true self through volunteer hospice service was that, in being able to be themselves, others would see them for who they really are. One experienced male volunteer stated that ‘‘we are humans just like those out there. Stop looking at our mistakes and look at the love we have for mankind. Hospice is a way of giving back to God and those who we hurt.’’ Women more often spoke of expressing their true self through volunteering in terms of making personal, meaningful connections with patients and other volunteers: I am a hospice volunteer because I enjoy helping others and providing companionship at the end of a person’s life. I feel it is a way for me to get know others and a way for me to give back to my community. It means giving of myself to those in need. It means sharing the good the bad the ugly in caring for each other. (Female volunteer, beginner) Personal Redemption (‘‘Making up for past wrongs’’). This describes volunteers finding redemption or making atonement for past wrongs. Volunteers wrote about acknowledging and erasing past faults through hospice work, making one indebted to God, so that expressing selflessness and God’s love is a way of giving thanks but also getting something in return—insurance. For example, an experienced male volunteer wrote: ‘‘Being a volunteer means an opportunity at redemption’’ and another stated: I can say to myself that even if I never be forgiven by all the people I hurt, I see them daily in my care of others. I’d like for my name to be used so my children and family can see, I did something other than be the bad guy. (Male volunteer, experienced) Other volunteers talked about hospice service as a way of making up for not being good family members, being absent, and unable to help when grandparents, parents, or children were sick. ‘‘I need to deal with the end of life and death through illness, I was afraid to be there with dying family members when I needed to be.’’ Similar comments appeared repeatedly in the survey responses. Doing God’s Work (‘‘Having a God kind of heart’’). This category was among the most common across all 3 groups, although it did appear relatively more frequently in the men’s responses compared with the women’s. In describing hospice care and their roles, the volunteers talked about doing God’s work as a way of both identifying themselves as special or chosen people and providing a deeply personal rationale for their service. Through this idea, they identified as a spiritual or religious person who has been given special skills, desire, and understanding—a ‘‘heart’’—by God to serve the sick and dying. Along with providing direct patient care, doing God’s work could also entail spiritual support and ministering. Either way, it required giving of oneself totally and selflessly. I believe God put the desire in my heart to care for people. It means giving my all to someone who cannot help myself. It’s by God’s strength that I can do this not my own. In my own strength I couldn’t do this only by God’s grace and mercy. (Female volunteer, beginner) You also need people that have a God kind of heart to make it work. The things I do as a volunteer for patients in hospice are no limits, whatever the patient need done I’m there for him. Brush teeth, bath[e] him, sing to him, read book, write letters, etc. I do what I do for patients, because I am not my own, I realize I have been chosen for this great task. (Male volunteer, experienced) Living the Golden Rule (‘‘I would want this for myself’’). This was also one of the most prominent ideas across all responses. Living the Golden Rule was largely expressed as a spiritual idea, but in Downloaded from ajh.sagepub.com by guest on March 5, 2015 American Journal of Hospice & Palliative Medicine® 31(7) 744 less overtly or specifically religious terms than having a God heart. It included expressions of the ethic of reciprocity that is a basic tenant found in numerous moral and cultural traditions. One should treat others as one would want others to treat oneself or one’s beloved. For the volunteers, this was most often described as providing the care that one would want oneself one day: ‘‘Coming to an understanding that life is not all about us, that we must begin to care for others as we ourselves may want to be cared for’’; ‘‘I am a volunteer of love, because that is what it is. If you’re not in this setting, it’s hard to explain but it’s the innate ability to want for my brother what I want for myself.’’ A female volunteer connected this idea with having someone to care for her own children if she could not: ‘‘I would pray that one day would show and give me or anyone in my family the same love I want to give. I have two handicapped children and I pray someone would do the same for them if needed. (Female volunteer, beginner) Another woman tied this to the idea that EOL care is a basic need for all people since death is a common experience: People die every day, whether they are in jail, or in society. And everyone should have someone by their side to help them at their lowest points—It’s basically doing for others as we would want them to do unto us. (Female volunteer, beginner) Witnessing and Legacy vs. Passing Without Notice (‘‘We are there till the end; We carry them forward’’). This category arose from the ways volunteers spoke about prisoners wanting to be remembered and not forgotten by society. For example, a male volunteer wrote: ‘‘We should not be forgotten people in prison that can’t care for themselves, need love, care compassion and help. We are people that made a mistake.’’ Volunteers grieve for their patients and feel an obligation to bear witness to their existence by carrying the burden of grief and the memories of their patients: ‘‘A compassionate service dedicated to making the last days of the patient as comfortable as possible physically, mentally, and spiritually, so that they can die with dignity and closure’’; ‘‘Hospice care to me is giving that person the best last day’s to help [them] be at Peace with his self. Hospice is being there communicating with the dying.’’ Often, volunteers stressed the importance of providing companionship in death—bearing witness—to those who cannot help themselves, ensuring no one dies alone: ‘‘Everyone has a right to proper care at the end of life. Nobody should be forced to die alone’’; ‘‘It is immoral for anyone to die alone and if I can change that, I embrace that wholeheartedly. I want to be there for them.’’ Stepping Up (‘‘It’s the right thing to do’’). This reflects the volunteers’ shared value of wanting to make a difference through helping others, even if other people do not understand their motivations or share this value, and despite any social backlash. In some cases, this was expressed as practical need: ‘‘ . . . hospice is needed within the prison system, not only because of the concern you have for your patient but also the help when there’s a shortage of medical staff on hand.’’ Many expressed this as a statement of value: I am a hospice volunteer because there is a need for the care here at Angola for those who become sick and for the dying prisoner. It means that not only is the patient who is a prisoner matter[s]; equally, I too matter because I have something to offer of value. (Male volunteer, experienced) This idea was also evident in how volunteers addressed what they saw as the immoral or unethical treatment of aging and ill prisoners. They suggest that this population should be removed from the general population and the prison rules should be reevaluated related to this group—even seeming to suggest that some of the regular prison rules should no longer apply to this group: The volunteers are not being used enough. The old people suffer and are living among young people. There is zero respect for the aged, at all levels. People in wheel chairs have to fight with their fists. So disgusting! We had a person in hospice care, for example, then the next thing I knew he was put in solitary to eat like a dog plus he is in diapers! I was told he broke a prison rule, so my time to watch him, feed him and help him shower was cancelled. Why? Because Medical has no control over prison rules. This man should be home but where are we? Thank you for reading this. Help these old people! (Male volunteer, beginner) Through hospice work, volunteers were identified as moral and ethical community leaders, motivated by the view that providing such service and protection is simply the right thing to do. Paying it Forward by Giving Back (‘‘Putting good out there’’). This category arose because of the ways that the respondents repeatedly linked 2 ethical ideas: paying it forward and giving back. Paying it forward included acts of repaying a good deed done on your behalf by doing something good for someone else, being altruistic. Or these can also be doing good deeds with the hope of this goodness carrying forward to others. Giving back in this manner is not about repaying a specific debt, rather it is about putting goodness out into the community for circulation, so that it becomes a resource that can keep this cycle of paying and giving moving forward, sustaining it. This form of indebtedness, forging links and keeping the chain going, creates responsibility, interconnection, and a broader ethical perspective. Responses about paying it forward by giving back tended to be secular rather than spiritual or religious in nature. For the inmate volunteers, this described an ethic born of necessity. For example, a surprising number of respondents described how in their absence, due to incarceration, someone else took care of their parent, grandparent, or child when they were not able to: It allows me to serve/pay it forward, and while in prison I’ve had family members pass. Not being present, I feel obligated to give and comfort those who has experience what my family members has gone through. (Male volunteer, experienced) Downloaded from ajh.sagepub.com by guest on March 5, 2015 Cloyes et al 745 The most important to share your love and you are there for them and you are there for them and you care and love them. I had a hospice working with my mother before she died. That someone was there when I couldn’t be there, that hospice volunteer sit there and care for my mother in the hospital while I was sitting in prison. That’s why I want to be that hospice for someone else. (Male volunteer, beginner) Collective Identity Through Common Humanity (‘‘We are all in this together’’). This category describes the idea of creating a collective identity through caring for vulnerable community members that was prevalent across responses. It represents an ethic of care that encompasses the idea of a community of people—a human family—bound by a chosen common purpose. For them, the ‘‘hospice experience’’ is the human experience, and hospice is a way of living one’s values, with prison being the place this unfolds. It encompasses taking care of vulnerable people and valuing human life without discrimination and without judgment: My volunteer work will show those guys that someone actually cares and you’re not being judged about anything you’ve done in life, but I’m here to be what comfort you desire in making your departure one of understanding. Your work is truly personal, not just volunteered. (Male volunteer, beginner) Volunteer work brings on attachment to a patient, but when a patient expires, that volunteer feels that pain from the bond that were developed by being the caretaker of that patient; this also shows that the volunteers were committed to that patient by serving him wholehearted. A volunteer must be committed to his duties as a volunteer or he won’t be able to serve with compassion and wholehearted. (Male volunteer, beginner) Volunteers value stepping in as family in prison, taking care of vulnerable members of their community, and the responsibility of caring for (prison) family with the ultimate value to not let anyone die alone. This ethic creates and supports feelings of family and community—both within the prison system and outside: Sometimes we lose all contact with our real families for any reasons. And some of us this is the only families we have. So giving someone an ear to listen to or a shoulder to lean on might mean everything. No one wants to feel alone. (Female volunteer) Hospice is showing the care and the concern to the people needing your love and care for them and giving the support love and care to the by giving back the love in our community. Our heart goes out to the sick beyond these prison walls. (Male volunteer, beginner) To show society hospice is important. Never give up on people who desire to be accepted as they are. We all must stand together in unity, bring boldness and togetherness through the experience of hospice. (Female volunteer, beginner) This category encompasses ideas about feeling connected to patients, family, the free world, and humanity through volunteer hospice work. Moreover, it is about humanizing prisoners and expressing humanity through nurturing contact with vulnerable people, both feeling human and showing the outside world that prisoners are human beings: ‘‘I am helping someone in their time of great need and vulnerability. I want to help further the human side of humanity’’; ‘‘It is helping people that can’t help themselves. You must show compassion and love to make it work. Prisoners are people too; we have feelings which we can express.’’ Identifying as a caregiver who serves and protects vulnerable community members connected volunteer motivation to the outside world, to history, to family, and to everyone else: [Hospice] is the opportunity to love someone to death. Hospice care is recognizing a need and being willing to go beyond all biases, prejudices, or pre-conceived ideas to fulfill that need. Hospice care is the closest thing to God’s Love—Agape–because it is unconditional. It is not based on society’s view of your worth. It is because you are human. (Male volunteer, experienced) The Transformative Process of Serving as a Prison Hospice Volunteer As we developed these themes based on constant comparative analysis of these data across groups and considered these findings in light of our ongoing ethnographic field research including interviews with inmates and staff and our observations of the hospice volunteer program in action, we began to see even deeper patterns that shaped their responses, particularly when comparing experience level (which we acknowledge, in this data, is intertwined with gender because of the nature of our sample). For example, themes of personal change, selfexpression, and redemption—in short, themes more oriented toward self-awareness and self-development—occurred more frequently and regularly in the responses of the less experienced volunteers than themes of patient centeredness, orientation toward others, and volunteer service as a way to build community and a sense of shared ethics. Guided by our grounded theory approach, we examined the 9 themes derived from the data and noticed how these could be understood as highlighting different levels of focus from selforientation to other-orientation and collective identity. After reviewing our process coding and connections among themes from this emerging perspective, we identified 3 overarching process themes that not only capture the action and concepts described in the themes but also locate them within a continuum that indicates underlying processes at work that shape the motivations of inmate hospice volunteers: (1) constructing self as a hospice volunteer; (2) constructing self in relation to others in and through service to the sick and dying; and (3) constructing collective identity as a community that cares for one another, united within prison and with the rest of the world through common humanity. Each of the 9 themes fit into one of these larger orientations, within an overall process of transformation that organizes and explains not only patterns in data content (reported motivations) but also differences in how volunteers with more or less experience were framing their responses. Downloaded from ajh.sagepub.com by guest on March 5, 2015 American Journal of Hospice & Palliative Medicine® 31(7) 746 These 3 overarching themes—constructing self as a hospice volunteer, constructing self in relation to others through hospice service, and constructing collective identity as a community that cares for its most vulnerable members—point toward an larger process that unfolds in relation to the volunteers’ hospice caregiving experience. In their roles and activities as peer care volunteers, inmate volunteers’ process of identification begins with constructing (or reconstructing) self-identity then, as volunteers become more patient and program oriented, their expressions of self-identity shift toward self-in-relation to others, and then self as understood as part of a collective identity built on the values and ethics of hospice. Figure 1 represents this process in connection with databased themes that comprise them. We theorize that this process of identity construction progresses in relation to gaining hospice experience and progresses along a continuum, with differing motivations associated with differing phases of development, and with these processes of construction being interconnected and iterative. Choosing and engaging in prison hospice volunteer work provides a way for inmates to actively construct not only unique individual identity but also a shared collective identity and an even larger sense of community based on an ethic of care and humanity (ie, prisoners are human beings too, capable of love, compassion, commitment, and ethical behavior). These senses of personal and collective transformation may then feed back into and support each other as well as ongoing personal and community growth. Discussion On first reflection, it may seem to be obvious that the experience of being a prison hospice volunteer would undoubtedly be a transformative one. This transformative potential is something that has been claimed in the mainly anecdotal prison hospice literature of the late 1990s through mid-2000s, but this claim has never been examined, based on empirical data, from a social scientific or health science perspective until now. Conducting research that explores and documents the processes that support prison hospice is vitally important to addressing concerns of prison systems that have been slower or more reluctant to consider prison hospice and peer-care volunteer programs as viable, much less necessary, options for providing adequate EOL care for aging and increasingly ill prisoners. Our analysis suggests the presence of an underlying process of identity construction and transformation at work in shaping the motivations of inmate hospice volunteers and may explain changes in self-perception and social orientation over time. Although this theory bears further development and study, this process is at least one important element in understanding the transformative potential of inmates’ service as prison hospice volunteers. This study shows that the motivations of inmate hospice and EOL care volunteers are highly complex, involving a range of interacting personal, social, moral, and ethical concepts that shape both intrinsic and extrinsic motivations and that likely change and evolve over time. Overall, these varied motivations are linked by the sense that volunteering service to others— especially vulnerable others facing death—is a defining characteristic of ‘‘true humanity’’ that brings value to life. One volunteer emphatically stated that to be a prison hospice volunteer, and to provide service to the dying, was ‘‘to be alive. Truly alive.’’ The use of volunteers to provide prison hospice peer care has been documented in the correctional, nursing, and hospice and palliative medicine literature for over a decade, mainly in reports on the development and implementation of prison hospice programs including case stories and speculation regarding the hoped-for effects of offering EOL care in prison.16,24-30 What has been left largely unexamined, however, is the central role of the inmate volunteer in the provision of prison EOL care. Little research has focused on the motivations of inmates who volunteer their time in service to their peers facing terminal illness and how they come to value these activities. One notable exception is study of Loeb et al, based on a smaller sample (n ¼ 17) of inmate volunteer caregivers who were providing EOL care for fellow inmates but were not part of a formal prison hospice program.31 Their research team identified 3 themes—Getting Involved, Living the Role and Transforming Self Through Caring for Others—in the accounts of inmates who voluntarily provide EOL peer care. These 3 themes resonate with our findings, but our research— conducted with a larger sample of volunteers who participate in a formal, organized prison hospice initiative within their prisons—reveals a more complex set of interrelated concepts, connected by an essential process of changing self-perception and social orientation that underlies the expressed motivation of inmates who choose to serve as prison hospice volunteers. We need to understand more about the interactions among these factors, and to develop models of the deeper concepts and processes with which they correspond, as this understanding will contribute to the effectiveness and sustainability of prison hospice and EOL programs that rely on inmate volunteers. This will also help us understand more about the potential benefits of volunteer service for inmates. Volunteers become involved, and stay involved, for a variety of reasons that change over time. Nonetheless, opportunities for personal growth, self-representation, interpersonal development, and social transformation remain vitally important throughout. The development of process models to explain these effects could also inform the selection and training of inmate volunteers and other sustainability-related aspects including staff support and peer mentoring. Therefore, more systematic investigation and wider dissemination of research related to volunteer-based, peer provided prison EOL and hospice care is greatly needed to examine how individual characteristics such as gender, age, and experience influence motivations for volunteer service and EOL caregiving, how these characteristics interact with social factors specific to the prison EOL care context, and personal changes that occur as a result of participation. For example, although this study touched on gender differences, we had too few women volunteers to fully explore gender differences in motivation for EOL peer care service, and we did not collect other potentially salient data such as age, length of incarceration, or Downloaded from ajh.sagepub.com by guest on March 5, 2015 Cloyes et al 747 concurrent engagement in other forms of service. Future studies focusing on the experiences of women who serve as inmate hospice volunteers could also be important in developing this knowledge base, and of eminent practical significance, as women prisoners are more likely to return to their communities and care for close others in their families and neighborhoods than men who are incarcerated.32 Finally, ongoing research should be conducted in collaboration with those on the front lines of practice that are responsible for implementing and overseeing the operation of related programs, including prison inmate volunteers, correctional health staff, corrections officers, and prison administrators. Research on prison EOL care will be most applicable when results are interpreted and applied within ongoing conversations about translating findings into real-world solutions, including how to balance identified concerns, resource limitations, and other potential barriers with flexibility and innovation. Conclusion Our study presented descriptive and thematic analyses, and an emerging process theory, of how inmate hospice volunteers perceive their service as prison hospice volunteers. Analyses showed that their expressed motivations were complex and, while there were a number of shared concepts across all volunteers, there was also variation by gender and caregiving experience. Participation as an inmate hospice volunteer corresponded to an underlying process of meaning construction and transformation, occurring along a continuum comprising construction and transformation of self, of self—in-relation to others, and of collective, community identity centered on an ethic of caring for vulnerable members. As the number of aging and chronically ill prison inmates in US prisons continues to grow, many institutions face a health care crisis of immense proportions. The use of innovative inmate volunteer programs, enlisting the commitment and help of those who are invested in and who value a culture of care, may be among the only realistic ways to meet the emergent need for EOL and hospice care in US prisons. That volunteer EOL peer care may also promote individual growth and a shared sense of ethics among prisoners should encourage the adoption of these programs. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by a university of Utah Center on Aging Pilot Grant (Cloyes, PI) and a University of Utah College of Nursing Faculty Research Grant (Cloyes, PI). References 1. Chiu T. It’s About Time: Aging Prisoners, Increasing Costs, and Geriatric Release. 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