Abstract
Background
We know little about how non-profit organizations create the conditions within their communities that support sustainable change – a process that has been referred to as scaling deep. In this paper we explore the implementation of a volunteer community-based navigation program, within 46 community-based organizations, to better understand how organizations seek to create the cultural and relational conditions to support sustainable change.
Objective
To examine the strategies organizations used to scale deeply during a volunteer navigation (Nav-CARE) program implementation.
Design
Qualitative descriptive interview study.
Methods
A qualitative descriptive study using semi-structured interviews conducted with key informants (n=30) exploring approaches used to scale deeply during program implementation.
Results
Informants described ways in which they raised the visibility of the program, used mindful messaging, deepened relationships, and expanded the possibilities of their organizational mandate. Community-specific dissemination strategies and a heavy emphasis on face-to-face interpersonal interactions were integral to raising program visibility. Messaging was sensitive to cultural and historical tensions, avoided negative or needs-based language, emphasized strength-based volunteer recruitment and drew upon ideas of collaboration rather than competition. Developing trust at all levels, both within and beyond the organization, was foundational to deepening relationships. Providing practical assistance, becoming a connecting point to other community partners, and demonstrating how they were driving policy change were important to expanding the possibilities of their organizational mandate.
Conclusion
Scaling deep for these organizations went beyond changing values and beliefs specific to the innovation. Rather, these organizations focused at a more fundamental level on: developing relationships of trust within and beyond their organization, emphasizing that community members needed one another, and demonstrating that their organization had a vital contribution to the overall well-being of the community. Such an approach had important implications for how organizations must “play the long-game” to effectively scale and embed social innovation.
Background
“It’s a scale that values the slow steady work of deepening relationships. It recognizes the significance of context, building connections that bridge diverse communities and it prioritizes inner work and healing as integral components of the scaling process.” Fraser, The Art of Scaling Deep, p.3.
The shift from top-down interventions to deeply embedded, community-rooted approaches is the essence of a growing movement in health and social care.
1
As populations age and health systems face increasing strain, community-based organizations—such as hospice societies and seniors’ support services—have emerged as vital actors in supporting individuals with declining health to age in place.
2
As significant social actors, these community-based organizations frequently implement social innovations as part of their funding and sustainability plan. However, we know little about how these organizations perform the vital work of creating the conditions within their communities that support sustainable change – the process of scaling deep.
3
There is an urgent need to better understand how to scale social innovations so that they can have maximum reach and impact.
3
The concept of scalability has traditionally included three interrelated dimensions:
Scaling deep is essential for achieving lasting impact in health and social care. Fraser defines it “as the deep personal and broad cultural transformational work that is required to create durable systems change.”3p. 13 It involves embedding initiatives within local contexts, fostering trust, and shifting deeply held beliefs. In its essence, scaling deep recognizes that “culture plays a powerful role in shifting problem-domains, and change must be deeply rooted in people, relationships, communities and cultures.”4p. 4 Methods for scaling deep involve storytelling, communities of practice, and transformative learning. 4 The evaluation of scaling deep entails asking questions about what values, beliefs, and narratives are necessary for the innovation to survive; how people and organizations are being engaged around these values, beliefs, and narratives; what shifts are occurring as a result of this engagement; and what is being learned about the culture that impacts the innovation? However, despite the importance of understanding the process of scaling deep there has been little research in this area. 3
Scaling deep may be particularly important for social innovations in which stigma plays an important role. The social innovation of volunteer navigation that is the focus of this paper has a goal of providing early support for older persons living in community who are experiencing declining health. Most are living with life-limiting chronic illness (e.g., advanced cancer, frailty, lung or cardiac disease) that is affecting their quality of life in ways that additional support is needed. One way to envision this support is through what has been called a palliative approach to care. A palliative approach to care has been defined as an early approach to care (i.e., when persons are experiencing advanced chronic illness but not actively dying) that assists persons in whatever context they are living (e.g., home, long term care). 6 As such, community-based hospice palliative care organizations have been important partners in this care. But it also means that organizations seeking to deliver such care are confronted with the public stigma related to aging, dying, illness, grief, and loss.7–9 Therefore, for programs to be successful in scaling deep they have to confront the misperceptions and fear that come with such value-laden terms.
The social innovation that is the focus of this paper is a volunteer navigation program called Nav-CARE, an acronym for Navigation: Connecting, Advocating, Resourcing, Engaging (see www.nav-CARE.ca). In Nav-CARE, experienced volunteers take additional training in navigation. They are then partnered one-on-one with clients living with declining health in community and they visit these clients regularly over an extended period of time. The volunteer works alongside the client to identify their quality-of-life concerns; to help them gain access to people, resources, and services that could help; and to facilitate their engagement in things that are meaningful to them. Ideally, this relationship continues as the client experiences the transitions that accompany declining health (such as changes in residential location and corresponding adjustments in care provision), thus providing relational stability for those who might otherwise be at risk for loneliness and isolation.
Drawing on more than a decade of evidence, we have learned that Nav-CARE has positive impacts on older persons’ social connection and engagement, access to cost-effective resources, and confidence in managing aspects of their health and healthcare.10,11 We also have a fairly clear picture of the factors that are important to Nav-CARE implementation and sustainability. For example, we have learned that successful implementation is dependent upon organizational capacity and connections, engaged leadership, messaging, well-prepared volunteers, and a clearly identified target population.12,13 But what is less clear are the strategies organizations used to modify these factors to facilitate implementation or why organizations who appeared to have these factors in place languished in their implementation of Nav-CARE while others with less capacity flourished. Therefore, the objective of this study was to examine the strategies organizations used to scale deeply during a volunteer navigation (Nav-CARE) program implementation. Nav-CARE’s implementation across 46 diverse community organizations offered a unique opportunity to investigate how efforts to foster cultural change and relational depth contributed to the viability of the program.
Methods
Design/setting
This was a qualitative descriptive interview study. Nav-CARE was implemented in 15 Centres of Excellence (COEs) in organizations across 8 Canadian provinces between June 2021 and March 2025. A COE was comprised of one primary organization and two satellite organizations (with the exception of one site that had three satellite organizations) for a total of 46 organizations. Framed as a ‘Hub and Spoke’ model, primary organizations (Hubs) were responsible for mentoring satellites (Spokes) to implement the Nav-CARE program.
Centres of Excellence breakdown.
Nav-CARE implementation
Implementation took the form of a rolling start. A call for proposals for developing a COE was issued in October 2021, 2022, and 2023 with five COEs onboarded each year. The call was announced through the Nav-CARE website, Canadian Hospice Palliative Care Association (CHPCA) media blasts (distributed to upwards of 10,000 individuals and organizations) and through conference presentations. Information webinars were also organized through the CHPCA. Proposals were independently evaluated by five assessors according to capacity (resources, current volunteer pool, ability to effectively recruit volunteers and clients to the program) and sustainability (the ability to integrate the program into the organizations’ strategic plans to facilitate the program beyond the initial 2-year implementation period). Overall, 28 applications were received and reviewed for 15 COE contributions. Successful Hub sites were given a stipend to hire a part-time Nav-CARE lead over the implementation period and were required to meet volunteer and client recruitment targets. Leads were invited to participate in a monthly community of practice (CoP) to discuss success and challenges over the implementation period.
Sample
The study sample (n=30) consisted of informants who played a lead role in the implementation of Nav-CARE. For the most part, only one person per organization undertook this role however, there were six organizations where the role was actively supported by a board member and 1 site where the role was co-lead with a program manager. As such, these people also participated in the interviews. The final sample included: 20 Nav-CARE volunteer coordinators, 6 board members, 2 executive directors, and 2 program managers of participating organizations. Most of the informants came from Hub organizations. Five informants represented Spoke organizations. The reason for such a small sample from Spoke organizations centred on the availability (and presence) of a Nav-CARE lead in the organization itself.
Data collection and analysis
Interviews were conducted using a semi-structured interview guide at the end of the first and second year of implementation for all COEs. The interview guide was validated prior to use. Interview questions centred on the context in which Nav-CARE was implemented focusing on internal (e.g., support for the coordinator) and external (e.g., organizations reputation in the community) enablers and barriers to implementation (See Supplementary materials for interview guide.). Field notes were also written from informal virtual meetings with key informants as well as from monthly CoP meetings. Interviews and meetings were facilitated by GP and KA.
Interviews were digitally recorded, transcribed, and entered into NVivo for analysis. Analysis was completed inductively and guided by thematic analysis outlined by Braun and Clarke. 14 Using a reflexive approach, the coding steps involved the following: investigators familiarized themselves with the data, initial codes were developed to identify salient features of the data, and a codebook was developed based on these initial codes. Coded data were then grouped into conceptual categories, and patterns and relationships between themes were identified. Trustworthiness of data was maintained by using three investigators to code the data (GP, KA, BP), using critical and reflexive discussion among team members to question interpretations and consider alternative perspectives. These discussions were helpful in challenging our assumptions and positionality in relation to the CoP; as GP and KA facilitated these meetings, holding each other accountable was especially important in maintaining a reflexive and ethical stance. Trustworthiness was also maintained by keeping an audit trail of analytical decisions and including data extracts to allow for a nuanced interpretation of the themes. 15
Results
Scaling deep lessons.
Raise the visibility of the program
A first step in scaling deep, and a key step in transforming values and beliefs, is raising awareness. In this case, raising the profile and visibility of the program occurred by getting the attention of the public, being purposeful in interpersonal interactions, and meeting with key partners in the community.
Capturing public attention
Informants talked about the importance of being visible in the community to attract attention from the general public. To do this, they leveraged media including print (e.g., newspaper inserts, posters, and flyers), social media campaigns, and radio spots. They attended events such as age-well expos, senior’s fairs, or brain health days. They set-up, and stood at, information tables in grocery stores, shopping malls, and libraries, sharing their own experiences of the Nav-CARE program. Importantly, informants talked about the necessity of putting the name and face of the Nav-CARE lead on any print materials to personalize such campaigns. This added a layer of trust and authenticity to the program which, in turn, built capacity in the community. “Showcasing us as coordinators, that was huge. Just sharing a bit about my experience and my passion for the program, that is what brought in a ton of volunteers. Because they can feel… they can feel that this is authentic, it’s genuine.”
Purposeful interpersonal interactions
The significance of informal, everyday interactions as avenues to raise the visibility of the program was emphasised by the informants. Volunteers were seen as important ambassadors of the program. Each conversation they had with someone else had the potential to multiply exponentially, particularly if those individuals were well connected in community. “A couple of women had come to talk to the volunteer who was there and to myself, saying, ‘My God, what a difference you made in my mother’s life!’ And the woman who said this has a very high profile within the community, and so she was then talking to everybody, too.”
This was seen as so important to raising awareness that some informants discussed developing wearable Nav-CARE branding to capitalize on such interactions. While the idea did not gain traction, it reflected the power of interpersonal interactions for raising awareness of the program. “One of the flavors for rural living is that you’re talking to people in the Canadian Tire parking lot. We can put as much advertising as we like on every bulletin board in town and take out ads in the paper and do 1000 meetings with 1000 people but basically, business is by relationships.”
Meeting with key partners
Finally, raising visibility also meant ensuring that health and social care organizations were kept apprised of the program. Informants described how they met with important potential partners in their communities, either as an individual or group, on an ongoing basis. While the conditions of the funding for this project required organizations to do five such engagement activities over the implementation period, they far exceeded this target. Nav-CARE leads across sites gave over 350 individual and group presentations to potential community partners: city/municipal councils, formal healthcare providers (primary care physicians, home health/home care services, etc.), community-based programs for older adults (e.g., United Way), advocacy organizations (e.g., Alzheimer Society), faith-based groups (e.g., Catholic Women’s League), representatives from Indigenous communities, and university and community colleges with health discipline programs. Raising visibility with potential partners was important for generating referrals to the program as these organizations often were aware of who needed support. “These people know better than anybody who’s out in the community and who really needs the Nav-CARE support.”
Use mindful messaging
While being visible in the community was important to raising the profile of the Nav-CARE program and the organization, key to building these relationships was being mindful of the socio-cultural context, language that should be avoided, and what messages were communicated. Audiences included clients, volunteers, the broader community, and other health and social care organizations.
Sensitive to cultural context
Informants talked about how important it was to be mindful of the community culture when communicating about the Nav-CARE program to potential clients, volunteers, and key stakeholders. This was an important learning especially for those relatively new in their communities. “I’m still getting to know this community having lived there for only a handful of years”. Being new to the community meant that they needed to spend extra time on cultivating relationships and understanding the dynamics between key partners. Those informants with deep roots in their community knew how their community “ticked” and used that knowledge to frame communication and build trust. For example, they described patterns of volunteerism within different cultural groups, historical interorganizational tensions, and between-community rivalries that shaped how they interacted with others. Understanding the culture of Spoke organizations was also vital, especially if those communities were distant to the Hub organization. For example, an informant talked at length about how a Spoke site had not yet developed any culture related to palliative care, and realized that she just “couldn’t impose a Nav-CARE program on the community without doing a lot more trust building.” Such understandings were central to messaging related to the Nav-CARE program and also led to a deeper understanding of why implementation may or may not have been successful.
Taboo words
In addition to being mindful of the particular context and culture, informants talked about the need to be mindful of the taboo words around dying, death, hospice, and palliative care: “People link the word palliative with dying. And either we are dying and we need help, or we don’t need help.” This informant makes an important point about cultural stereotypes of who needs help, and offers insight into why it may be difficult for those who need help to reach out. Moreover, they also needed to be careful about how they framed ‘declining health,’ a term that is used to describe the population receiving support in the context of Nav-CARE. Potential clients simply did not want to admit that they had health concerns and needed support. “Anything that had verbiage such as compromised health, declining health, end of life, you know, loss of mobility. Even the sense of the sense of isolation or loneliness. Loneliness was another taboo. All of those words were triggers to just put up walls.” Some informants surmised that this was typical of the older population they were trying to reach – people who were described as “prideful” and “fiercely independent”, and while they may need help, they were reticent to accept such help, unless it comes from family. To counter this, informants talked about the importance of doing something small and meaningful for clients such as driving someone to an appointment or picking up their groceries. These smaller gestures, if done well, provided an opportunity to give more substantial assistance without clients needing to admit that their health was declining or independence compromised.
Framing the volunteer role
Being mindful of taboo words was also important when the program was introduced to potential volunteers. While informants noted that most volunteers were comfortable with the notion of palliative care, others were less comfortable, equating ‘palliative’ with active dying and sitting vigil during the last moments of someone’s life. Instead, one informant described a palliative approach to care as “pre-pre-pre-pre-pre palliative care” in hopes that volunteers would be less intimated by the concept. Others simply moved away from describing the role in relation to palliative care at all. They recognized that any program needed to be re-conceptualized in a way that made it acceptable to their community. So, though Nav-CARE was designed as a program to provide a palliative approach to care in a theoretical sense, they might frame the volunteer role as “neighbours helping neighbours”, appealing to simple ways of helping each other out.
Other organizations chose not to brand the volunteer role but rather to focus on the skills of the volunteer and assets of the community to frame the role. For example, in the following quotation, the informant describes a personalized asset-based approach to attracting volunteers.
Like, you are an expert on what you do and what you do great is great. You as a personal navigator with your own connections to the community and your own conduits is important. Your own circle of care becomes this family circle of care and it's individualized in a way that I feel is like really satisfying as a volunteer experience.
In this way the informant was focusing more on the strengths of the volunteer, their connections, and their ability to link someone to a circle of care rather than trying to attract them to a role that was unfamiliar to them. Such adaptations were crucial to successfully recruiting and retaining volunteers.
Collaboration vs competition
Mindful messaging extended to how the Nav-CARE program was framed in relationship to other organizations serving similar populations or who relied on volunteers. Informants described how volunteer recruitment and retention can be a struggle for all organizations and that there was competition for a limited pool of volunteers. As one informant explained, “Recruiting volunteers– training volunteers, you could get in ten and only two make it through the recruitment process. So, those two that you got, you want to hang on to, right? You’re not sharing them with anybody.”
To help mitigate the possibility of competition, sites sought to frame their message as collaboration versus competition thus reassuring other organizations of how they could complement existing programs. “I’m really big on stressing about how it’s supposed to be a collaboration and helping already existing programs. I don’t want them to feel like I’m stepping on toes or looking to take their volunteers.” In taking such an approach, they avoided competition by demonstrating how Nav-CARE complemented existing programs in the community by filling service/resource gaps. Informants noted that this was an ongoing exercise in messaging and meeting with key partners, particularly when other organizations experienced turnover in leadership or shifted their own priorities toward other initiatives. These were critical transition times in which maintaining cooperation was essential.
Deepen relationships
Informants recognized that even the most skillful awareness raising and messaging must be undergirded by deep, trusting, and authentic relationships both within and across organizations. They spoke of the importance of having the Nav-CARE lead be deeply embedded within their own organization, of supporting long term client-volunteer relationships, of being careful about structuring organizational partnerships if mentoring is the purpose, and of connecting organizational leads across sites for mutual support.
Embedding the Nav-CARE lead in the organization
Nav-CARE leads played a pivotal role in ensuring the success and sustainability of the program. Recruiting, training, and mentoring volunteers; home visits to potential clients and including follow-up visits; and community engagement activities all contributed to a role that required significant organizational backing. Informants discussed the importance of trust on the part of the organization to enable them to enact the role in the way that worked best. For example, this included the recognition of the need for flexibility in the role and giving space for self-direction. Such trust enabled Nav-CARE coordinators to adjust to evolving program needs and respond effectively to emergent situations. “The organization should allow flexibility because sometimes you have to be able to change your timing to do things that sometimes wasn’t a part of your previous week’s schedule.”
In addition to a foundation of trust, it was important to embed the Nav-CARE coordinator into the broader organizational team to attenuate the feeling that they were shouldering their responsibilities alone. “Everyone’s been so supportive and excited. The support has been amazing. Like, I don’t feel like I’m out on a raft on my own.” For Nav-CARE leads working in larger organizations with multiple programs, this embeddedness gave them practical support from colleagues, the ability to coordinate volunteers across different programs, and provided access to important networks, including the ability to capitalize on colleagues’ reputation in the community. Such support fostered a sense of teamwork and motivation. “We have an amazing team. I don’t think I’ve ever worked for such a cohesive team where there’s no micromanagement. I can really be myself.”
In terms of board-run organizations, the relationship between the Nav-CARE lead and the board was especially important. “We have like a unicorn board. Everybody’s like just let us know what the problem is. And they’re very supportive on not just programming wise, but also ‘how is it going in your position?” In contrast, the lack of board support (or a shift in board priorities) could quickly lead to a dissolution of the program even if it had already gained significant momentum.
Supporting long-term volunteer-client relationships
The hallmark of the Nav-CARE program is an early approach to palliative care. Volunteers become involved with clients as soon as their illness begins to affect their quality of life and the volunteer follows the client over the long term as their health declines. This is in contrast to the traditional hospice palliative care model in which volunteers are often involved too late to establish a long-term relationship. Having volunteers get involved early with clients supported a deepening of the relationship between the two which had benefits over the long term. Volunteers suggested that clients felt like there was someone to whom they could turn for help aside from their family and healthcare providers. “The fact there’s somebody that cares about you aside from those that are looking after you and supporting you… is really good.” This deepening of relationship also helped to offset the potential psychosocial effects of living with the impacts of a long-term illness. “Sometimes the best thing the volunteer can do is bring themselves and their presence and eliminate some of that loneliness and isolation.” Because volunteers worked with clients over a long period of time, they were able to notice subtle changes in clients that might not come to the attention of healthcare providers. “He got better care from us because of Nav-CARE. We were able to see the decline as it happened… I was able to reach out and then facilitate a transfer.” Notably, the changing role of the volunteer also meant that these volunteers could reach into “homelike” spaces such as long-term care, thus providing relational connection across transitions in care. Such impacts had important implications for scaling deep because these stories could influence beliefs about the importance of the program.
Embedding through organizational mentorship
The Hub and Spoke model was envisioned as a way for organizations to build capacity through the development of relationships with other organizations who may not have the capacity to build a Nav-CARE program on their own. Spoke organizations were supported by the Nav-CARE lead through mentorship, support to train volunteers, and assistance with making community connections (if needed). However, this idea of mentorship to smaller communities and organizations had mixed effects. If the Spoke organization had some capacity to begin with (e.g., a champion, stable volunteer base) and there was a specific need that the Hub could assist with (e.g., formal education) then the relationship could develop into a supportive one. However, a lack of specific funding for the Spoke sites, geographic distances (combined with inclement weather) between Hub and Spoke sites, and organizational instability within the Spoke sites were significant deterrents to the development of a supportive relationship. We learned that attempting mentorship across organizations was challenging, in part, because of how context-dependent successful scaling deep is.
Connecting Nav-CARE leads across sites
Over the duration of the project, Nav-CARE leads were invited to participate in a monthly community of practice (CoP) held over Zoom and facilitated by GP and KA. These meetings were intended to enable leads to network and learn from each other. Informants were unanimous about the value of the CoP; indeed, all voiced concern that they would no longer be invited to the CoP once their formal implementation period was completed (the CoP has been successfully sustained). The value of the group was in the organic forming of relationships with others from across the country, within diverse contexts, and at different stages of implementation. These relationships became an important source of support and for several informants, such support was likened to the nurturing and mentorship they gave to their volunteers. “This stewarding of the volunteers and the nurturing and taking care of the employees too is really important, it’s just really appreciating us, and you really feel like you’re valued. And that’s huge because it could be one of those jobs that, the risk of burnout and feeling overwhelmed could be real.” The CoP was also an opportunity to share tacit knowledge in relation to implementing Nav-CARE specifically and volunteer coordination generally. An important part of developing this tacit knowledge entailed “thinking together” and generating knowledge in the moment. “I take copious notes and I get lots of little ideas that kind of trigger stuff. It’s so cool to see other people doing the same thing you’re doing, and having the same barriers or struggles.” As participants shared their successes and challenges with one another, they felt heard and valued by their peers. This was significant as informants noted that these avenues for making connections with peers was out of reach for most Nav-CARE leads. One informant reflected that while the formal healthcare system held CoP meetings for those involved in palliative care, as a lead in a community-based organization, she was not invited to such tables. This made her feel “undervalued” and “isolated.” The emergent and evolving nature of the group meant that the structure was flexible, other than sharing updates related to Nav-CARE developments, the agenda was open to topics and issues arising from the group in the moment – topics centring on volunteer boundaries, how to build relationships with potential community partners, and how to dismantle taboos around dying and death. This engendered mutual engagement and trust within a shared practice.
Expand possibilities
An important aspect of scaling deep, particularly from an organizational perspective, is sharpening or altering beliefs about the role of the organization in the community. In particular, many of these organizations were intent on changing beliefs about the possibilities of hospice in community. This included their role in providing practical assistance, in becoming a connecting point to other organizations, and in driving policy change.
Providing practical assistance
In implementing the Nav-CARE program, hospice organizations in particular were reframing beliefs about the role of hospice. “In implementing Nav-CARE we were able to announce all that hospice is doing, the information, the resources, the integration they have in the community.” The practical emphasis of the Nav-CARE program helped to alter beliefs that hospice was only about psychosocial care at end of life. “I know you’re not into that death and dying stuff, but you’re struggling and we can help there. And so, it gives us a way to talk about ‘here’s something we can offer’.” Overall, informants felt that the implementation of the program had enhanced their role within community, particularly if other organizations could see that the volunteers connected clients in ways that benefited the community overall. “So now we can support people a little bit better, a little bit more fully with the enhanced awareness of our volunteers that are going out to the community.” “It’s been a major change. It’s been a major improvement in who we are as an organization and the service we offer today.”
Becoming a connection point
The navigation aspects of the volunteer role meant that these volunteers were a connecting point for clients to other people, services, and organizations. “So, the Nav-CARE program serves as the action point for all that they know about the community, about the health, about all the available resources.” This shifted the role of the volunteer beyond supportive psychosocial care or individualized practical support to one of connection to other important services. For example, informants emphasized the role of the volunteers in supporting caregivers by being a sounding board and encouraging self-care; and, helping families stay informed. Nav-CARE volunteers then became important members of a client’s “circle of care” often serving as a bridge between clients, families, and healthcare providers. Another informant spoke of how the volunteers could connect clients to services even if normal referral sources were missing in the community. “So, because they don’t get a palliative doctor doesn’t mean they don’t get connected to Hospice.” By cultivating ongoing relationships within their community, Nav-CARE became part of the constellation of services that their communities offered and leveraged access to those services, thus benefiting the profile of those organizations in community. “You don’t really need our services yet, but there is this other program that can help you. Kind of partnering up – we can all work together.” As one informant explained, developing a partnership with an organization that is already trusted in community provides legitimacy for your own initiative, and if your initiative is successful, it amplifies their reach as well. Further, it ensures that organizations are working together to maximize their reach and impact.
Driving policy change
Informants talked about the importance of identifying policy directions set by the key decision makers, envisioning how Nav-CARE aligned, and leveraging this synergy when discussing the program. “I did another talk and I said, early identification is one of the goals of care, one of the standards for hospice palliative care. And I said, I see this as helping us with early identification.” Other informants highlighted the contributions of Nav-CARE to aging in place policies, an important focus within all provincial jurisdictions. “What Nav-CARE really brought to the community here was early engagement and not just focusing on end of life or terminally ill but in keeping people in their homes or helping them transition into alternate care homes. I just think it’s such a, a huge piece to our whole in aging in place.” The ability of organizations to adapt the Nav-CARE program to local policy priorities was also seen as a benefit of the program. “So the flexibility of Nav-CARE is kind of like its superpower up here. And basically, puts all of its little feelers through all communities and is so useful to all communities…because they can pivot it to their own needs.”
Because organizations could promote their Nav-CARE programs as meeting important policy directions, additional funding often became available, thus supporting organizational sustainability. As one informant shared, “I can’t say enough about how that gave us stability… now we’ve gotten other grants, we are in such a different financial position.” However, stable funding was a problem for many organizations. “I really think the biggest problem for all of us is begging for funds.” While many organizations had received additional grants to grow the Nav-CARE program, informants were unanimous in their perception that uncertainty around funding made it difficult (or impossible) to make concrete future plans: “You’re waiting for months and months and months to see whether or not you get any funding. And, if we have a grief group or something running, we can’t say to people, “it’s to be scheduled for this time.” You have to wait and see if the funds come in.”
Although policy change is often viewed as a function of scaling up rather than scaling deep, there was an important aspect of changing beliefs in the community before such policy change was possible. Informants spoke of numerous beliefs that diminished the contributions of volunteer organizations that needed shifting. It was clear that informants perceived volunteers as an integral member of a person’s care team however, this role was rarely formalized in policy (e.g., inclusion in healthcare teams). Most felt that the healthcare team were either unaware of the potential contributions volunteers could make or, conversely, exploited the role by asking volunteers to do work that would otherwise be allocated to paid staff. Such ambiguity often resulted in uncertainty among care team members regarding what volunteers could offer, or, inappropriately expanded expectations of volunteers’ responsibilities. Informants suggested that changing beliefs about the capacities of volunteer programs were essential to seeing significant policy shifts.
We’re diverting people out of, or delaying putting them into assisted living or long-term care where those services are already oversubscribed right now. People just end up there sometimes way before they really need to be there, just because they don’t have any community level supports. At every opportunity I get to the public to say, you people need to back us up. You need to speak out, you need to speak to the press, you need to speak to whoever you can speak to, so that government understands.
Discussion
Findings from these 30 informants provided important insights into the work of scaling deep in the context of one organizational innovation. Across the data, important thematic threads related to values, beliefs, and narratives emerged that provided the focus for scaling deep efforts. Central to these threads was the value of developing and cultivating relationships of trust, the belief that the organization had a vital contribution to make, and the narrative that community members fundamentally need one another.
Unlike many public messaging campaigns 16 that seek to change peoples’ ideas around experiences that carry stigma (e.g., illness, death, dying, and grief), this group of informants recognized that such a change had to start at an even more fundamental level. They suggested that it was less about the message itself and more about the trustworthiness of the person or organization delivering the message. The importance of trust was also identified in a recent article exploring barriers to hospice care for diverse populations. 17 When community members perceived the organization as trustworthy, this served as the starting point for transforming messages. Importantly, this trust originated within the organization itself. The Nav-CARE lead needed to be trusted by the organization and entrusted with involvement in the organizations core activities. When considering public messaging, informants emphasised the importance of having an identifiable name and face as a way of building trust with the Nav-CARE program. Cultivating relationships with other trusted individuals who could share the impact that the program had on their lives further expanded this circle of trust. Moreover, the mindful messaging described by these informants was consistently characterized by trust. Strategies included respecting cultural contexts and historical tensions, preserving client dignity by avoiding language that framed them as needy or dependent, and conveying that both the organization and the social innovation it supported were trustworthy. Fraser, in her work on scaling deep, similarly describes connection-based practices that include creating an ecosystem characterized by trust, humility, and respect in collaboration. 3 She describes this process as “taking the long view” p. 16 to scaling deep, recognizing that this trust-building work only happens over extended periods of time. Further, she suggests that not only is trust foundational to scaling deep but that scaling deep itself builds trust in a reciprocal way. 3
Building upon this strong emphasis on trust over the long game, informants spoke of leveraging the belief that their organization, and social innovation, had something important to contribute to the community. This belief was meant to counter the longstanding bias in society that volunteer organizations are nice but not necessary. 18 Instead, these participants actively reframed their contributions to pressing social issues. They emphasized the practical support they were able to provide that transcended the stereotype of hospice being simply a friendly visiting service and sought to show how their new social innovation could be a connecting point that would raise the visibility and contributions of other programs in the community. Most importantly, they sought to send a message that what they were doing was contributing to important policy directions such as aging in place, early identification of those needing help, and facilitating goals of care conversations. In this way, informants from these organizations were seeking to strategically shift power so they too would be seen as an important social actor in the field of older person care, an important part of scaling deep. 3 A remarkable finding in this data was the capacity that these organization had to meet with potential partners as a way to facilitate change in their beliefs; over 350 formal and informal meetings were held over a relatively brief contribution period.
The flexibility of the Nav-CARE program proved to be a critical asset in achieving change. If the program could be adapted to address what the community perceived as their most important gap in care, then the belief that the organization had something to contribute was amplified. This finding illustrates the important connections between scaling deep and scaling up. Changing policy, or scaling up, may first require changing beliefs about who the important actors are in realizing policy change. When organizations were successful in substantiating the belief that they had an important contribution to make in solving key problems, funding for the organization followed. Although achieving sustainable funding remained the most pressing problem for these organizations.
Within a milieu of trust, and alongside the belief that their organization had something meaningful to contribute, the most important narrative was that people in the community fundamentally needed one another. This was meant to counter the predominant problem-focused and needs-based narrative characteristic of most social policy. 19 Social narratives are often framed in the following way: problems are defined, populations are then identified as having needs, and social innovations are targeted to meet those needs. But these informants sought to change that framing, recognizing that persons living with conditions in community do not want to see themselves as dependent or needy and volunteers may not see themselves as having the capacity to meet such overwhelming needs. The framing of the narrative changed to something much more meaningful; the narrative that small but significant investments in one another’s lives make a large difference. A meaningful task completed for a person living in community was more important than having that person believe that they had needs that the organization could meet. Volunteers were attracted by emphasizing their strengths and current capacities rather than having them buy into a new social innovation in which they might have doubts about their ability to fill the volunteer role. The connecting point to community that these volunteers fulfilled was a good example of the type of volunteer engagement with community that is considered best practice for volunteer recruitment and retention. 20 At an organizational level, informants understood that the only way to overcome the inherent competitiveness that exists between non-profit organizations in community, was to construct a narrative of mutual support, one that emphasized the need for collaboration and shared responsibility in order for them to build a community of care. In this way, participants’ actions mirror what Moore et al., 21 describe as a key scaling deep strategy: reframing dominant narratives by being sensitive to what resonates with those whom you seek to involve. Typically, these dominant narratives are changed in a way that shifts power. In the case of this study, those living with declining health were not portrayed as needy or dependent and a strengths-based approach characterized the recruitment of volunteers.
Findings also offered important learnings for Nav-CARE implementation. First, was the importance of the community of practice in connecting Nav-CARE leads across study sites. Moore et al., suggested that one of the most important strategies for scaling deep is to invest in transformative learning because “the support of like-minded peers was essential to sustain the innovators.”21,p. 81 In this study, informants suggested that the community of practice helped them to share learnings, to be heard and valued, and to offset the risk of burnout and feeling overwhelmed when trying to implement a new program. Maintaining this community of practice over the long term is an essential sustainability strategy. Second, we learned about the critical importance of the organizational culture to the implementation of Nav-CARE. It was the overall health of the organization, particularly its capacity to establish and maintain trusting relationships both internally and within the community, that was pivotal in determining the ability to scale deep with the Nav-CARE program. Previous studies of volunteer navigation using an implementation science framework revealed the importance of organizational capacity in implementing a successful program.12,13,22 However, data from this study suggests that the organizational culture in which Nav-CARE is implemented might be the single most important determinant of whether the program takes hold. If scaling deep is about social transformation and relationship as the literature suggests, then it makes sense that the health of the organization out of which that scaling is done becomes a primary predictor of success. Finally, we learned that a Hub and Spoke model of
While providing key insights about scaling deep, we acknowledge that there are several limitations to these findings. The small number of informants from spoke sites not only limits our understanding of their experiences of implementing the Nav-CARE program within their own organization/community, but as scaling deep is context dependent, the lack of representation from Spoke sites also limits our understanding of scaling deep within the Hub and Spoke model. It is possible that factors related to organizational capacity, their position within their respective communities, and the relationship between the Hub and Spoke itself influenced how effectively the Spoke could scale deep. Further, we did not analyze the data in relation to urban and rural contexts; it is possible that there is a strong geographic influence in how organizations position themselves within community and seek to influence community.
Conclusion
This study helps to address the paucity of literature exploring practical strategies of how social innovations are scaled deep. The most significant finding of this study was that the influence of values, beliefs, and narratives, that are the cornerstone of scaling deep, was focused as much on the organization supporting the social innovation as on the social innovation itself. This suggests that for community-based, non-profit organizations such as the ones under study here, the organizational milieu and its reputation within the community may be the most important predictor of the possible scale. Moreover, the degree to which organizations play the long game in scaling deep has implications for the length of time that may be required to effectively scale and embed social innovations. Further research is required to explore the relationship between scaling deep and scaling up. Theoretically, the relationship between the two is bi-directional and synergistic. By scaling deeply, organizations can also mobilize the policy change and sustainability characteristic of scaling up, and conversely, scaling up supports the transformation in values and beliefs that is the hallmark of scaling deep. 4 Such relationships are important to explore from an empirical perspective.
Supplemental material
Supplemental material - Strategies used by organizations to scale deep: Lessons from a volunteer navigation intervention
Supplemental material for Strategies used by organizations to scale deep: Lessons from a volunteer navigation intervention by Gloria Puurveen, Kelly Ashford and Barbara Pesut in Palliative Care and Social Practice.
Footnotes
Acknowledgements
The author team would like to acknowledge the participants who gave so generously of their time and wisdom.
Ethical considerations
This study was approved by the Behavioural Research Ethics Board of the University of British Columbia Okanagan [H24-00343].
Consent to participate
Participants provided written and informed consent to participate in this study.
Consent for publication
Participants provided consent to include de-identified quotes from the transcripts of their interviews in publications.
Author contributions
GP, KA and BP contributed to designing the study, collecting and analyzing data, writing the manuscript, and editing it for content. All authors approved the final manuscript.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project out of which this data was collected was funded by a Health Canada contribution (AWD-016626).
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author, [BP], upon reasonable request.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
