Factors that Influence PSW Role Implementation
In this section, the literature on factors influencing PSW role implementation is reviewed. Table 2 shows the factors at each level and reflects the interlevel influences. It is important to note that the themes we report are not mutually exclusive. Separating themes is necessary for presentation purposes, but as our analysis will show, a factor can operate at various levels, as well as intralevel.
Factors at the Macro Level of Analysis
Factors at the macro level pertaining to PSW role implementation relate to the macro socio-cultural context, the regulatory and political context, and the economic and financial context.
Macro Socio-cultural Context
Literature shows that dominance of the medical model in mental health care and professional power dynamics influence PSW role implementation. The medical model culture that prevails in mental health services is a major barrier to recovery-focused approaches and to PSW role implementation (Byrne et al., 2016). This culture privileges a hierarchical structure whereby power lies in having a medical or clinical background (Ehrlich et al., 2020). Tensions exist between the view of those in favor of peer support and the traditional view based on the medical approach. These tend to be opposing discourses, and Byrne et al. (2016) refer to such opposition as two worlds colliding (p. 217). While advocates of peer support rely on the principles of recovery, experiential knowledge, and the philosophy of self-determination and empowerment (Gillard et al., 2017), the medical model has an emphasis on the “expert knows best” attitude, medication treatment, therapy, and other highly regulated services (Byrne et al., 2016, p. 220).
The medical model and the “expert knows best” approach encourage power imbalances in favor of organized professions (Byrne et al., 2016). Peer support is based on personal relationships and caring, and PSWs’ effectiveness depends on quality of relationship and mutual trust that they establish rather than use of knowledge obtained by academic qualifications (Repper & Carter, 2011). However, established professions show resistance to PSWs’ practice through prejudice, stigma, and discrimination (Walker & Bryant, 2013), hindering the implementation of PSW role. Byrne et al. (2019) refer to the “institutionalized discrimination” towards people with a history of mental illness in Australia and “prejudicial attitudes” from the mental health professions that inhibit the PSW role development. Such discrimination has been observed in other jurisdictions as well such as Canada (Mulvale et al., 2019).
Despite enduring dominance of the medical model, there has been increasing attention to recovery-oriented approaches and acceptance for the role of PSWs (as we show in the next section). This has accompanied attention in several jurisdictions to developing training programs to enhance the competencies of PSWs and to provide certification (Rebeiro Gruhl et al., 2016). Hence, PSWs can be formally certified allowing their qualifications to be recognized in the mental health system as has been the case in many states in the US (Grant et al., 2012). Certification is also available in other countries, such as Australia (Fan et al., 2018) and training programs have become more common (e.g. several European countries, Japan) (Berry et al., 2011; Burr et al., 2020; Matsui & Meeuwisse, 2013). Training and certification help enhance the legitimacy of PSWs in an otherwise professionalized domain and can facilitate their integration into the mental health system.
Regulatory & Political Context
System-level policies have influenced the implementation of PSW role in mental health care through downward directives. In the US, there have been state and federal health care policies that mandate mental health centers hire PSWs called “certified peer specialists” (Grant et al., 2012). Grant et al. (2012) showed successful integration of the PSW role in these settings. In Canada, the Mental Health Commission of Canada has recommended the development of peer support in mental health care, however, the integration of PSW role in clinical settings has remained a challenge (Mulvale et al., 2019), showing that recommendations by high level bodies are helpful but likely not sufficient. This is in contrast to stipulations that the inclusion of peer specialists is a requirement in Assertive Community Treatment (ACT) teams in some Canadian provinces such as Ontario (White et al., 2003).
In the UK, the policy decision to include recovery in frontline services resulted in the creation of a peer support worker role by the NHS that has been distinct in terms of offering mutuality, empowerment, modeling hope, and the sharing of lived experience with peers (Gillard et al., 2015). PSW role implementation in the NHS has also led to enactment of occupational health practices, staff training, and other measures such as developing referral processes (Berry et al., 2011; Creamer et al., 2012).
High level regulation can target various areas of PSW employment, including, for example, recruitment, working hours and pension. Burr et al. (2020) found that PSWs in Switzerland work 35% of a full-time equivalent (13 h per week) because mental health organizations had no legal obligation to employ PSWs. In Ontario, Canada, the Ministry of Health requires 0.5 full-time-equivalent paid staff in a PSW position in Assertive Community Treatment Teams and PSWs have been consistently recruited throughout the province (White et al., 2003). Directives from higher levels of authority on recruitment and remuneration policies enable the integration of PSWs in mental health organizations.
In Australia, policy mandates to include people with lived experience started in the 1990s, and ever since, government plans and standards have recognized the employment of PSWs (Byrne et al., 2019) and have advocated for the employment of lived experience roles as essential to the implementation and development of recovery-orientated service delivery (Byrne et al., 2019; Franke et al., 2010). Despite this policy environment, challenges persist in Australia because of prevalence of the medical model and tokenism of lived experience (Byrne et al., 2016; Ehrlich et al., 2020), indicating that policies that are not accompanied by changes in the dominant views in the social/cultural environment may lead to compliance but not genuine change in terms of embedding peer support in the mental health system (Siantz et al., 2016). The importance of increasing political commitment has been highlighted as a means to develop legal requirements and stipulations that are favourable to PSW role integration in the mental health system (Burr et al., 2020). These legal requirements in turn help legitimize the PSW role as an integral part of the system. However, the literature also calls for caution so as not to tightly regulate or prescribe the PSW role, pointing to potential disadvantages and explaining that peer support involves inherent creativity and flexibility in the role, which enables PSWs to provide individualized support (Asad & Chreim, 2016; Berry et al., 2011; McCarthy et al., 2019).
Economic & Financial Context
Providing financing for PSWs’ services has been an influencing factor, and countries that have accounted for peer support services in the financial structure of the health system have been able to integrate the PSW role in mental health care (Grant et al., 2012). For example, several states in the US have provided Medicaid reimbursement for services of certified peer specialists and paved the way for PSWs to be formally employed (Grant et al., 2012). Literature shows that system-level funding support enables financial arrangements for PSWs within mental health organizations, e.g., through funding for embedded peer support programs in mental health care or the development of training opportunities (Davis et al., 2010; Ibrahim et al., 2020). Research also indicates that PSW services create a social return on investment and emerging evidence supports the economic justification of investing in the recovery-focused services that they provide (Ibrahim et al., 2020).
Despite the relative affordability of services of PSWs, obstacles remain to formal integration of their role in mental health systems, due in part to enduring patterns and established views. Peer support comes from a history of consumer-run movement (eighteenth century in Europe and during the 1970s and 1980s in North America) which is founded on naturally occurring, voluntary peer support (Ibrahim et al., 2020; Mulvale et al., 2019). Therefore, PSWs have a long history of not being paid for the services they offer. The interlevel impact of a history of voluntary work is reflected at the level of organizations, where there tends to be absence of pay scale and other HR policies related to PSW remuneration (Hebert et al., 2008; Ibrahim et al., 2020; Wall et al., 2020). This reflects a relative devaluation of the PSWs’ skills within the hierarchy of occupations in mental health care (Asad & Chreim, 2016).
Other high level economic factors such as national economic uncertainty can pose barriers to funding that can secure PSWs’ employment. For example, in the US, the 2008 economic crisis budget cuts could jeopardize PSWs’ position mainly because Medicaid funding could be eliminated for services of the certified peer specialists (Grant et al., 2012). Economic uncertainty as an influencing factor is a topic that has not received sufficient attention in the literature.
In sum, impediments to implementation of the PSW role in mental health care systems include dominant and enduring structures and discourses on mental heath care that favor the medical approach and professional designation in service delivery, discrimination against and lack of understanding of the value of recovery for mental health, and economic uncertainty that leads to cuts in mental health services. However, in various jurisdictions, there appears to be a shift in views and increasing recognition of the value of peer support, the provision of training and certification that enhance the legitimacy of the role, changes in policies and regulations, and increased financing that enable integration of the PSW role in the mental health care system.
Factors at the Meso Level of Analysis
Factors at the meso level include organizational culture, organizational leadership, change management and workplace strategy, and human resource management policies.
Peer support services are offered within organizations that have different organizational cultures. Literature often refers to common challenges relating to PSWs’ integration into more hierarchical organizations—challenges that include lack of appropriate supervision (Creamer et al., 2012; Gopalan et al., 2017) and unclear role definitions, accountability, and boundaries (Byrne et al., 2019). These organizations tend to show apprehension relating to PSWs’ access to peers’ medical records (Chinman et al., 2010).
Comparative studies including organizations with more or less hierarchical cultures have been conducted to identify how contextual factors influence PSW role implementation. In a study in the US, Moran et al. (2013) found that contextual factors that create challenges to the PSW role differ between “conventional” mental health settings (e.g., ACT teams) and consumer-run agencies. They showed that challenges for the employed PSWs in conventional mental health services that are run by non-peers include direct and indirect expressions of prejudice, lack of recovery focus, and being the only PSW in the organization. A comparative case study in the UK showed that expectations related to the role of PSWs vary across organizations (Gillard et al., 2015). This study showed that in organizations with a structured and hierarchical culture, the distinctiveness of the PSW role in bringing a “meaningfully different practice” was undermined as the expectations from the PSWs were that they demonstrate roles similar to existing health care roles that have “clinical-like boundaries” (p.690). Hence the role became constrained, and when its implementation was an early decision with lack of understanding of the role in the team, staff resistance occurred. In contrast, the PSW role maintained its distinctiveness in organizations with a solid collective understanding of the role and a culture supportive of peer work (Gillard et al., 2015).
Organizational Leadership and Supervision
Commitment of organizational leadership has been found to be an important factor in preparing the organization for implementation of PSW role and supporting PSWs in integrating into mental health teams (Franke et al., 2010). As indicated above, at the macro level, policy leaders can offer opportunities for training, certification, and funding for PSW positions at a health systems level, and can create systems for evaluation of peer support programs (Mulvale et al., 2019); in turn, organizational leaders can build upon the macro system-level foundation and implement strategies that include recovery-oriented principles to facilitate integration of PSWs in mental health teams.
Support from senior organizational leaders enables changes in services when a PSW role is introduced, especially where a clinical setting is new to the role and needs orientation on importance of and practices associated with lived experience (Hopkins et al., 2021). Leaders can provide a vision for integration of PSWs as part of person-centred care teams and offer education about the PSW role and its benefits “while recognizing that adoption of peer support requires a culture change that takes time” (Mulvale et al., 2019, p.72). Organizational leaders can alter organizational policies and set goals to move beyond medically focused services and to include recovery-oriented services that enable employment of PSWs (Byrne et al., 2016). They can also facilitate hiring and training of PSWs (Chinman et al., 2012; Gates et al., 2010; Shepardson et al., 2019).
Educating immediate supervisors of PSWs about the role can also facilitate integration since supervisors “broker” the relationship between the organization and PSWs and between the PSWs and co-workers (Kuhn et al., 2015). The importance of supervision is strongly highlighted in the literature and has been associated with “success” and sustainability of peer support programs (Creamer et al., 2012; Gopalan et al., 2017; Kemp & Henderson, 2012; Siantz et al., 2016; Walker & Bryant, 2013).
Change Management and Workplace Strategy
Implementing the PSW role often requires that the mental health organization demonstrate openness to change, especially when the culture and dominant views at the organization are not supportive of recovery practices or incorporating lived experience as part of mental health care services (Berry et al., 2011). Research shows that mental health organizations can benefit from a change management model. Such model would consider system level policies, strategies and changes and translate them at the organization, practice, and individual levels (Mulvale et al., 2019). Alignment with supportive national and regional level government policy directives can help mental health organizations better implement the PSW role (Hopkins et al., 2021).
Chinman et al. (2010) describe a multi-step approach used successfully in the VA (Veterans Affairs) mental health system. It entailed consultation and solicitation of those involved in the peer role implementation and consisted of several steps, namely exposure (providing information and discussion on the role), adoption (leadership decision and subsequent support for the role implementation), implementation (trial use of PSWs and refinement of the role based on discussions and decisions). Franke et al. (2010) provide another example of a change model. Spearheaded by South Australian Department of Health, the Peer Work Project was launched for training and sustainable employment of PSWs. This project suggested a model (prepare, train, support) as a tool for the introduction of formal PSWs at the employing organization. The model included a segment on organizational preparation (including role definition, training staff, developing policies, procedures, and induction processes) and followed with organizational support (including supervision, staff meetings, and workplace mentoring) to achieve sustainable employment for trained PSWs (Franke et al., 2010). This program shows how directives and programs enacted at the system level can be taken up by organizations intent on change that supports the implementation of the PSW role.
Consultation of various parties involved in the change, such as supervisors, clinicians and PSWs paves the way to achieve better integration (Gates & Akbas, 2007; Gillard et al., 2017; Otte et al., 2020a; Shepardson et al., 2019). It has also been pointed out that PSW role development and integration can be an ongoing process involving proactively monitoring and removing challenges (Chinman et al., 2012). Evidence points to a workplace strategy alongside change management to effectively promote the PSW role integration (Gates et al., 2010; Gillard et al., 2017). A workplace strategy that develops a comprehensive peer support program structure and appropriate human resource policies enables the sustainability of PSWs’ role (Gillard et al., 2017; Kuhn et al., 2015).
Human Resources Management Policies
The literature refers to organizational policies on hiring, remunerating, training and socializing, and retaining PSWs as enabling or hindering PSW role integration.
With respect to hiring, the literature shows the importance of establishing criteria for the recruitment of PSWs. A research project in the VA in the US called Peers Enhancing Recovery demonstrated potential for integration of PSWs in case management teams (Chinman et al., 2012). The findings showed that the Human Resources department, based on past experience with hiring professionals, often did not know how to utilize lived experience as a hiring criterion, causing confusion and preference to hire individuals with credentials other than lived experience. Organizational guidance on how to utilize PSWs is identified as a factor that supports placing PSWs in work roles that are centered around lived experience and helping others in recovery (Mancini, 2018). Development of a program structure for the integration of PSWs’ role rather than siloed recruitment of PSWs on an ad-hoc basis (Hebert et al., 2008; Frank et al., 2010; McCarthy et al., 2019) also enables role implementation.
(Mis)understanding of the importance of lived experience impacts the remuneration of PSWs. Remuneration is a gauge for the level of education, expertise, and hierarchy of positions in mental health organizations (Asad & Chreim, 2016; Ibrahim et al., 2020). Inadequate remuneration and limited workplace resources give the impression that the skills of a PSW are not valued (Asad & Chreim, 2016; Vandewalle et al., 2016). Literature shows that interprofessional power dynamics that manifest at the system level also appear at the organizational level when considering remuneration disparity (Burr et al., 2020; Repper & Carter, 2011). Findings show that an appropriate “pay scale classification” for PSWs (Otte et al., 2020a) that fairly values their contribution to the wellbeing of the service users (Gates & Akabas, 2007) is essential for the formal integration of PSW roles in mental health organizations.
Training offered by organizations also enables PSWs’ integration into mental health services. Asad and Chreim (2016) found that there are different types of training that enhance PSW role integration, including training that is offered to all staff as a socialization process, workshops specific to peer support services, and ongoing learning opportunities during the job. In addition, training may be delivered through several contributors who all agree to provide a holistic and continuous training experience to the PSWs (Chinman et al., 2010). For example, in the VA in the US, training is provided by other employed PSWs, other staff from mental health intensive case management through shadowing, and/or contractors who train for specific mental health programs (Chinman et al., 2010).
Training for PSWs and mental health teams holds several benefits. First, PSWs tend to develop their sense of professional identity and a more distinct role as they differentiate their strengths from other mental health workers (e.g. their unique relationship with peers, having authentic empathy and a normalizing function, and a “different sort of creativity” in working with the peers [Berry et al., 2011]). Wall et al. (2020) identified that PSWs showed high intrinsic motivation and high self-efficacy after training. Second, training alleviates potential conflicts in mental health teams by improving teams’ tolerance and acceptance for PSWs’ work practices (Berry et al., 2011; Matsui & Meeuwisse, 2013; Rebeiro Gruhl et al., 2016). Training PSWs and teams lessens potential discrepancies (experienced by both the PSWs and the teams) between the job description presented at the recruiting interview, and the reality of the PSWs’ role (Berry et al., 2011; Davis et al., 2010; Gates et al., 2010). Mancini (2018) found that it was essential and important for PSWs to seek ongoing professional development opportunities and continuing education similarly to other “helping professions” that are mandated to keep skills up to date. The author pointed to the need for career advancement with incremental pay and ranks that reflect skill level and experience and that these various methods “would allow them greater legitimacy and bargaining power within traditional mental health organizations” (p.132).
In addition to training, organizations can facilitate PSWs’ self-education and access to resources. One such resource is access to material or workshops that help PSWs understand the technical terminology typically used in mental health settings (Asad & Chreim, 2016; Ibrahim et al., 2020). Other resources become available when organizations hire simultaneously or employ multiple PSWs as this can offer a network of peers; this empowers PSWs to discover their strengths and to support each other through collegial consultation (Berry et al., 2011; Burr et al., 2020; Gillard et al., 2017; Wall et al., 2020). The Peer-to-Peer Resource Center in VA is an example of a PSW network for continuous training and support on general peer support skills (Chinman et al., 2010).
Another organizational human resource policy that enables integration of PSW role refers to sick leave as part of PSW employment. In the VA in the US, for example, a sick leave policy is applied for the employed PSWs in the same way that it applies to other staff (Chinman et al., 2010). Human resources policies that enable integration of PSWs would also benefit from looking ahead at retention. Retention of PSWs relates to providing not only proper remuneration (fairly balanced between workload and compensation (Wall et al., 2020), training, and job development opportunities, but also physical resources such as a computer and an office to meet with peers (Burr et al., 2020; Ibrahim et al., 2020; Moran et al., 2013). Comprehensive human resources policies that acknowledge the value of the skills and work of PSWs enable integration and sustainability of the role.
In sum, the following facilitate the implementation and the sustainability of the PSW role: a supportive organizational culture, leadership commitment at all levels of the organization that signals the importance of lived experience and recovery in mental health services and supports the implementation of the PSW role, adoption of change management and workplace strategies, and finally, enacting comprehensive human resources policies.
Factors at the Micro Level of Analysis
Micro level influences on PSW role implementation include the relationships with team members and (in)ability to achieve wellbeing.
Relationships with Team Members
Tensions in relationships with other mental health staff have limited PSWs’ integration into mental health teams (Otte et al., 2020a). These tensions are partly because of a lack of trust in and understanding of the experiential knowledge of the PSWs (Ibrahim et al., 2020). Literature highlights that PSWs find stigma prevalent and a “normal” part of their job in mental health care, which is ironic given their vital contribution to stigma reduction (Byrne et al., 2019; Mancini, 2018).
PSWs may experience various forms of stigma. They experience structural stigma that emanates from lack of HR policies (as mentioned above) related to PSWs. There are cases where PSWs do not have the same privileges at work as their non-peer colleagues e.g., career development and other employment benefits (Mancini, 2018; Siantz et al, 2016). PSWs also experience stigma relating to stereotypes about mental illness that negatively affect health professionals’ attitude and lead to discrimination towards the PSWs (Byrne et al., 2019; Otte et al., 2020a). The reflection of such attitude is evidenced as “direct and indirect expressions of prejudice” (Moran et al., 2013, p.284). PSWs may experience prejudice from the staff in general, and especially in cases when the PSW transitions from a “patient” to a PSW (Moll et al., 2009). In the case of colleagues who had previously treated the PSW, negative attitudes can manifest in absence of courteous collaboration (Ibrahim et al., 2020; Walker & Bryant, 2013). As such, PSWs can experience exclusion from meetings or lack of reciprocal communication with the other staff that hinder PSW integration within teams (Byrne et al., 2016; Shepardson et al., 2019).
Research findings show that a low “readiness” level of the PSWs and the non-peer staff for the integration of the PSW role in the team play a significant part in the PSWs’ experiences of stigmatization (Mancini, 2018). PSW integration within teams may happen gradually as attitudes shift and team members develop an understanding of the role (Asad & Chreim, 2016; Ehrlich et al., 2020; Mulvale et al., 2019; Tse et al., 2017). Findings of a peer support project in Hong Kong (Mindset project) showed that despite the uncertainty about the PSW role at the beginning of the implementation, staff progressively developed trust and awareness about the role and changed their perception of peer support services to a point that they viewed PSWs as an “asset” both for the staff and the peers (Tse et al., 2017).
Another aspect of relationships with other staff that may influence integration is PSW disclosure of details about their own mental illness to the teams, which can be experienced as a challenge by the PSW (Chinman et al., 2010; Gates et al., 2010; Kemp & Henderson, 2012). Literature points to cases when mental health teams (e.g. Mental Health Intensive Case Management for the veterans in the US) strongly agreed on hiring PSWs who are comfortable disclosing about their mental illness and sharing their recovery experience (Chinman et al., 2010). This can enable integration of PSWs by helping them build trust with team members, although—as we have argued above—for this approach to be effective, there needs to be acceptance of the value of lived experience and belief in recovery on the part of team members.
There are other disclosure issues that can create challenges for the integration of PSWs within teams and which concern PSWs’ sharing of information on the peers (or service users) with the other staff (Asad & Chreim, 2016; Kemp & Henderson, 2012; Moll et al., 2009; Repper & Carter, 2011). PSWs’ effort of maintaining a balance between their commitment to providing support for their peers and the expectations of the mental health professionals to obtain information on clients is an enduring challenge (Ehrlich et al., 2020; Otte et al., 2020a). Sharing insights and achieving agreement on peer information disclosure within the team enables PSW role integration (Gillard et al., 2017; Repper & Cater, 2011). Overall, issues related to defining the role boundaries of PSWs can impact whether role integration is hindered or enabled (Asad & Chreim, 2016).
Maintaining PSWs’ wellbeing is another micro factor that enables role implementation. This is an important issue for PSWs because of potential for being burdened when engaging in peer support (Otte et al., 2020a, 2020b; Vandewalle et al., 2016). There are also issues of managing the boundaries with the peers that include for example, after-hours involvement, friendship vs. friendly behavior, and setting a distance (Chinman et al., 2010; Otte et al., 2020a; Rebeiro Gruhl et al., 2016). Interactions with the peers may lead to emotional involvement or attachment and PSWs need to manage their feelings at the end of their professional relationship (Moran et al., 2013; Vandewalle et al., 2016). Evidence suggests that access to self-care, training, and supportive supervision can help address some of these concerns (Chinman et al., 2010; Davis et al., 2010; Ibrahim et al., 2020; Otte et al., 2020a; Walker & Bryant, 2013).
The importance of self-care (e.g. psychotherapy, meditation, relaxation techniques) (Burr et al., 2020) and access to sick leave (Shepardson et al., 2019) have been reported in the literature. Moreover, findings from a systematic review show that PSWs’ access to a peer support network or a community of practice helps them better address the potential challenges concerning their wellbeing (Ibrahim et al., 2020). Gates and Akabas (2007) have identified a lack of networking opportunities and social support as one of the stressful hindrances to PSW integration in mental health organizations. Berry et al. (2011) report on a PSW’s experience: “I seem to be the only one that’s working in this pure peer role and that has, on occasions, felt a bit lonely” (p.244). Isolation can take a toll on PSWs. The theme of isolation is prevalent in the literature, and the phenomenon of isolation is particularly evident in health systems and organizations that do not have depth and breadth in policies and practices that enhance peer support. We have outlined various areas where policy makers and leaders in organizations can intervene to help create system and organizational change that values peer support work and enriches the work life of PSWs.
In sum, the focus at the micro level is on the PSWs’ relationships and experiences. The literature indicates that cultivating professional, positive and trusting relationships with team members facilitates integration of PSWs in mental health teams. As our discussion indicates, however, the onus is not only on the PSW to cultivate positive relationships, as this is difficult to undertake when one faces stigmatization, discrimination, and prejudice from other staff. This points to the importance of change management and training approaches at the organizational level to educate those in the PSWs’ role set about the importance and practice of peer support (as we discussed in the meso factors section). Ensuring wellbeing and setting role boundaries with both peers and team members enables implementation of the PSW role.