Adm Policy Ment Health DOI 10.1007/s10488-014-0603-z
ORIGINAL ARTICLE
Introducing New Peer Worker Roles into Mental Health Services in England: Comparative Case Study Research Across a Range of Organisational Contexts Steve Gillard • Jess Holley • Sarah Gibson • John Larsen • Mike Lucock • Eivor Oborn • Miles Rinaldi • Elina Stamou
Springer Science+Business Media New York 2014
Abstract A wide variety of peer worker roles is being introduced into mental health services internationally. Empirical insight into whether conditions supporting role introduction are common across organisational contexts is lacking. A qualitative, comparative case study compared the introduction of peer workers employed in the statutory sector, voluntary sector and in organisational partnerships. We found good practice across contexts in structural issues including recruitment and training, but differences in expectations of the peer worker role in different organisational cultures. Issues of professionalism and practice boundaries were important everywhere but could be understood very differently, sometimes eroding the distinctiveness of the role.
S. Gillard (&) J. Holley S. Gibson Population Health Research Institute, St George’s, University of London, London SW17 0RE, UK e-mail:
[email protected] J. Larsen Rethink Mental Illness, London, UK M. Lucock Centre for Health & Social Care Research, University of Huddersfield, Huddersfield, UK E. Oborn Warwick Business School, University of Warwick, Warwick, UK M. Rinaldi South West London & St George’s Mental Health NHS Trust, London, UK E. Stamou Together for Mental Wellbeing, London, UK
Keywords Peer support Organisational culture Qualitative research Comparative case study Mental health workforce
Background Policy Context Peer workers—people with personal experiences of mental health problems employed to use those experiences in supporting others—are being introduced into mental health services in a number of English-speaking countries. This change programme is, at least in part, policy driven. In the US the Centers for Medicare & Medicaid Services (CMS) have indicated that peer support specialists—people who have used mental health and addictions services—can constitute an important component in a State’s delivery of effective treatment (CMS 2007). State Medicaid agencies may choose to provide funding for peer support specialists where they hold a state-recognised peer supporter qualification (Kaufman et al. 2012). New Zealand’s Mental Health Commission strategy, Improving mental health and well-being for all New Zealanders, has identified peer support as an evidencebased, self-care approach in primary and community mental health settings that helps people regain resilience and supports relapse prevention (MHC 2012), resulting in the introduction of peer support workers as a part of the mental health workforce. In Australia, The Charter of Peer Support was launched in conjunction with the Centre of Excellence in 2011 in order to advocate for the inclusion of peer support in mental health service provision (Centre of Excellence in Peer Support 2011). National training standards have been
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developed to enable peer workers to gain a recognised qualification, thus greatly enhancing the recognition of peer support work by government and not-for-profit sectors [Industrial Skills Council (ISC) 2013]. The Mental Health strategy for Canada—Changing Directions, Changing Lives—has recognised peer support as an essential component of mental health services and is increasing appropriately resourced peer support initiatives at peer-run organisations, workplaces, schools and health care settings as a result (Mental Health Commission of Canada 2012). In the UK mental health workforce policy has identified the potential for peer supporters to fill skills gaps in mental health teams (DH 2007). More recently a UK mental health policy implementation framework (DH 2012) has recommended that mental health service organisations provide peer support as a means of improving recovery outcomes. Current Evidence Base There is also an emerging evidence base in support of the introduction of peer worker roles. A recent literature review reported a large number of qualitative studies which indicated a range of benefits of introducing peer workers; for service users, peer workers themselves and for mental health service delivery (Repper and Carter 2011). From the service user’s perspective, the peer support relationship addressed issues of social isolation (Coatsworth- Puspoky et al. 2006), and improved quality of life, independence and empowerment (Ochocka et al. 2006). Additionally, peer workers described how adopting a helper role benefited them by way of skill development and personal discovery (Salzer et al. 2002). In terms of organisational benefits, introducing peer workers into mental health service teams can improve information sharing with service users and enable better understanding of the challenges service users face (Coatsworth- Puspoky et al. 2006). The role may serve as a ‘bridge between the mental health system and the patient to improve service delivery’ (Chinman et al. 2010, p 185). A number of quantitative studies report a reduction in readmission rates (Davidson et al. 2006, Lawn et al. 2008) and longer community tenure (Min et al. 2007). On the basis of this evidence and similar pilot studies claims have been made for the cost savings of employing peer workers (Trachtenberg et al. 2013). Role development, implementation and guidance There is an established organisational literature that suggests that a lack of distinctiveness of a new role, in comparison to other roles in the team, has been shown to mitigate successful role adoption (Dierdorff and Morgeson
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2007). A number of studies exploring the introduction of new peer worker roles (see below) have echoed this basic premise. A survey of managerial and human resources staff in agencies employing peer workers in the USA identified role conflict and confusion as undermining role integration (Gates and Akabus 2007). Outside the field of mental health it has been noted that, where new roles become a repository of unwanted tasks for the team, the role can become diluted (Bach and Della Rocca 2000). Creamer and colleagues (2012) conducted an international Delphi study in order to develop evidence-informed peer-support guidelines for use in high-risk organisations. The findings suggested that clear boundaries of what is, and what is not expected of the role facilitates appropriate distribution of tasks between peer and non-peer staff. Other studies have suggested that clarity of job description (Kemp and Henderson 2012), access to appropriate training and support (Tse et al. 2013), preparation and training for the team that will be working alongside peer workers (Stewart et al. 2008), and well-signalled strategic support for the peer worker role from the top of the organisation (Gates and Akabas 2007) all facilitate introduction of the peer worker role. Again, these factors have empirical validity in the wider role adoption literature (Turner 1990). Efforts have been made to develop guidance in support of implementation of new peer worker roles. For example, in the US national guidance has been developed in support of the state Medicare accreditation requirement (NAPS 2012). In the UK the Implementation of Recovery through Organisational Change programme hosted by the National Health Service (NHS) Confederation is building on a programme of piloting peer support worker roles with practical guidance published for NHS providers who are in the process of implementing new peer support worker roles (Repper et al. 2013). However, the heterogeneity of emergent peer worker roles represents a challenge when developing guidance for the introduction of new roles. For example, a Cochrane review of peer worker roles (Pitt et al. 2013) describes both peers working in roles generally occupied by professional or support staff (e.g. case management and outreach work), and roles that are adjunctive to usual service delivery (e.g. advocacy, drop-in and discharge support). The review includes interventions where peer workers were employed by statutory (governmental) mental health service providers and those where voluntary sector (non-governmental, not-for-profit) organisations were the employers. A mapping exercise carried out by the UK mental health charity Mind (Faulkner 2013) similarly indicated a disparate array of peer support initiatives in England—providing social support, crisis support and advocacy—in the voluntary and statutory sectors, as well as in cross-sector partnerships; i.e. where peer workers were employed in the voluntary sector
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to provide support for people using statutory sector services, often through sub-contracting or co-funding arrangements. As such, both the current evidence base and the practicebased experience that might inform the introduction of new peer worker roles is likely to be derived from a range of more or less idiosyncratic approaches. In particular, it is not clear how learning from a study or initiative taking place in one organisational context—for example, where peer workers are employed in the voluntary sector—might usefully inform the development of a peer worker role in any other organisational context (e.g. the statutory sector). Given the current policy impetus behind the introduction of peer worker roles, the diversity of emerging roles and the corresponding heterogeneity in the evidence base, there is a need for comparative research (Ferlie 2005) that seeks to understand where conditions supporting peer worker role introduction are widely generalisable, or are specific to particular organisational contexts. In this paper we aim to establish whether organisational conditions supporting adoption of new peer worker roles in England apply across all mental health providers (or provider partnerships), or whether there are implementation issues that are specific to particular organisational contexts.
Method Settings Using a comparative case study design, we explored the introduction of peer worker roles into ten mental health
services in voluntary and statutory sectors, and in organisational partnerships in England. Key features of the cases are given in Table 1. Sample At each site approximately two peer workers, two service users (mental health service consumers), two members of the mental health team not working in a peer role, two team managers and two strategic managers were interviewed. Participants were purposively selected, by a member of the research team and the project lead at each site, to provide data on a rich range of experiences of the peer worker role (Creswell 2013). We had initial concerns that this approach might yield a sample that was favourably biased. Researchers spent time at each site discussing the project and recruitment with project leads resulting in a sample of participants who expressed a wide range of views, sometimes critical, as can be seen in the Results section to follow. The characteristics of the total sample of 91 participants are given in Table 2: Data Collection We developed a structured interview schedule based on: (1) the empirical literature cited above; (2) authors’ expertise in researching, developing and delivering peer worker-based interventions; (3) four group discussions with members of a service user research reference group at the lead research site. We held three further group discussions with the service users, peer workers, mental health professionals, managers (from voluntary and statutory
Table 1 Case study characteristics Case
Organisation
Setting
Population
Role
STA1
NHS Mental Health Trust
Community Mental Health Team
General adult mental health
Peer support worker
STA2
NHS Mental Health Trust
Inpatient Psychiatric Ward
General adult mental health
Peer support worker
STA3
NHS Mental Health Trust
Community Mental Health Team/ Recovery College
General adult mental health
Recovery coach/peer trainer
PAR1
NHS Mental Health Trust/ Peer-led organisation
Inpatient Psychiatric Ward/ community activity groups
General adult mental health
Inpatient advocacy worker/ user involvement worker
PAR2
NHS Mental Health Trust/ Social Services
Community day service
General adult mental health
Support worker
PAR3
NHS Mental Health Trust/ Peer-led organisation
Inpatient Psychiatric Ward
General adult mental health
Peer support worker
VOL1
Peer-led organisation
Community crisis house
General adult mental health
Crisis support worker
VOL2
Peer-led organisation
Community arts project
Adult personality disorders
Project worker
VOL3
Voluntary sector organisation
Community service user network
Black African/Black African Caribbean adult mental health
Project worker
VOL4
Voluntary sector organisation
Community mental health awareness and wellbeing work
Black & Minority Ethnic adult mental health
Community activists/ community health educators
STA statutory (governmental) sector organisation, PAR organisational partnership, VOL voluntary (non-governmental, not-for-profit) sector organisation, NHS National Health Service
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123
22
10
3
2
9
9
4
22
3
9
9
21
7
4
0 3
14
57
Statutory 2
Statutory 3
Subtotal
Partnership 1
Partnership 2
Partnership 3
Subtotal
Voluntary 1
Voluntary 2
Voluntary 3 Voluntary 4
Subtotal
Total
White British
Statutory 1
Case
91
Total
6
Voluntary 3
10
9
Voluntary 2
34
3
9
Voluntary 1
Subtotal
2 6
Partnership 3 10 Subtotal 29
2
2
6
2
Partnership 2 10
Ethnicity
2
2
2
Voluntary 4
Team manager
Strategic manager
1
4
3
0 2
0
1
1
0
1
0
0
0
0
0
White Irish
18
8
2
2
2
2
2 6
2
2
4
2
1
2
2
2
0 0
2
0
0
0
0
0
0
0
0
0
White European
17
6
2
0
3
1
2 5
2
1
6
2
2
1
14
4
1
1
1
1
2 5
1
2
5
2
2
3
8
6
5 1
0
0
0
0
0
0
2
1
1
0
Black African/Black Caribbean
20
6
2
1
1
2
2 7
3
2
7
1
3
4
5
58
23
8
2
7
6
7 16
4
5
19
4
10
1
0
0 0
0
0
0
0
0
0
1
1
0
0
Indian
33
11
2
4
2
3
3 13
6
4
9
5
0
17
6
2
0
3
1
2 5
2
1
6
2
2
2
18–25
Age
2
0
0 0
0
0
1
0
0
1
1
1
0
0
Bangladeshi
Women
Men
Coworker
Peer worker
Service user
Gender
Role
9
Partnership 1
28
9
Statutory 3
Subtotal
9
10
Statutory 2
Case total
Statutory 1
Case
Table 2 Key characteristics of the sample
14
4
1
1
1
1
2 5
1
2
5
2
2
1
20
6
2
1
1
2
2 7
3
2
7
1
3
3
36–45
4
4
0 4
0
0
0
0
0
0
0
0
0
0
Chinese
26–35
58
23
8
2
7
6
7 16
4
5
19
4
10
5
56–65
2
0
0 0
0
0
2
1
0
1
0
0
0
0
Asian other
33
11
2
4
2
3
3 13
6
4
9
5
0
4
46–55
6
3
1 0
1
1
1
0
0
1
2
2
0
0
Mixed
17
6
2
0
3
1
2 5
2
1
6
2
2
2
Over 65
5
2
0 0
2
0
3
0
0
3
0
0
0
0
Not known
14
4
1
1
1
1
2 5
1
2
5
2
2
1
Not known
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sectors) and academics who comprised the wider project advisory group to refine the schedule for clarity and to ensure coverage of relevant issues. The final 40 item schedule was organised into six domains: recruitment, job description and career pathway; expectations of the role; peer workers and diversity; supervision, training and support; team working and management; strategic support. The domain peer workers and diversity was added at the later group discussion stage as that was largely missing from the existing literature. Each domain comprised a number of statements (items) describing organisational conditions that might support the introduction of peer worker roles (for example: Peer workers are recruited through a formal recruitment process; Peer workers receive training which is specifically designed for the role). Participants were invited, on a paper copy of the schedule, to (A) indicate the extent to which each item applied in their case (yes; partly; no; don’t know; not relevant), and (B) rate the importance of that item from their perspective (extremely important; quite important; not very important, not at all important). Participants were also invited to enlarge verbally on their thinking and rationale for their answers, and were asked additional questions about the ‘success’ and ‘essence’ of the peer worker role. Interviews were digitally recorded and in-depth responses transcribed verbatim. Analysis Responses to structured questions and in-depth data were first analysed separately and then synthesised. Structured data were analysed using descriptive statistics (for each item percentages of total responses in each category for question (A) were calculated; mean score on a scale of 1 (not at all important) to 4 (extremely important) for question (B) were calculated. In-depth data were analysed using a complementary thematic and framework approach (Gillard et al. 2012) to produce a set of analytical categories that largely corresponded to individual questionnaire items, groups of items or domains. Analyses were synthesised using a pattern matching approach (Yin 2004). That is, our questionnaire articulates a particular pattern of peer worker role adoption; the organisational conditions under which peer worker roles might be successfully introduced into mental health services. Yin suggests that where a proposed pattern is replicated across multiple cases the pattern provides a valid explanation for the phenomenon being investigated (Yin 2004). Where the pattern is not replicated in particular cases, and that variation can be accounted for in terms of a predictable set of circumstances, then rival explanatory patterns can be iteratively developed. In this study we were interested both in the replication of organisation conditions
for introducing peer worker roles across our cases (i.e. where questionnaire responses were largely similar across cases), and where specific patterns were evident in particular organisational contexts (statutory or voluntary sector, or organisational partnerships). To explore patterns in our data at the level of organisational context we undertook the synthesis of our analyses in five stages: (1)
(2)
(3) (4)
(5)
Based on the analysis of structured data, we identified individual items from the schedule, or groups of items within a particular domain, which either confirmed our proposed pattern or were suggestive of alternative patterns; We identified the categories from our analysis of indepth data that were relevant to the particular item(s) we were considering; We identified the organisational contexts we wanted to compare to explore emerging patterns; We used qualitative analysis software to collate indepth data from those categories within each relevant organisational context; Where the pattern suggested by the structured data was also evident in the in-depth data we used the indepth data to develop explanatory narrative for the emerging pattern.
We repeated this process systematically for all our data. The resulting narrative, presented below using exemplar quotes from the in-depth data, was produced initially by the first author and then refined iteratively by all authors. Participants are identified by type of site (STA = statutory sector; VOL = voluntary sector; PAR = organisational partnerships) numbered in the order they appear in Table 1 (above) and by role (PW = peer workers; SU = service user; CW = non-peer co-worker; MA = team manager; SM = strategic manager).
Results Common Issues Across Organisational Contexts Across interview domains there were a number of issues that were regarded as important in all organisational contexts, and were reported as widely in place, such as the existence of formal recruitment processes for peer workers and the provision of training that was specifically designed for the peer worker role: …it actually recognises that the role is a proper job … if they go through a recruitment process they realise the importance and the responsibility the job brings. (PAR1PW02)
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We really looked to people developing their recovery stories and exploring what they’re comfortable with sharing and what that means to share your experiences and stuff … somebody might want to support someone and someone might have their experiences but they might not be at the place where they’re willing to really open up and share their own. (STA1MA01) There was also widespread evidence of strategic support for peer worker initiatives at the highest organisational level, and good fit between the introduction of peer worker roles and other organisational, strategic agendas: … it’s about our Trust’s strategic objectives … the kind of mental health service we’re going to be… if we truly believe that the principles of recovery are of primary importance to us in terms of our vision and our strategic development then … the training and employment of peer workers is kind of putting our money where our mouth is in terms of that strategy. (STA2SM02) There was a further set of issues that were considered equally important across cases, but were understood differently in different organisational contexts. For example, professionalism in the peer worker role was seen as important in all contexts, but different understandings of professionalism could apply. In the voluntary sector professionalism was often about doing the job as well as possible: … professional means doing what you’re supposed to do, doing a job, doing it as well as you can, and if you can’t do it as well as you can sometimes because you’re not very well, well that’s fine but you’re trying to do as well as you can and you’re a professional person. You’ve got your qualifications, you’ve got your experiences therefore you are treated as somebody who can do that job. Why shouldn’t you act professionally? (VOL2CW01) For some, across contexts, professionalism could be associated with over-formalising the role and, as such, diluting some of the core peer qualities of the role: … the whole point about peer workers is having this not being so much part of the establishment, but by professionalising it … we actually make people part of an establishment. (STA3CW01) It’s an important issue that they’re not as professional as a normal worker … if they were formal they would have a completely different appearance and approach to things than if they were informal… (PAR3SU1).
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In the statutory sector professionalism could be about maintaining professional boundaries in the workplace: … we had to be quite sort of sensitive in saying ‘look, it’s okay for you to disclose things, but there’s things that are appropriate for you to disclose and things that aren’t, and although you know your experiences are very valuable, you also need to keep a professional boundary’. (STA2MA02) The issue of managing boundaries was also indicated as highly important in all contexts, although understood differently in different cases. Where peer workers were employed as members of multi-disciplinary teams in the statutory sector there was evidence that the maintenance of conventional, clinical-type boundaries was considered important, here in an inpatient (hospital) setting: Having the peers in teams on wards, you naturally get all the kind of anticipated kind of anxieties or worries or concerns … around ‘will they be professional?’, the issues around boundaries, ‘they actually could make everything much worse, they don’t really know what they’re doing’. (STA3SM01) In our voluntary sector cases, and where peer workers were employed by a voluntary sector organisation in a partnership arrangement, there was evidence that peer worker roles represented an opportunity to challenge and reconsider working boundaries as personally determined, rather than professionally defined: … staff are told, as professionals that they shouldn’t be friends with service users … and [peer] workers are encouraged not to be friends … the danger is if you take that too far you ghettoise people with mental health problems … I’m not saying I don’t believe in boundaries, but … if you go too far the other way you have a very impersonal ‘them or us’ culture… and we have to find a line between the two … because there are professions who have built their boundaries so tall and so high and so thick that this sort of thing threatens it a bit. (PAR2SM01) … if they become a member of staff, for example, it’s possible that they may become aware of issues of some of the people that they’ve previously been peers with … it’s hard to get your head round … the re-negotiation of boundaries and friendships … it’s worth trying to traverse that grey area … (VOL4SM01) Peer Workers in the Statutory Sector There were specific challenges to directly employing peer workers in statutory sector organisations. Introducing this
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new way of working into large organisations that were highly structured and had well-developed cultures of practice resulted in tensions observable in a relative lack of shared expectations of the peer worker role in the statutory sector compared to other contexts. Clarity of job description did not always address the issue of expectation within teams: I think different people see the role in completely different ways. You’d think we were talking about two different job descriptions. So there needs to be clarity and clarity about expectation and how it benefits the service user and the team. (STA2MA01) Where there was a lack of shared expectation peer workers could find themselves expected to take on generic task that they did not feel was core to the role: I get a lot of the care co-ordinators saying, ‘I need you to fill out these personal budget forms.’ And I’m like, ‘Well, no, I’m not doing that. Why should I be doing that?’ If it’s for my client then, yes, I will do it … so they have been trying to get away with trying to offloading me with stuff. (STA1PW01) So we’re not just sort of writing up the flip charts or collecting the hand outs, but… the peer role does end up as unglamorous assistant, as it were. (STA3PW02) Team members in statutory sector cases often expected the peer worker role to be functionally very similar to other, non-peer support worker roles, and this could lead to feelings of insecurity among staff working in roles they perceived as similar: … staff were not clear what she was supposed to do … it would have been helpful if, maybe in a meeting we sat down and spoke about her role, maybe before she came … she was overwhelmed because people didn’t understand her role initially and they would ask her to do things. It was more like they were looking at her as a support worker role. (STA3CW02) Managers in statutory sector cases also saw the peer worker role as functionally similar to some existing nonpeer roles, but that the peer worker would bring an added dimension to their work, based on their lived experience of mental health problems: … [peer workers] are carrying out roles which would be consistent with duties you’d find in Healthcare Assistants, Support Workers … etc. in terms of the kind of tasks and functions, with some additional elements, which only a peer can carry out … it is in the person specification, or the job description, that peers will disclose and talk about their experience of recovery … it then infuses everything else that you
do. So, even if you are carrying out the same duties as other roles that exist, actually you’re doing them in slightly different ways, you’re doing them in a more collaborative way with people … (STA3SM01) As such peer workers were required to undertake the same mandatory training as other staff, with additional training in how to relate their lived experience as part of the role: There is a lot of mandatory training we have to do. There is a lot of recommended training that is for the NHS generally… (STA3PW02) They may use their lived experience in an inappropriate way. They may not understand the importance of things like hope and experience and understanding and compassion and mutuality. All those things you get taught in a course. (STA2SM01) There were a range of issues around management and peer workers in the statutory context. There could be a lack of awareness and support for the introduction of peer workers at all levels of management in the organisation: … it’s your middle level of organisations … which always block change … So ground level people can be really up for doing stuff … and at a very high strategic level they kind of say ‘yes, this is a good thing we should be doing’ … it’s [the] mass of general managers and things like that in the middle … that kind of leadership bit should … filter through the entire organisation. (STA3SM01) At the middle management level managers could have low awareness of the peer worker role, and did not necessarily have the skills to support peer workers well: … we had a manager then who didn’t quite understand … when I actually spoke to him and said ‘look, this is what a [peer worker] is’ … he said ‘well I wouldn’t tell the team that you have mental health issues.’ (STA3PW01) … that might suggest they would actually assess the skill set of a team manager before you agree to place a peer worker in that team. I don’t think that happens … I think it’s been much more the other way round, that teams have put their hands up and agreed … I don’t think that there’s then any assessment of ‘well, actually are you the right manager?’ (STA2SM02) Turnover of managers at a strategic level in statutory organisations could disrupt consistent strategic support for the introduction of peer worker roles: .. the nuts and bolts of how that translates down is still being re-defined and we will have then another
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Chief Executive … who will then have their own views and opinions about staff and we’ll have to go through that again … (STA3SM01)
signal who was working from a lived experience perspective and who was not. This approach was not universally appreciated:
There was a small amount of evidence that resistance to the introduction of peer worker roles in the organisation was as a result of stigmatising attitudes among the staff team. Individual managers who were supportive of peer working had a role to play in addressing that resistance:
I don’t think people individually do need to know who is and who isn’t. I think it models something far stronger just the fact that some of us are and some of us aren’t. Actually, it doesn’t really matter and we are both equally capable. And that’s kind of the ethos that we’re hoping people will then subliminally [absorb] when they’re thinking about the expectations themselves. (VOL2PW02)
I have noticed her mood has gone up and down and there were comments from other staff, nursing staff, saying to me ‘oh, she’s bipolar’, which obviously we don’t sort of… I don’t tend to want to diagnose or, you know, stick a label to anybody because we’re obviously trying to sort of eliminate sort of mental health stigma. (STA2ST01): That was certainly true at the initiation of this project, that there were quite a small but very committed group of people at a quite high level in the organisation who pushed this through … (STA2SM02) Peer Workers in the Voluntary Sector Peer worker roles had generally been established for a longer period of time in our voluntary sector cases compared to the statutory sector. There was evidence of strong, shared understanding of the peer worker role across participants in our voluntary sector cases, frequently attributed to a well-established culture of peer support that spread through the organisation: 90 % of the organisation is people who might be classed as a peer worker or someone from lived experience … that is the mantra and vision of the organisation … when the organisation kind of started and has evolved [it] has had that at its very heart … (VOL2SM01) … it’s been the ethos that underpins everything that the organisation does … it permeates through everything … empathy, unconditional positive regard, congruence … as part of the organisation I get a feeling of genuineness of working with people that I work alongside here and then all the kind of things that you would hope the … [service] users of the organisation get from here, you’d get the same thing as staff. (VOL1PW01) However, expectations of the peer worker role were not always completely clear in our voluntary sector cases. Some of our cases sought, through their activities, to support people to develop self-identities that were not defined by mental illness and so, intentionally, did not always
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I think I would quite like to have known, from the beginning, who was and who wasn’t somebody with a similar lived experience to me … (VOL2SU02) Similarly, it was not always clear what the specific role of lived experience was in the work that the organisation did: … the notion of [peer workers] in the organisation has never really been talked about. It’s been a bit tokenistic. Yes, it was great to employ someone with a lived experience in our organisation, it’s fantastic, but the thinking doesn’t go beyond that. And only a few people in the organisation are involved in that discussion about those peer workers. So other staff within the organisation kind of have a vague idea that they may have that lived experience and they’re peer workers but don’t really understand what they’re doing or ‘are they really different to us?’ … (VOL3SM01) Peer Workers in Organisational Partnerships A particular set of issues characterised the introduction of peer workers in the context of partnerships between statutory sector, and voluntary sector or social care partner organisations. Employed as they were by external agencies, peer workers’ roles were experienced, and described, in direct contrast to the roles of statutory sector employees (mental health professionals and support workers) in the host organisation: If a psychiatrist is talking to you or a mental health nurse you sort of think ‘they don’t really know … it’s not a living experience’. Whereas somebody else who has had mental health difficulties and they’ve come through it … you realise that person is telling you the truth and you can see that because they’re saying things that you’ve felt … (PAR1SU01) A distinctive way of working was articulated that seemed to be founded on first making a connection based
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on shared lived experience, then using that relationship to elicit the particular challenges the service user was facing before role-modelling, through the peer worker role itself, hope in moving beyond those challenges: … you go and try and talk to the individual and then I’m upfront. I say, ‘You know, I’m a service user. I’ve been on the ward like you,’ and their expression immediately turns to delight and they say, ‘Oh, have you. Can you help me?’ And, you know, they immediately make a connection with you … (PAR1PW01) … it buoys you up as well because you know that these people are able to get on with their lives. And, in my view, it’s being of value to your community and to your fellow people and these people are. And they’ve managed to do that even through mental health issues. (PAR2SU01) The distinctiveness of peer worker roles in the context of organisational partnerships could also be highly valued by the staff who worked alongside them: … it feeds down so that trust develops a little bit quicker for us … they’ve got a chance for working more closely with somebody. Whereas we don’t have time to… and then once they’ve got that trust he can say, ‘Well, tell [staff member]. He’ll sort it out for you.’ And then because he’s said it they trust it’s going to happen, because he’s developed a closer relationship than I can do. (PAR2CW01) However the challenges of working to contrasting organisational value systems in partnership arrangements were acknowledged, with some resistance to the peer worker role reported, initially at least: [The clinical team] are still a bit medical model, you know. Nowhere near like it was a few years ago … it’s taking a long, long time to change but it’s definitely so much better than it was … (PAR3CW01) … some staff thought that you weren’t really doing a proper job … you’re just there to have a chit chat, with a cup of tea and they thought that you were just … getting paid to doss about … there was that sort of hostility, where they sort of looked at you and thought, ‘Well, what are you doing?’ But I think they understood it a bit better sort of a few months into it. (PAR3PW02) Senior managers were keen to address this issue of organisational culture clash in order to ensure that the distinctiveness of the peer worker role was not lost:
I’m really concerned about the degree of creep that there is in some organisations that [peer workers] are becoming just like say a nursing assistant or a day centre worker … the ethos is very different … somebody in those roles is reading notes, writing in notes, feeding back, whereas the peer relationship should be more equal than that, somebody shouldn’t be feeling ‘the [peer worker’s] going to go off and write every word I’ve said in the main notes and everyone’s going to pathologise it.’ (PAR3SM01)
Discussion Our comparative case analysis suggests that many of the structural issues around introducing peer worker roles indicated as important in the international evidence base— around recruitment procedures, role-specific training and strategic support—are also evident in mental health services in England, across organisational contexts. In addition, we found that some of the issues that were rated as highly important across organisational contexts were, when we examined our in-depth data, understood differently in different organisational contexts. For example, while it was widely seen as important that peer workers worked to high professional standard, there was some antipathy, in statutory as well as voluntary and partnership cases, to ‘overprofessionalisation’ as somehow undermining core, peerqualities of the role. This was in marked contrast to a view, reported by other voices in statutory sector cases, that the peer worker role should conform to a professionalism that was largely defined as maintenance of professional boundaries. Notably boundaries, while also considered important in voluntary sector and partnership cases, were here understood as personally-determined, rather than professionally-defined, enabling peer workers to take control over exploring their shared lived experiences with the people they were supporting. Perhaps unsurprisingly we observed different expectations of the peer worker role emerging in different organisational contexts as a result. In the statutory sector there were expectations among management and peer workers’ professional colleagues that the peer worker role would be similar to existing health care roles in function—peer worker roles were often deliberately designed to be functionally similar–but that the peer worker would bring an additional dimension to the role through the guided telling of their personal stories in their work. However that sharing of lived experience could be undermined by both a requirement to maintain clinical-like boundaries in sharing personal experience, and a defaulting to generic task where
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expectations were placed on the peer worker to do so. As such the distinctiveness of the peer worker role in statutory sector cases could be diluted by the constraining expectations of the role. As noted earlier, lack of distinctiveness of a new role in comparison to existing roles in the team has been shown to mitigate successful role adoption (Dierdorff and Morgeson 2007). Further, this wider literature also suggests that when a new role is perceived to infringe the jurisdiction of an existing professional group then resistance to the new role can be encountered (Currie et al. 2009). Our data suggest that such resistance might be largely symptomatic of early implementation and a lack of awareness among the existing workforce of the new role, rather than an explicit mistrust or stigmatisation of peer workers by other members of the team. Indeed, as we report elsewhere (Gillard et al. 2014), peer workers could be powerful agents for building trust and challenging stigmatising attitudes within teams. Nonetheless the fact that, in the statutory sector, peer worker roles seem to have been designed as functionally similar to other (non-peer) roles in the same teams potentially constrains successful introduction of the role. The ability of the incumbent to bring power to a new role (Turner 1990)—their own distinctive way of working—especially when they do not bring the ‘community of practice’ of a established professional discipline (Currie et al. 2009) has also been shown to be a crucial facilitator of role adoption. In our voluntary sector cases there was a strong sense of shared understanding of the role, underpinned by an ethos of peer support that ran through organisations. However we caution that the rationale behind peer support roles was not fully developed or shared in all our voluntary sector cases, and that there remained a sense that it is not enough just to employ people on the basis of their lived experience; that shared understandings of how and why peer identity brings about change needs to underpin the role in all organisations. The voluntary sector organisations in our cases also tended to be smaller, more flexibly structured organisations. Literature exploring organisational change in large, highly-structured statutory sector healthcare organisations is replete with examples of change being stymied at the level of middle management (Balogun 2003), of the vulnerabilities of change that requires continuity in a championing style of leadership (Addicott et al. 2007), and of the constraints that rigid pay and grading practices place on innovation (Truss 2003). We did observe good strategic support for peer worker roles in our statutory sector cases, and the role demonstrated good alignment with a range of strategic drivers for the organisation (Saunders et al. 2008; Nadler and Tushman 1980). At the time of this study peer workers in our statutory sector cases were being introduced as pockets of innovative practice, rather than integrated
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into mainstream, whole-system change. It has been noted that where innovation is project-based it benefits from some freedom from the constraints that characterise large organisation culture, but spread of innovation can be hard to sustain when attempts are made to mainstream new practice across the organisation (Nembhard et al. 2009). In our statutory sector cases the distinctiveness of the role was, in comparison to our voluntary sector cases, at times constrained by expectations within a rigidly structured and hierarchical NHS culture, and the potential for the new role to bring meaningfully different practice to the team could be inhibited. Again, as noted above, sometimes this was where the team, initially at least, were not expecting a peer worker, and the need to prepare teams to work alongside peer colleagues has been noted (Stewart et al. 2008). As such data in our statutory sector cases reflects a live debate; where peer workers are to be introduced as members of multi-disciplinary mental health teams arguments have been made in favour of standardising and regulating the role (Stewart et al. 2008). Others have suggested that formalisation will undermine the peer ‘essence’ of the role (Faulkner 2013), and that there is a risk of peer workers becoming ‘socialised’ into the working culture around them and of the distinctiveness of the role being lost (Schmidt et al. 2008). In our study, where peer workers were employed by voluntary sector organisations in partnership arrangements some of the apparent pressure to formalise the role seemed to be obviated. The peer worker role was here at its most distinct in comparison to the professional and support roles of the host statutory sector organisation as the voluntary sector employer imported its flexible, peer-led culture of practice into the statutory environment. It would seem that maintaining role distinctiveness might be easier to achieve where peer workers are introduced into roles that complement and function alongside the existing team, rather than taking on a ‘replacement’ role within the team. In these partnership arrangements a need, observed elsewhere, for peer workers to negotiate a complex identity that is neither staff nor service user (Gillard et al. 2013), and of feeling ‘othered’ by the professional team (Berry et al. 2011) and disempowered as a result, seemed to be largely circumvented. In the partnership context we saw evidence that peer workers, employed outside the host organisation, were able to bring power—in the form of a distinctive way of working—into the work environment. They used their lived experience to build relationships based on shared experience, to communicate openly with service users and to rolemodel change (Gillard et al. 2014). An industrial relations literature identifies influence as the defining characteristic of a new ‘actor’ in the work environment—workers with collective consciousness of belonging to a group and of having common interests—explaining that industrial actors
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demonstrate agency by their direct action, and impact on process by influencing the actions of others (Bellemare 2000). Host teams in our partnership cases, on the whole, valued rather than resisted the distinctive way in which peer workers worked as this ultimately enabled them too to work more closely with service users. Furthermore, successful new actors have been defined as taking on a leadership role, drawing on the support of a readily identifiable constituency (Dickinson 2006). Most of the voluntary sector organisations in our study, including those in our partnership cases, were peer-led and a strong sense of peer leadership – derived from shared lived experience rather than professional training – underpinned the development, function and practice of the peer worker role in these cases. Strengths and Limitations As a limitation of this study we did not include private sector (for-profit) organisations. In addition we lacked cases that included large, national, professionally-led voluntary sector mental health service providers. As such, our findings do not include the full range of organisational types that typically constitute a mixed provider economy. A strength of this study was the robust, mixed method approach we applied to the pattern matching approach to cross-case analysis (Yin 2004). Because of the structured nature of our data we were able to make direct comparisons between different organisational contexts. Apparent between-case similarities and differences in our structured data were systematically triangulated with in-depth data. We report comparisons in the structured data where there were multiple sources of triangulation in the in-depth data, typically from more than one case and more than one type of participant. The conclusions we draw are thus derived from a robust synthesis across datasets (Patton 1990). Implications for Policy and Practice First, this study has confirmed the importance, suggested in a range of literature, of shared expectations of the peer worker role; that where those shared expectations are not in place, within teams and across organisations, there is a risk that the essential peer qualities of the role become diluted, and its potential impact lessened. To minimise that risk, organisations planning to introduce peer worker roles for the first time would be advised to ensure that service delivery and managerial staff at all levels of the organisation are fully engaged in the role development process. Issues of professionalisation and the nature of practice boundaries were particular sites of tension. On a policy level it is possible—as has been demonstrated in various countries—to mandate skill sets, competencies and training that begin to define a body of peer practice. However our
study indicates the benefits of locally-developed role specifications and training programmes, again to ensure that peer workers and the teams they work alongside share understanding both of role function and of how lived experience is to be used within the role. Further, longitudinal research might usefully track the way in which organisations respond to these role implementation challenges over time. Other implementation issues that we observed as largely in place across cases—around recruitment, training and strategic support—should be seen as good practice to be adopted in all organisational contexts. Second, this paper raises important issues that impact on planning and commissioning decisions around the introduction of new peer worker roles. Decisions about who will employ peer workers will often depend on where organisational capacity exists locally, on whether well-established partnerships between statutory sector and peer-led providers are already in place, or whether there is predisposition within a statutory sector provider organisation or commissioning body to keep the role ‘in-house’ or to look to the voluntary sector to provide innovative approaches to service delivery. The analysis above is indicative of the particular challenges and opportunities implicit in different organisational approaches to employing peer workers. Our analysis also suggests that those decisions about organisational arrangements for employing peer workers can impact on the extent to which peer worker roles replicate existing mental health support roles in function, or offer a distinctive, peer-focused way of working that is different to clinically-boundaried norms. In short, sufficient evidence exists—in our study and in the wider literature—to enable informed decisions to be made about the nature of the role that is to be implemented. Third, this paper provides evidence of at least the potential for a distinctive body of peer worker practice in mental health services, in so doing revisiting the issue of guidance in the development of the peer worker role raised in the introduction. Is the peer worker role best sustained by establishing a quasi-professional body of practice that has some authority at a national system-level—as in the US—or by a looser, values-based approach that is predicated on ensuring that essential qualities of peer support underpins the role? Further research is necessary to determine if and how both formal practice guidance and standards statements impact on both the practice of peer work and subsequent outcomes for peer workers and the people they support.
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