Abstract
Background:
Being aware of the challenges that may occur during the implementation of peer support work in psychiatry is important to facilitate the integration of peer support workers (PSWs) into multidisciplinary mental health-care teams.
Aim:
The purpose of this study is to explore the challenges faced by PSWs during their integration into hospital-based mental health-care teams.
Methods:
Qualitative content analysis of nine open-ended, semi-structured interviews with PSWs is undertaken in five adult psychiatric hospitals in North Rhine-Westphalia, Germany.
Results:
The analysis of the data revealed three themes: (1) ‘Pioneers and the pressure to succeed’; (2) ‘a colleague, a rival or yet another patient?’ and (3) ‘sharing of information, boundaries and professionalism’. All three themes relate to several concrete challenges on different systemic levels and have the potential to impede the PSWs’ integration process.
Conclusion:
Specific implementation strategies which address potential barriers on the different systemic levels should be developed and applied prior to the start of the integration of PSWs into multidisciplinary mental health-care teams.
Introduction
Trained peer support workers (PSWs) use their experiential knowledge and specific skills to support the recovery of individuals who seek help within and outside mental health-care facilities (Mahlke et al., 2014; Repper & Carter, 2011; Slade et al., 2014; Stratford et al., 2019). Over the last few decades, peer support has been increasingly implemented in various countries and mental health-care settings (Davidson et al., 2012; Farkas & Boevink, 2018; Mahlke et al., 2014). A recent position paper regarded the use of peer expertise as a key element of high-quality community mental health care (Keet et al., 2019).
With its increasing implementation, peer support has become a subject of intensive research and has been investigated both with quantitative- and qualitative-empirical methods. Randomized controlled trials, meta-analyses and systematic reviews of quantitative-empirical studies focus mainly on the outcomes of peer support (Bellamy et al., 2017; Chinman et al., 2014; Fuhr et al., 2014; King & Simmons, 2018; Lloyd-Evans et al., 2014; Mahlke et al., 2017; Pitt et al., 2013). Qualitative-empirical studies primarily investigate the personal experiences and attitudes of the various stakeholders, including their views on facilitating and impeding factors for the integration of PSWs into multidisciplinary mental health-care teams (Ibrahim et al., 2019; Vandewalle et al., 2016; Walker & Bryant, 2013). Furthermore, benefits of peer support work and challenges occurring during its implementation have been investigated in surveys (Burr et al., 2019; Salzer et al., 2013).
Regarding the challenges which occur, the existing literature refers to multifaceted problems, such as dual relationships and role conflicts (Carlson et al., 2001), poorly described job structures (Gates & Akabas, 2007; Moran et al., 2013), low payments (Doughty & Tse, 2011), negative effects on the PSWs’ own well-being (Asad & Chreim, 2016; Holley et al., 2015; Hurley et al., 2018; Mowbray et al., 1998) or a lack of appropriate supervision and support (Dixon et al., 1994; Kemp & Henderson, 2012). Most of these studies were conducted in Anglo-Saxon countries, where PSWs often work in community mental health-care settings rather than in inpatient settings (Cronise et al., 2016; Stratford et al., 2019). Therefore, it is mostly unknown whether these challenges also occur in more hospital-based mental health-care settings outside the Anglo-Saxon sphere and how potential challenges can be best addressed in these settings.
In our qualitative-empirical study, we aimed at evaluating the integration of PSWs into multidisciplinary mental health-care teams in adult psychiatric hospitals in Germany. As we have already published and discussed the reported positive experiences and beneficial effects of peer support work elsewhere (Otte et al., 2019), we focus on the challenges faced by the PSWs during their integration process in this article.
Methods
Following approval from the Research Ethics Committee of the Medical Faculty of the Ruhr University Bochum (Reg. No. 15-5387), Germany, we conducted open-ended, semi-structured interviews with eight PSWs in five adult psychiatric hospitals. The interviews were part of a larger project (Gather et al., 2019) and were complemented by non-participant observations and focus groups. There was a meeting of the PSWs and the directors of nursing prior to the qualitative-empirical research to exchange ideas about potential tasks and mutual expectations. In addition, there was a 1-hour meeting of our research team, the PSWs and the non-peer mental health professionals (MHPs) at each site in which we informed the participants about the research planned. Furthermore, we provided background information on the idea of experienced involvement and the content of the 1-year training programme all PSWs had completed prior to their employment. All hospitals participating belonged to the ‘Psychiatry Network’ of the Regional Association of Westphalia-Lippe (LWL), located in the German federal state of North Rhine-Westphalia. During the study period, the PSWs worked mainly on open wards in general psychiatry and offered one-on-one conversations and various groups for patients. Further details of the overall methodological approach and the project background are described elsewhere (Gather et al., 2019; Otte et al., 2019).
The interview guide was, in a first step, based on the preliminary results of the previous observation study for which we observed 25 multiprofessional team meetings and 5 transregional PSW meetings over a period of 6 months. At the latter, all eight PSWs came together and discussed their experiences acquired at their workplace. The results of the observation study are intended to be published elsewhere. In a second step, we further enriched the interview guide with information and questions extracted from a literature review. We used relevant databases (e.g. PubMed, Google Scholar) and search terms (e.g. peer support, experienced involvement) for the literature search. Furthermore, we reviewed the references quoted in the studies extracted to further strengthen the corpus of the relevant literature which was then used as a foundation for our interview questions.
The interview sample consisted of all eight PSWs (six females, two males) hired in the participating hospitals at the time of our study. We interviewed one PSW twice as he changed the psychiatric unit during the study period and was, therefore, a member of two different mental health-care teams. Thus, we conducted nine interviews in total. The shortest interview lasted for 47 minutes and the longest for 85 minutes. All PSWs were hired at approximately the same time by the hospitals, and they were usually the first employed and paid PSWs in the respective unit. The interviews usually took place 7 to 12 months after the initial hiring. Only one PSW had already been working in his job for 24 months. All PSWs participating gave their written consent. No interviewee chose to discontinue the interview and no interview had to be repeated. A member-check of the interviews was not requested by any of the participants. However, all findings were discussed with the participants during focus groups at a later point in time.
All nine interviews were audiotaped and transcribed verbatim, and the protocols were thoroughly anonymized during the transcription process. Four members of our research team, each with different disciplinary backgrounds (sociology, psychiatry, medical ethics/philosophy and peer support work), analysed and discussed the transcripts. The coders followed the principles of qualitative content analysis. The data were repeatedly coded according to Mayring (2014), moving from concrete passages to a more abstract level of coding, deriving themes from the data and searching for repeating concepts. All findings were tested critically and discussed within our research team. We resolved any disagreements by discussion.
Results
Upon the start of their new employment, PSWs reported feeling under pressure to succeed, as they were usually the first PSWs who were hired and integrated into these teams. They also stated, however, that this pressure was mainly self-made and not placed on them by the non-peer MHPs: PSW 1: I am the first here, I am a pioneer if you want to put it that way, and, of course, I feel a bit under pressure, because if I mess this up, I mess it up for everyone who might come after me.
The PSWs further described that they were hesitant to call in sick, because they feared that colleagues would label any absence as a symptom of mental instability: PSW 6: I talk less about myself and the difficulties that I have. For example, colleagues often discuss their difficulties sleeping at night, etc., and I am too scared to admit these kinds of things. I only talk about it when it is clear that it is something solely physical, because I am always afraid that they think I am too fragile to work here.
They also had the feeling that the non-peer MHPs regarded and treated them as a patient rather than as a colleague: PSW 2: I feel like they observe me like a patient. They ask me numerous times ‘Is everything okay? Are you okay?’ They don’t do this with the other team members.
The PSWs further reported that they felt rejection from non-peer MHPs because of their history of mental illness or because non-peer MHPs were afraid that PSWs would take away their jobs or replace them: PSW 7: There is this one physician I work with who blatantly says: ‘Ex-patients do not belong on the side of mental health professionals. They should not work in psychiatry.’ PSW 9: There was this huge prejudice that I would replace them, especially nurses felt that way, like ‘What is their task here? What do they want?’ A huge insecurity that was felt by many coworkers was that I am here to steal their jobs.
Such negative attitudes made it more difficult for the PSWs to grow into their new roles. Since the PSWs in the study were usually the first to take on this new task, the exact scope of their duties was unclear, especially at the beginning. PSWs described this feeling as insecurity about whether they were useful or only an ‘unnecessary extra’: PSW 6: Sometimes, I still feel this way. It is like a little identity crisis. I ask myself ‘Am I useful? Is a peer support worker really necessary?’ But then I get feedback from patients that I helped them with their recovery and I feel ‘Yes, I am in the right place!’
Due to the undefined and unclear scope of duties, PSWs also experienced conflicts with other team members, for example, when patients trusted the PSWs with information which would have been better addressed to their therapist: PSW 5: Yesterday they’ve told me that some things should be better discussed with the therapists than with me. That I am part of the nursing staff, that I am not a therapist. That’s what they’ve said. But to me, my work is already very different from the work of the therapists; unlike the therapists, I never schedule my conversations with patients; they come to me spontaneously, and when a patient opens up to me instead of their therapist . . . what can I do . . . it is not my fault.
Another difficulty was described by the PSWs as a ‘choice of sides’. The PSWs felt that it was their job to be on the side of the patient, which would not work if they spent too much time with the non-peer MHPs in their office: PSW 7: I just want to be on the side of the patients, because they are my team. They are the people I care for and they are the people that I want to support, and I feel that this is only possible when the patients know that I am not with the usual mental health team or in their office all the time . . . that I am with them!
The PSWs admitted that it was difficult for them when they worked with patients who had a different mental illness than they themselves, because their knowledge is often limited to their own crisis experiences: PSW 6: What I struggle with is the lack of knowledge when it comes to other illnesses. When someone suffers from something similar to what I have experienced, then it is easy for me to empathize . . . but in cases where I do not know the symptoms, I have to fill the gap with books.
While PSWs made use of their own crisis experiences in order to help patients, they also faced the challenge of situations which can potentially trigger them: PSW 4: It is hard to keep my balance. For that, I have to keep a certain level of distance, but, at the same time, I have to stay in this close contact with the patient . . . where my experience allows me to connect with them, to better understand them. When I shut down this part of me, my experience, then I am also losing this special bond. The big challenge is to protect myself so I don’t get triggered or too involved.
Discussion
Our qualitative findings highlight several challenges that can arise during the integration of PSWs into hospital-based multidisciplinary mental health-care teams. These challenges can be categorized into three main themes.
Pioneers and the pressure to succeed
In our interviews, the PSWs spoke about their fear of failure and illustrated how this feeling made it difficult for them to integrate into the multidisciplinary teams. They regarded themselves as pioneers, burdened with an immense pressure to succeed with no room for failure – otherwise they feared there would be no opportunity for other PSWs to be hired in the future. Although the PSWs stated that neither the managers in the hospitals participating nor the representatives involved from the superordinate mental health-care institution had ever articulated such high expectations explicitly, it became obvious that the PSWs were burdened and hampered by this worry.
Two strategies to deal with this challenge might be the employment of more than one PSW per hospital and the establishment of regular inter- and supervision for the PSWs. Findings from other studies indicate that hiring more than one PSW in one institution can facilitate integration and reduce the individual pressure perceived (Aretz & Jungbauer, 2019; Burr et al., 2019; Chinman et al., 2008). Furthermore, a higher number of PSWs hired in a hospital or at least in facilities of the same mental health-care provider fosters the establishment of regular fora for their mutual exchange. In our project, the PSWs met regularly at transregional PSW meetings for intervision and to get support from an external supervisor (Gather et al., 2019). Results from other studies also refer to inter- and supervision as a helpful strategy to deal with challenges occurring in daily routine, to clarify mutual expectations and different opinions within multidisciplinary teams and to support PSWs in their personal and professional development (Aretz & Jungbauer, 2019; Chinman et al., 2008; Kemp & Henderson, 2012). In line with this, the literature review by Vandewalle et al. (2016) points out that supervisions which, on the contrary, neglect emotional and personal concerns are perceived as inadequate and a barrier to a successful integration of PSWs.
A colleague, a rival or yet another patient?
A common challenge concerning the implementation of peer support work in mental health care is a lack of acceptance of PSWs as new and valuable team members (Rebeiro Gruhl et al., 2016). In our interviews, the PSWs reported that they often had the impression that the non-peer MHPs regarded them as ‘a patient’ or a person who is fragile and, therefore, needs special attention. In practice, this can lead to the problematic circumstance that PSWs do not dare to call in sick since they are afraid that non-peer MHPs interpret this as a sign of instability or weakness. This experience of being referred to as a patient suffering from a mental illness rather than as a colleague and professional on an equal level is also known from other studies (Asad & Chreim, 2016; Burr et al., 2019; Walker & Bryant, 2013). To address this challenge, it is often recommended to educate and prepare non-peer MHPs prior to the employment of PSWs (Chinman et al., 2008). One aim of an adequate preparation should be the promotion of a general openness towards peer support and respectful relationships between PSWs and non-peer MHPs, which are both regarded as helpful for integration by PSWs (Burr et al., 2019). In addition to such educative strategies, time aspects also seem to be relevant to foster mutual respect and to demonstrate that PSWs are not only well qualified but have also recovered enough to perform their new job as a member of a multidisciplinary team (Asad & Chreim, 2016; Chinman et al., 2008; Moll et al., 2009; Moran et al., 2013). As Asad and Chreim (2016) pointed out in their study, an ‘evolution of acceptance’ by ongoing interactions between PSWs and non-peer MHPs leads to a better understanding of each other’s roles and capacities and the value of each other’s work. Regarding the implementation strategy evaluated in our study, it can be stated that the periods of staff training conducted prior to the empirical research were apparently insufficient to fully prevent mutual distrust between PSWs and non-peer MHPs. Therefore, a more promising strategy for staff education could comprise repetitive and joint meetings of PSWs and non-peer MHPs, especially in the initial phase of employment.
Another challenge described by the PSWs was that non-peer MHPs often did not know what to expect from their new colleague, sometimes even indicating that they were worried that the PSWs could replace them and ‘steal’ their jobs. From our point of view, the fear of replacement can be reinforced by heterogeneous and low pay scale classifications for PSWs and scarce financial resources. The wages for most PSWs in the adult psychiatric hospitals evaluated in this study were lower than for non-peer MHPs (Gather et al., 2019). This can lead non-peer MHPs to the assumption that they might be replaced by the ‘cheaper’ PSWs in the future. In addition, low payments can cause discontent among PSWs themselves and hamper a successful integration into mental health-care teams (Aretz & Jungbauer, 2019; Doughty & Tse, 2011; Ibrahim et al., 2019; Moran et al., 2013). Therefore, a transparent and well-justified pay scale classification for trained PSWs should be developed and established in the context of existing tariff systems.
A further challenge regarding the integration of PSWs is the fact that they are often unclear about their specific role within multidisciplinary teams in which most of the non-peer MHPs have well-defined and established roles and tasks (Cabral et al., 2014; Chinman et al., 2008; Hurley et al., 2018; Ibrahim et al., 2019; Vandewalle et al., 2016). This challenge became apparent in our study when PSWs reported feeling like an ‘unnecessary extra’. An unclear allocation of tasks can lead to further trouble in the relationship and cooperation between PSWs and non-peer MHPs. Against this background, a clearer job description with tasks for PSWs which complement rather than compete with those of the non-peer MHPs could be a strategy to eliminate such uncertainties within multidisciplinary mental health-care teams (Cabral et al., 2014; Gillard et al., 2013; Hurley et al., 2018; Moll et al., 2009; Otte et al., 2019).
Sharing of information, boundaries and professionalism
A further source of conflict between PSWs and non-peer MHPs which we identified in our study is the sharing of information which a patient has confided to the PSW. This problem is also described in other studies (Carlson et al., 2001). Gates and Akabas (2007) reported that PSWs, in some cases, hesitate to share confidential information with non-peer MHPs because they do not want to breach the trust of the patient. There is quite a large body of literature referring to this problem as ‘friend vs. client’ dilemma which can cause insecurity about what information to pass on to non-peer MHPs and how to handle information which has been given within a friendship relationship (Asad & Chreim, 2016; Carlson et al., 2001; Dixon et al., 1994; Gates & Akabas, 2007; Moll et al., 2009; Mowbray et al., 1998; Otte et al., 2019; Repper & Carter, 2011). The PSWs in our interviews described situations in which they felt as if they had to pick a side, and that they usually tended to pick the side of the patients, because they ‘are the people we care for’ (PSW 7). The apparent existence of ‘sides’ can make it difficult for PSWs to bond with the non-peer MHPs and, therefore, integrate themselves into the team successfully. Furthermore, as one PSW in our interviews put it, it can be difficult for PSWs to define the adequate distance in their relationships with patients, since their connection is based on shared experience and empathy. It can be complicated to stay professional while still being able to share this ‘special bond’ (PSW 4). It is suggested in the literature that PSWs reflect on their professional identity (Hurley et al., 2018; Moll et al., 2009; Otte et al., 2019; Vandewalle et al., 2016) and receive training on policies related to confidentiality, the sharing of information within the mental health-care team and strategies how to inform patients about the policies arranged (Gates & Akabas, 2007).
Another challenge which became apparent in our results was the PSWs’ feeling of not being competent enough to support patients with mental illnesses the PSWs themselves had no own experience with. This seems to be a special aspect of the known general problem that some PSWs do not feel trained and prepared enough to succeed in daily work (Burr et al., 2019; Ibrahim et al., 2019). Therefore, we would recommend not only to address this issue during the PSW training programme but also to discuss preferred work areas with PSWs individually before employment. While some PSWs might choose to work with patients with whom they share similar crisis experiences, others might prefer the opposite in order to protect themselves from being triggered and burdened. The risk of being burdened or even re-traumatized during daily work was not only mentioned by the PSWs interviewed in our study but is known in the literature as a common challenge (Asad & Chreim, 2016; Holley et al., 2015; Hurley et al., 2018; Moran et al., 2013; Mowbray et al., 1998; Vandewalle et al., 2016).
Limitations
A major limitation of this article is the fact that it only reports the content of the interviews with PSWs and no results from other subprojects in which non-peer MHPs were involved. Thus, our findings are limited to the PSWs’ perspective. In addition, qualitative data can usually not be utilized for generalization, especially when it is based on small sample sizes. However, our results reinforce various findings of other studies and, thus, seem transferable to other settings in different countries and suitable to enrich the current scientific discourse on peer support work in psychiatry.
Conclusions and directions for further research
Our qualitative interview study with PSWs in Germany indicates that they face many challenges during the integration into mental health-care teams in adult psychiatric hospitals. The analysis of our data revealed the three themes: ‘Pioneers and the pressure to succeed’; ‘a colleague, a rival or yet another patient?’ and ‘sharing of information, boundaries and professionalism’. All themes relate to several concrete challenges on different systemic levels which should be targeted specifically: (1) Challenges on an institutional level, such as the question of an appropriate pay scale classification for PSWs or the number of PSWs being hired in one hospital, should be clarified on a superordinate level of a hospital’s or mental health-care provider’s management. (2) Preparatory training as well as ongoing team training should be offered for mental health-care teams, including the PSWs, to meet the challenges regarding relationships within the multidisciplinary team, such as the initial scepticism of non-peer MHPs towards PSWs. (3) Challenges which relate to the PSWs’ own professionalism, such as the question of how to locate oneself between the non-peer MHPs and the patients, should be reflected in the PSW training programmes and during ongoing super- and intervision.
Many of the challenges discovered in our study have already been reported in other studies from different countries and more community-based mental health-care settings. It seems as if the challenges faced by PSWs were relatively independent of the sociocultural context and appeared regardless of the concrete psychiatric setting in which peer support is being implemented. Whether and how it is possible to newly integrate PSWs into mental health-care teams without being hampered by the multiple challenges described in our study and known from the scientific literature should be investigated in further studies. We recommend developing specific implementation strategies which involve all relevant stakeholders and address potential barriers on each of the three systemic levels described. The programme should be applied prior to the start of the PSWs’ integration process. We support the recommendation of other authors (Asad & Chreim, 2016; Vandewalle et al., 2016) to assess future implementations in longitudinal research designs and to evaluate their success at various points in time from the perspective of the different stakeholders involved.
Footnotes
Acknowledgements
We would like to thank the participating PSWs for their time and trust. We thank Marco Knoll and Anita von Lünen for their help in conducting our research. We thank the LWL and the LWL Hospital Department (Prof. Dr. Meinolf Noeker, Thomas Profazi) for their help in realizing this study. Finally, we thank all members of the LWL working group ‘Trialogue’ for their continuous support.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We thank the LWL and the LWL Hospital Department for funding this study.
