Integrating mental health peer support in clinical settings: Lessons from Canada and Norway

Abstract

Mental health peer support is an evidence-based approach called for by Canada’s mental health strategy that presents health leaders with an opportunity to transform mental health service experiences, improve health outcomes, and lower overall system costs. Originally offered in community settings, peer support has been expanding to clinical settings, but challenges to integration exist. This qualitative case study of peer support in clinical settings in Canada and Norway examines the perceived value of peer support and change management strategies that health leaders, managers, staff, and peer support providers can use to support integration of peer support in existing healthcare teams in clinical settings. Recommended strategies for health leaders include adopting a gradual approach to integration, building champions, demonstrating value, focusing on resistant groups, adopting a continuous improvement approach, setting peer support as an organizational priority, and linking peer support to patient-centred care.

Introduction

Mental health peer support is an evidence-based approach that can improve quality of life, alleviate symptom distress, provide social support, and reduce the need for hospitalization for people with mental illness.^1,2 It presents health leaders with an opportunity to transform mental health experiences, improve health outcomes, and lower costs,^3,4 consistent with the Triple Aim.⁵ Canada’s Mental Health Strategy calls for the expansion of peer support as an essential component of mental health services.⁶ Since the strategy’s release, national peer support guidelines have been created.⁷ Despite growing support, little is known about how to integrate peer support into existing healthcare teams in clinical settings.

Peer support is “a system of giving and receiving help, founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful.”⁸ Informal and formal peer support dates back to the 18^th century in Europe, but during the 1970s and 1980s took root more formally in communities in North America as people came together because of common experiences of stigma, discrimination, and trauma—often associated with the experiences of institutionalization and poorly supported deinstitutionalization.⁹ Rather than being based on traditional psychiatric models of care, peer support offers empathic understanding of another’s situation based on shared experiences of emotional and psychological pain.^2,10 Peer support values include: hope and recovery, self-determination, empathetic and equal relationships, dignity, respect and social inclusion, integrity, authenticity and trust, health and wellness, lifelong learning, and personal growth.⁷ Peer support can serve as a bridge to more formalized support, complement treatment, and support community involvement.^2,10 It is an important measure in the development of more recovery-oriented services.^9,11

A Peer Support Provider (PSP) is a person with lived experience of mental illness and/or addiction who is trained to provide emotional and social support to others with mental illness/addiction.⁷ Peer support providers carefully leverage their own lived experience to connect, support, and inspire hope in others.^7,12,13 Family PSPs are family or friends (caregivers) of people with mental illness who offer peer support to other caregivers.¹⁴ The role of a PSP is to provide intentional support through groups or one-to-one services that assist the person receiving support (the peer) with their recovery goals, mental health and addiction systems navigation, and systemic/individual advocacy.⁷

A review of peer support suggests considerable variation in the spread and range of program offerings in Canada.² Over time, formalized peer support programs have evolved from being offered in grass roots, consumer/psychiatric survivor organizations to also being offered in hospital (inpatient and outpatient) and community-based clinical settings. Peer support delivery and supervision and the degree to which PSPs are integrated into healthcare teams vary in these settings. In this article, we focus on the perceived value of peer support and the strategies used to support PSP integration in clinical settings based on a case study of mental health peer support programs in Ontario and Norway.

Methods

This exploratory case study¹⁵ is guided by a conceptual framework (see Figure 1) that describes factors influencing collaboration in interprofessional care teams.¹⁶ We sampled peer support in diverse clinical settings where the PSPs were employed: (1) in hospital and managed by individuals with lived experience, (2) in Assertive Community Treatment Teams and Early Intervention Programs and managed by individuals who did not have lived experience, or (3) in a consumer-survivor initiative with placements in local hospital mental health inpatient units. We interviewed 68 participants (9 peers, 33 PSPs, 20 managers/health team members, and 6 policy/decision-makers) through focus groups (PSPs) and individual interviews (other participants). Interviews were recorded and professionally transcribed. Data were managed using NVivo12 qualitative software. Three study team members coded a sample of interviews based on the conceptual framework and met to refine the codebook to capture emerging themes. Interpretive description was used in our qualitative analysis.^17,18 Data were triangulated across sites and with the perspectives of Steering Committee members (government officials, regional health system and local organization managers, peer support advocates, and PSPs). The Hamilton Integrated Research Ethics Board approved the study #2943. Participant codes refer to participant type (peer, PSP, manager/staff—MS, policy/decision-maker—P) and number, setting of employment (hospital—H; community—C), and country (Canada—1, Norway—2).

Figure 1.

Framework of factors influencing interprofessional collaboration.

Findings

Value of peer support

Table 1 summarizes key themes that arose pertaining to participants’ perceived benefits of peer support. Most participants perceived that peer support contributed to improved health, quality, team functioning, and cost-effectiveness. Peer support providers were described as role models for their peers when it came to problem-solving and decision-making. They broke down isolation by offering “another relationship outside the clinical team…because a lot…don’t have family, they don’t have friends” [MS2-H1]. Peer support providers could more easily establish rapport with hard-to-reach peers through relaxed relationships that opened connections with the broader care team. Peer support providers were also described as living examples of the hope of recovery. They fostered greater patient-centredness in teams by advocating for individual peers and by leading incident debriefings that “everybody’s responsible to learn from…from the patients to the nurses.” [PSP2-H1]. Several managers perceived their work could be cost-effective in reducing hospitalizations and in supporting transfers from hospital to community programs.

Table 1.

Participants’ perceived value of peer support on outcomes.

Health	Quality	Team functioning	Cost-effectiveness
Perceived positive impact on peers across all settings PSPs can link peers to broader community supports and programs PSPs may be influential in creating a circle of support around peer PSPs can assist with problem-solving overwhelming day-to-day challenges PSPs work to foster peer independence in decision-making Some PSPs find their work beneficial to their own recovery and personal growth	PSPs can reach out to hard-to-reach peers and link them with the rest of the team PSPs help create a relaxed relationship that can encourage less inhibited discussion PSPs provide a living example of recovery and hope PSPs may assist by conducting debriefings from all perspectives PSPs help to fosters peer-centredness in the team	Contributes a unique understanding and perspective that may enhance team discussions May help team members understand perspectives of those with lived experience May help balance clinical and peer perspectives PSPs can advocate for peer within the team	Perception that peer support reduces hospitalization PSPs may support transition to community services

Abbreviation: PSP, peer support provider.

Although acceptance is growing, some team members remain skeptical about the value of peer support.

But when I started, nobody knew what [a PSP] was…Also, there was a lot of skepticism…what are you going to do and what can we use you for? [PSP4-H2]

One manager said, “I don’t have the heart to say, ‘Yeah, you know what? Half my nursing staff, they think the role is bullshit.’” [MS5-H1] One peer was concerned that “[PSPs] may not fully understand the problems that I’m going through …” [Peer2-H1]. Other staff valued lived experience but were concerned “… when it takes over the whole process, then that becomes an issue.” [MS4-H1].

Change management strategies

Participants discussed strategies for organizational leaders, managers at the practice level, individual PSPs, and at the system level to facilitate the integration of PSPs into clinical teams, which are summarized in Table 2. An overarching theme was that this process “won’t happen overnight” [MS10-H1].

I’ve been here for seven years and I’ve noticed, as our team grew and they [PSPs] were more visible, that has increased staff’s willingness to see the value of peer support. [PSP3-H1]

Table 2.

Change management strategies: Canada and Norway.

Organizational level: Leadership strategies	Practice level: Managerial strategies for all staff^a	Individual level: PSP strategies	System level: System strategies
Recognize culture change is slow	Advance communication about upcoming changes	Get to know the rest of the team and the challenges they face	Train all staff
Integrate gradually	Educate management and staff about roles, rules, and regulations	Be a consistent presence	Offer PSP certification
Build champions	Offer lunch and learns by PSP staff	Have a solid understanding of the hospital environment	Increase funding for PSPs
Evaluate to demonstrate value	Offer joint training sessions	Have or gain a background in psychosocial rehabilitation	Support evaluation
Identify and focus on resistant groups	Recognize possible discomfort among staff who are lower in clinical hierarchy	Have an understanding of mental illness and its treatment	Facilitate knowledge exchange
Adopt a continuous improvement approach	Address and resolve problems as they arise	Receive individual guidance and support from leaders who understand PSP role
Promote as an organizational priority	Orient all staff to the PSP role during recruitmlnt	Obtain support from a community of practice outside the workplace
Link to the vision of person-centred care	Involve PSPs in non-traditional activities within the team

Abbreviation: PSP, peer support provider.

^a Includes physicians.

Leadership strategies

Leaders need to make peer support an organizational priority and link it to a broader vision that promotes patient-centred care. By adopting an incremental approach, peer support can be added and benefit demonstrated on one unit at a time. This can build a momentum for change and create champions who can share their experiences with other units.

I think it worked a bit better with the [hospital] doing step-by-step…by the time our staff went into the ER, the inpatient team were like, “Oh my God. You guys need these guys so bad.” The whole team was their cheerleaders. [MS1-C1]

Another strategy was to identify and focus on resistant groups, who may worry that PSPs may interfere with their work.

…[they] felt like this was being imposed upon them. So it took a lot more, “Hey, why don’t we come in and meet up and chat about this?”…And so, the convincing had to start. [MS1-C1]

Adopting a continuous improvement approach was useful in helping to build support over time. One manager found that “…with each transition of peer support workers…it’s been a shorter time…for the staff to warm up…” [MS2-C1]. Building initial and ongoing evaluation into implementation helps in demonstrating value.

Management strategies

Early communication by managers can be critical in preparing team members. More education about the role of peer support and its benefits, regulatory concerns, and stigma is recommended.

The whole team at the hospital [needs education] about the role of peer support and exactly how it benefits the patient, [and] how it can benefit our team [in terms] of helping the patient recover. [MS6-H1]

Managers also need a solid understanding of the PSP role. Activities that promote contact between staff and PSPs, such as joint training sessions about issues of common interest, were recommended. “Lunch and learns” in the hospitals gave team members a chance to spend time getting to know PSPs and asking questions.

Managers need to recognize that other team members may feel threatened by a perceived loss of professional turf and challenges to traditional hierarchy.

…my understanding of peer support is that, “Hey, you know, nothing for us without us. We have a place at the table. We have a right to be a part of these decisions.” [MS10-H1]

It is also important to demonstrate the value of peer support to staff such as nurse managers, who may initially resist change, but ultimately become protective allies of PSPs.

“You touch that peer-support worker, your ass is mine.”…and it goes from being you’re the person on the outside, coming into the thing that they value, to you’re then on the inside of the thing that they value…And they will fight for you like you are their baby cub…[MS1-C1]

Peer support provider strategies

At the individual level, PSPs do eventually build relationships with the rest of the team. This requires taking time to appreciate the challenges other team members face, having a consistent presence on each unit, and being sensitive, adaptive, and creative.

So I asked, “Well, what about a little information session? And we’ll just bring coffee, and people can come and go?” And so we called it a drop-in, instead of a group. They were fine with that. Now…if they miss their Wednesday morning coffee drop-in, it would be devastating to staff and peers…But they still don’t want anything called a group. [PSP2-C1]

While a centralized PSP team offers mutual support, it can be harder for PSPs to fully integrate with teams across multiple hospital units when they are not there every day.

They have to build relationships with people, because they’re not on the unit all the time every day. So they’re not part of one unit culture. They have their own team culture. [MS8-H1]

It also helps PSPs when they are offered individual feedback separately from the rest of the team, when leaders have a good understanding of the PSP role, and when they have support from a community of practice outside the workplace.

Systems strategies

At the system level, there was general consensus that more training should be offered to health professionals about the role of peer support in psychosocial rehabilitation and recovery. Certification was seen to be important for consistency and continuity of care when PSP turnover is high, and so that “…other clinicians…would feel more of a buy-in.” [PSP4-H1]

More funding is needed to meet the demand and to offer PSPs more stable full-time positions. Many PSPs who discussed working part-time did not have extended health benefits to support their own mental health. Additional funding can also support evaluation and knowledge exchange.

Unfortunately, there isn’t enough peer support workers to go around, and that’s the problem we run into most often.…And I think that’s vital. [MS2-H1]

Conclusions

This article contributes to the field of leadership by offering strategies that health leaders at all levels can adopt in championing peer support as a transformative, evidence-based innovation that can complement existing services while advancing the commitment to patient-centred care. The findings suggest strategies that can be used to advance the integration of mental health peer support into clinical settings in Canada and Norway. While most participants valued peer support’s impact on health, quality of services, team functioning, and cost, some did not, and not all PSPs felt supported in their roles. For transformation efforts to be effective, leaders must prioritize peer support and back this up with action. Leaders must actively inspire a vision for the integration of peer support workers as part of the person-centred care team, while recognizing that adoption of peer support requires a culture change that takes time. Our findings suggest that adopting an incremental approach, fostering champions, and evaluating to support continuous improvement can help turn resisters into supporters. Managers must offer timely education and opportunities for staff and PSPs to get to know each other personally. This could be through planning exercises, building peer support education into clinical staff orientation, and anticipating concerns about professional turf. Peer support providers need to take time to get to know the rest of the team, understand their environment, and be creative in building confidence and trust. Policy leaders can offer training and support certification, fund more PSP positions, and support program evaluation and knowledge exchange. With time and due attention to these considerations, integration of peer support in clinical settings can achieve transformative change resulting in improved health outcomes, care experiences, and lower costs.

Footnotes

Authors’ note

We would like to express our sincere thanks and acknowledge the contributions of study participants. Sincere thanks go to Lee Purins for her able research assistance in this project.

Funding

This research was funded by a seed grant provided by the Michael G. DeGroote Health Leadership Academy.

ORCID iD

Gillian Mulvale https://orcid.org/0000-0003-0546-6910

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