The author has disclosed no potential conflicts of interest, financial or otherwise.
When going through tough times, talking to someone considerate who knows from personal experience what you’re going through can prove invaluable. Therefore, few will be surprised by growing evidence that mental health service users who offer help to fellow service users show outcomes that are at least as effective as those achieved by professional care staff.
The evidence for peer support is persuasive. A new Cochrane Database systematic review looked at the results of 11 randomized controlled trials involving approximately 3,000 participants in which service users provided a range of interventions to other service users, including peer support, coaching, and advocacy (Pitt et al., 2013). In five trials, they found outcomes across a range of measures no different than when services had been provided by professionals. Another six studies compared mental health services with or without the addition of service user providers and found no significant differences between the two types of service on a range of outcomes for patients. In one study, the inclusion of peer workers reduced emergency service use.
But there is more. Researchers looked at the results of 14 randomized controlled trials of peer support for individuals with depression. This meta-analysis found that peer support interventions for depression were superior to usual care in reducing depressive symptoms and similar in effectiveness to group cognitive-behavioral therapy (Pfeiffer, Heisler, Piette, Rogers, & Valenstein, 2011).
Hence, outcomes for peer support workers are at least equivalent to those achieved by “professional” staff, and there is no evidence of harm associated with involving user-providers in mental health teams. Most trials took place in the United States and the quality of some studies was low, but this evidence of effectiveness and the results of smaller pilot studies and evaluations in the United Kingdom (Repper & Carter, 2011) are influencing policy documents and reports in that country. These call for the roll-out of peer support roles and recommend the use of peer workers to drive recovery-focused organizational change (Repper et al., 2013). Similar developments are taking place in Australia and New Zealand.
In the United States, Medicaid has defined peer support services as reimbursable and the peer workforce has continued to expand, such that 27 states have collaborated to create a scoping and guidance document for peer support. The 25 Pillars of Peer Support has been developed for use in state-funded and other services (Daniels et al., 2010; Daniels, Bergeson, Fricks, Ashenden, & Powell, 2012).
Should mental health nurses be worried? Although mental health nurses may welcome the concept of peer support in principle, the introduction of peer workers comes at a time when nursing in the United Kingdom is under threat as part of a response to the global economic crisis.
In “austerity Britain,” the taxpayer–funded National Health Service is grappling with the challenge to yield massive financial savings. Already, approximately 5,000 nursing posts have been cut and health care assistants are taking on more and more roles and responsibilities of the traditional nurse.
And it’s not just in the health service. Unqualified staff and soldiers are replacing teachers, whereas civilian staff and security firms are increasingly taking on policing roles. The political climate, which sees the skills mix across public services diluted to cut costs, gives good reason for some to view the growing presence of less expensive peer supporters as a potential threat. Already, some nursing posts are being replaced by peer workers as vacancies arise.
In the current climate, professional defensiveness is an understandable reflex, but not necessarily a helpful one. Instead, the focus has to be on providing a strong argument for mental health nursing, and it is in our interests and those of our service users and their families to do so in partnership with peer workers.
Studies evaluating the views of service users and carers show that mental health nursing has a lot to offer with skilled, knowledgeable, caring clinicians providing a range of therapeutic interventions and organizing and coordinating multi-disciplinary care (Bee et al., 2008). We also produce high quality research and education. Areas for improvement include enhancing physical health care, being more respectful in our interactions, and working more in collaboration with service users and families.
Professional confidence should allow us to recognize that our role can profit from collaborating with and listening to colleagues who have first-hand experience as service users. A willingness to learn can militate against professional complacency and improve recovery outcomes for service users.
We need to articulate and evidence our effectiveness and value as nurses, while embracing a more recovery-focused role and enhancing our compassionate core. Alongside peer workers we can discuss how we best work collaboratively with service users and carers to focus on recovery and strengths, not just symptoms, deficits, and illness. We can explore how we best negotiate the need for boundaries in relationships without becoming remote and uncaring. We can explore alternatives to physical restraint and seclusion and how we can work in ways that ensure the safety and well-being of service users, peers, staff, and public. We can collaborate in educating service users, peer workers, staff, and students, and conduct meaningful research together.
We have much to offer each other, but this necessarily needs to be a reciprocal, mutually respectful relationship in which we nurses show a willingness to listen and learn from our peer support and service user colleagues who have ideas and ways of working that we can benefit from.
When the mental health nursing profession is under threat, it can be very difficult to keep our minds open to the positive possibilities that these times may bring. Nurses and peer workers have many common interests, and we need to find ways to collaborate with those who are keen to advance, redesign, and improve the way we care for, sustain, and empower people in mental distress.
Far from being worried, nurses should embrace the presence of service users on the wards and in teams as colleagues. We are considerably stronger united than divided.
Alan Simpson, PhD, BA Hons, RMN
Professor of Collaborative Mental Health
School of Health Sciences
City University London
- Bee, P., Playle, J., Lovell, K., Barnes, P., Gray, R. & Keeley, P. (2008). Service user views and expectations of UK-registered mental health nurses: A systematic review of empirical research. International Journal of Nursing Studies, 45, 442–457. doi:10.1016/j.ijnurstu.2007.02.008 [CrossRef]
- Daniels, A., Bergeson, S., Fricks, L., Ashenden, P. & Powell, I. (2012). Pillars of peer support: Advancing the role of peer support specialists in promoting recovery. Journal of Mental Health Training, Education and Practice, 7, 60–69. doi:10.1108/17556221211236457 [CrossRef]
- Daniels, A., Grant, E., Filson, B., Powell, I., Fricks, L. & Goodale, L. (2010). Pillars of peer support: Transforming mental health systems of care through peer support services. Retrieved from http://www.parecovery.org/documents/Pillars_of_Peer_Support.pdf
- Pfeiffer, P.N., Heisler, M., Piette, J.D., Rogers, M.A. & Valenstein, M. (2011). Efficacy of peer support interventions for depression: A meta-analysis. General Hospital Psychiatry, 33, 29–36. doi:10.1016/j.genhosppsych.2010.10.002 [CrossRef]
- Pitt, V., Lowe, D., Hill, S., Prictor, M., Hetrick, S.E., Ryan, R. & Berends, L. (2013). Consumer-providers of care for adult clients of statutory mental health services (Article No. CD004807). Cochrane Database of Systematic Reviews, 3. doi:10.1002/14651858.CD004807.pub2 [CrossRef]
- Repper, J., Aldridge, B., Gilfoyle, S., Gillard, S., Perkins, R. & Rennison, J. (2013). Peer support workers: Theory and practice. Retrieved from http://www.nhsconfed.org/Documents/ImROC%20Peer%20Support%20Workers%20Theory%20and%20Practice.pdf
- Repper, J. & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of Mental Health, 20, 392–411. doi:10.3109/09638237.2011.583947 [CrossRef]