Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Evaluating the Selection, Training, and Support of Peer Support Workers in the United Kingdom.

Alan Simpson, PhD, BA(Hons), RMN; Jody Quigley, BSc(Hons); Susan J. Henry, BA(Hons); Cerdic Hall, MSc(MHN), DipAppSci(Nursing)

Abstract

This article describes the preparation, selection, training, and support of a group of people with lived experience of mental distress/illness and mental health service use to work as peer support workers (PSWs). The PSWs were recruited to provide support alongside conventional aftercare to service users discharged from acute psychiatric units in London, England. Training was delivered over 12 weekly, 1-day sessions from April to July 2010. Supervision and support were provided by a peer support coordinator and a training facilitator. The overall view of the training by those who went on to work as PSWs was that it was a valuable, challenging, yet positive experience that provided them with a good preparation for the role. A key area for improvement concerned the strength of emotional involvement and feelings PSWs had for their peers, especially in regard to ending the support relationship. Skilled, sensitive supervision and support is essential for the success of such roles. [Journal of Psychosocial Nursing and Mental Health Services, 52(1), 31–40.]

Dr. Simpson is Professor of Collaborative Mental Health Nursing, Adult Years Division, School of Health Sciences, City University London, London, England; Ms. Quigley is PhD Researcher, School of Psychological Sciences and Health, University of Strathclyde, Glasgow, Scotland; Ms. Henry is Peer Support Coordinator, and Mr. Hall is Primary Care Mental Health Liaison Nurse, East London NHS Foundation Trust, London, England.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This article outlines independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Reference No. PB-PG-0408-16151). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

The authors thank all of those who took part in Peer Supporter training, those who provided peer support, and those who have supported the project in any way.

Address correspondence to Alan Simpson, PhD, BA(Hons), RMN, Professor of Collaborative Mental Health Nursing, Adult Years Division, School of Health Sciences, City University London, Northampton Square, London EC1V 0HB, United Kingdom; e-mail: a.simpson@city.ac.uk.

Received: October 31, 2013
Accepted: November 05, 2013
Posted Online: December 04, 2013

Do you want to Participate in the CNE activity?


Abstract

This article describes the preparation, selection, training, and support of a group of people with lived experience of mental distress/illness and mental health service use to work as peer support workers (PSWs). The PSWs were recruited to provide support alongside conventional aftercare to service users discharged from acute psychiatric units in London, England. Training was delivered over 12 weekly, 1-day sessions from April to July 2010. Supervision and support were provided by a peer support coordinator and a training facilitator. The overall view of the training by those who went on to work as PSWs was that it was a valuable, challenging, yet positive experience that provided them with a good preparation for the role. A key area for improvement concerned the strength of emotional involvement and feelings PSWs had for their peers, especially in regard to ending the support relationship. Skilled, sensitive supervision and support is essential for the success of such roles. [Journal of Psychosocial Nursing and Mental Health Services, 52(1), 31–40.]

Dr. Simpson is Professor of Collaborative Mental Health Nursing, Adult Years Division, School of Health Sciences, City University London, London, England; Ms. Quigley is PhD Researcher, School of Psychological Sciences and Health, University of Strathclyde, Glasgow, Scotland; Ms. Henry is Peer Support Coordinator, and Mr. Hall is Primary Care Mental Health Liaison Nurse, East London NHS Foundation Trust, London, England.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This article outlines independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Reference No. PB-PG-0408-16151). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

The authors thank all of those who took part in Peer Supporter training, those who provided peer support, and those who have supported the project in any way.

Address correspondence to Alan Simpson, PhD, BA(Hons), RMN, Professor of Collaborative Mental Health Nursing, Adult Years Division, School of Health Sciences, City University London, Northampton Square, London EC1V 0HB, United Kingdom; e-mail: a.simpson@city.ac.uk.

Received: October 31, 2013
Accepted: November 05, 2013
Posted Online: December 04, 2013

Do you want to Participate in the CNE activity?


Mental health service users have long acknowledged the benefits of the informal mutual support provided by their peers as they try to make sense of their personal distress and often challenging experiences of using mental health services (Repper & Carter,2011). Peer support can be provided informally through mutual support of friends and acquaintances sharing similar experiences, through the provision of user-run services, or through formal peer support. Increasingly, mental health service providers are attempting to harness this naturally occurring companionship to provide more formal peer support either alongside or in place of mainstream or “professional” mental health services (Repper, 2013), often with impressive results (Pitt et al., 2013).

Purpose

The aims of this article are to: (a) describe the preparation, selection, training, and support of a group of peer support workers (PSWs) recruited to provide support alongside conventional aftercare to service users discharged from acute psychiatric units in London, England; and (b) report the findings of an evaluation of the training and support provided. Results of the trial are reported elsewhere (Simpson et al., 2013).

From Hospital to Home

Mental health service users recently discharged from the hospital often fail to continue with treatments that include medication, relapse, and are readmitted to the hospital. In England, it was reported that between 20% and 40% of psychiatric patients were re-admitted within 6 months of discharge, with the peak period within the first month (Meehan et al., 2006). Suicide is also a significant and increasing risk (National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2013). In interviews with 60 randomly selected service users across 136 psychiatric wards, more than half said they would miss the 24-hour presence of nursing staff and the support of their peers when discharged. One suggestion to improve postdischarge outcomes was the provision of peer support by fellow service users alongside existing aftercare services (Jones et al., 2010).

Peer Support

A recent Cochrane Review assessed the effects of using consumers of mental health services as providers of services in roles that included peer support, coaching, advocacy, case management, and outreach or crisis work (Pitt et al., 2013). Five trials involving 581 people compared consumer-providers to professionals in similar roles and found no significant differences across a wide range of measures. A small reduction was noted in crisis and emergency service use for clients receiving care involving consumer-providers. Consumers who provided mental health services did so differently compared to professionals; they spent more time face to face with clients. Six trials involving 2,215 people compared mental health services with or without the addition of consumer-providers. Again, there were no significant differences across various measures between groups with consumer-providers as an adjunct to professional-led care and those receiving usual care from health professionals alone. The quality of studies was moderate, with most undertaken in the United States.

A few studies have focused on reducing re-admissions. In Australia, a pilot study of peer support reported significant reductions in admissions and re-admissions, less use of emergency services, and associated cost savings (Lawn, Smith, & Hunter, 2008). In Canada and Scotland, trials of a transitional discharge model in which support was provided jointly by ward staff and PSWs reported reductions in re-admissions and use of emergency services, lower costs, and increased satisfaction (Forchuk, Reynolds, Sharkey, Martin, & Jensen, 2007). No trials had been conducted in the United Kingdom examining the effectiveness of peer support as an intervention for patients at the transition point of being discharged from the hospital.

The Peer Support Project

The Peer Support Project was designed as a pilot randomized controlled trial (RCT) comparing peer support in combination with care as usual following discharge, with usual care alone. Follow up was at 1 month and 3 months postdischarge. PSWs would make initial contact while the service user was still an inpatient and then offer 4 weeks of support following discharge. This would be in addition to usual aftercare, such as medication monitoring, risk assessment, psychoeducation, counseling, and support, with a range of social needs, provided by community teams. Service users in the control group would receive usual aftercare arrangements. A full-time peer support coordinator (PSC) was employed to provide training, coordination, supervision, and support to the PSWs and to liaise with staff and service users on the wards.

Recruitment and Selection

The preparation and support of the PSWs and development of training materials was informed by guidelines produced by those with experience of employing peer support staff (Bluebird, 2008; Clay, 2005; McLean, Biggs, Whitehead, Pratt, & Maxwell, 2009; Reifer, 2003; Woodhouse & Vincent, 2006) and through discussion with others developing similar programs. A role description and person specification was developed to aid recruitment and selection. These focused on the recovery-focused aspect of the role and the ability of people to draw on their personal lived experience of mental illness and mental health service use to support others in their recovery and in making adjustments following discharge from the hospital. The role was envisaged as being complementary to existing aftercare services provided by mental health service providers, which included the coordination of their care by a care or case manager.

Advertisements inviting applications for training as PSWs were circulated within the local mental health service provider and service user organizations in early 2010. The training program was open only to people who had direct experience of inpatient psychiatric care. No time limit was placed on when this experience took place, nor were the reasons for admission a factor in deciding who should access the training. Potential participants were required to pass two stages of selection. The first stage required them to make telephone contact with the PSC to discuss their interest in and suitability for the training and how comfortable they were talking about their personal experiences of mental health. Participants were asked to give examples of providing previous or current formal/informal support. Though desirable, experience of providing support was not an essential criterion for selection, and the majority of those invited to the next stage had no previous experience of providing formal support to others. Successful participants at this stage all demonstrated an understanding of the skills and attitude needed to effectively support a peer. Fictitious scenarios were used to allow potential participants to consider how they might effectively support someone. Based on this discussion, a mutual decision was reached between the PSC and inquiring individual as to whether he or she was ready to attend the Open Day.

The second stage of selection was attendance at an Open Day, facilitated by mental health staff at City University London, members of SUGAR (Service User and Carer Group Advising on Research), and the training program facilitators (S.J.H., C.H.). Twenty-five participants were given an introductory presentation on peer support and then took part in paired and group exercises that reflected the style and content of the 12-week training program. They could opt out of selection midway through the day. Those who remained were asked to select five other people in the group who they thought would make effective peer supporters. This was then matched to the observations and reflections of the facilitating team. Successful applicants were then contacted the next day and offered a training place following further discussion of any concerns or questions. Those considered not ready to be offered training as a PSW were also contacted and given feedback and encouragement about other possible initiatives. Sixteen participants were selected for training.

Overview of Training

Training was delivered over 12 weekly 1-day sessions from April to July 2010 in a newly built medical education and training center attached to a hospital site in East London. Each session ran from 10:00 a.m. until 4:00 p.m., with a 1-hour break for lunch (provided) and two shorter breaks during the morning and afternoon.

The aim of the training was to prepare and support people who have lived experience of mental distress/illness and mental health service use to work alongside others with similar difficulties, to facilitate recovery through providing practical and emotional support and promoting hope during the transitional period from psychiatric hospital to home.

The training program was divided into two clear objectives. First, there was an emphasis on participants drawing on their own unique experiences and using these to guide their understanding of the various topics covered. Personal development, reflection, and an exploration of individual experiences of mental health, mental health services, and recovery formed the main component of the training. Alongside this, the training program focused on developing key skills and preparing participants for the peer supporter role. Effective communication, particularly attentive and active listening, ran through each session.

To successfully complete the training program and move on to become peer supporters, participants were required to attend at least 8 of the 12 sessions. Participants also needed to demonstrate an understanding of the topics and an ability to put theory and skills into practice. This was assessed by the facilitators throughout the program and by the PSC during individual supervision. Successful transition to the peer support role was also dependent on the results of an enhanced criminal record check, which all participants who accessed the training were required to undergo.

Content and Delivery

Training was developed and delivered by two facilitators (S.J.H., C.H.), both experienced in delivering training in mental health and substance use services. The PSC’s involvement in the training as one of the facilitators (S.J.H.) meant that there was a regular point of contact for participants from training through to providing peer support. This also allowed the PSC to become attuned to the strengths of participants and structure supervision accordingly. To develop a sense of containment and safety, each session began and ended with a brief check-in to establish how the participants were feeling, whether related to the training or not. These checks also gave space for any residual feelings from the previous session to be aired. The Table outlines the sessions in the training program.

Peer Supporter Training Program Outline

Table:

Peer Supporter Training Program Outline

A variety of activities and methods were used, including the Tree of Life method, described below. Factors influencing choice of delivery method included the objectives of each session, participants’ individual personalities, sensitivity of the information under discussion, and direct requests from the group. Paired and small-group work were often used to encourage less confident members of the group to feel comfortable sharing their experiences. This structure also encouraged listening to one or a small number of people without distraction. Large group discussion brought ideas together and could be easily recorded. The training program utilized role-play to enable participants to experience “real-life” situations. All role-plays were carefully structured with guidelines regarding behavior, ensuring participants remained emotionally safe throughout. Fictitious written scenarios also provided a real-life feel, enabling groups to discuss differing approaches and options (Figure). Additional training in breakaway techniques was also organized at the request of the trainees.

Training example on peer supporter boundaries.

Figure.

Training example on peer supporter boundaries.

Within the overall training framework, each session was devised and written after the previous one was delivered. Although time consuming, this approach enabled the facilitators to think carefully about the previous session, what activities ignited enthusiasm, and which participants struggled. That, coupled with a growing understanding of the dynamics within the group, was fundamental to devising the sessions. Participants received a write-up of each session, detailing key discussion points and areas of learning as an memoir aid. This was a useful tool within supervision, as it acted as a reference point when specific situations occurred for a PSW.

The Tree of Life Method. The training sessions were experiential, drawing on participants’ individual and shared experiences of mental distress, service use, and recovery. This included using the Tree of Life methodology, a narrative approach that enables people to speak about their lives in ways that make them stronger. It involves people drawing their own “tree of life” in which they get to speak of their “roots” (where they come from), their skills and knowledge, their hopes and dreams, as well as the special people in their lives. The participants then join their trees into a “forest of life” and, in groups, discuss some of the “storms” that affect their lives and ways they respond to these storms and protect themselves and each other (Dulwich Centre, n.d.).

Overview of Support Provided

During each training day, both facilitators were available to provide support where needed. From Week 3 of the training program, participants received fortnightly individual support with the PSC. This provided space to discuss how they were experiencing the training, revisiting aspects of it for clarification, and preparing them for their role as PSWs. Providing individual support at this stage also introduced participants to the supervision process, as it would continue to be a key aspect when going on to provide peer support.

Those who went on to become PSWs attended regular supervision while they were providing support. Sessions lasted approximately 1 hour and gave individuals an opportunity to discuss in depth the support they were providing and its effect on both the peers and themselves. Space was also kept free for PSWs to talk about their own mental well-being and ways in which their participation in the project and any other factors might be affecting their mental health. When not providing peer support, supervision was not provided unless there was a specific request. However, regular contact between PSWs and the PSC was maintained. PSWs were frequently in contact with the PSC outside supervision to hand in worksheets, manage expenses, or arrange appointments. During these times, informal support was given. These occasions were invaluable, as often PSWs would discuss their participation and any issues that had arisen between supervision sessions.

PSWs also attended a monthly support group, run by the second training program facilitator (C.H.), where experiences could be discussed and shared. These sessions ensured that PSWs remained in regular contact with each other, as often they worked individually with their peers and had little other contact with others providing this unique type of support.

Ethics

The impact of the PSW training, supervision, and support was evaluated as part of the pilot trial of peer support by the principal investigator (A.S.) and a researcher (J.Q.). The project received full ethical approval from East London and The City Alpha Research Ethics Committee. All potential participants, including PSWs, were given written and verbal information about the study and provided written consent before taking part.

Evaluation of Training, Supervision, and Support

Sample

The 13 trainees who completed the training (9 men and 4 women) were included in the evaluation. Ages were normally distributed and ranged from 32 to 55, with a mean age of 42 (SD = 6.71 years). According to self-reports, 5 were White British, 4 Black Caribbean, 3 Black British, 3 “other White,” and 2 British Bangladeshi individuals, reflecting the diversity of East London. All PSWs had personal experience of inpatient mental health care and a variety of relevant experience from informally supporting friends and family, attending support groups, specific mentoring, befriending, and support work.

Method

The Nottingham Peer Support Training Evaluation Tool (NPSTET) (V2) was developed by Julie Repper (personal communication, October 2009) to evaluate peer supporter training in Nottingham and was adopted for this study. It consists of 27 Likert-style items requiring respondents to reflect on their own qualities and assess their ability to perform many of the skills required for effective peer support (e.g., “I know how to stand up for myself,” “I am clear about when to talk about my own experiences with a person in distress”). There are also six open-ended questions, which allow some of the quantitative items to be investigated in more detail. The tool was adapted to explore trainees’ expectations, experiences, and feelings in relation to the training and the peer support role at the start of the training and at the end of the 12 weeks, so that responses could be compared. The NPSTET was administered to all peer support trainees (n = 18) by J.Q. at the start of the first training session and was completed in a group setting. The posttraining version was administered to those who completed the training (n = 13) and was completed in a group setting after the last training session.

Focus groups with the PSWs were held after 4 months of providing peer support and again after 10 months, as they completed the project providing peer support. The focus groups were designed to explore PSW experiences, including specific questions on how well they felt their training had prepared them for their roles. All focus groups were facilitated by A.S. and J.Q.

Interviews were conducted by an independent researcher with the PSC at the halfway point and again at the end of the project, to explore her views on the progress of the project, including specific questions about how well the training had prepared the PSWs for their roles. Data from these interviews were used to inform the discussion later in this article.

Data Analysis

Quantitative data were analyzed using SPSS version 16. Each of the 27 quantitative items on the NPSTET was rated on a 7-point Likert scale ranging from “strongly disagree” to “strongly agree”; the higher the score, the more positive the response. Due to the small sample, the nonparametric Wilcoxon signed-rank test was used to determine any directional change of scores and also the strength of that change. All digitally recorded interviews were professionally transcribed and then checked against recordings by J.Q. Qualitative data from the open-ended items on the NPSTET, along with relevant responses from the focus groups and interviews, were organized and explored with NVivo 6 software (QSR International, Victoria, Australia)and analyzed using framework analysis (Smith & Firth, 2011).

Results

Of the initial 16 trainees, one withdrew in the first week, expressing concerns about taking on too much and his mental well-being. A second person withdrew in Week 2, realizing he had too many other commitments. After discussion, two other applicants were interviewed and invited to join the training and joined at Week 3. At Week 8, a third person withdrew, citing deterioration in her mental well-being, as did a fourth person in Week 10. The following week, a fifth person withdrew as he realized he needed to prioritize other external commitments. So, of a total of 18 participants, 13 successfully completed the training and received certificates of achievement at the graduation ceremony. Following “readiness to work” interviews, 11 of those who completed training were accepted as PSWs. Due to difficulties completing criminal record checks and two people becoming unwell, eight PSWs provided support to service users as part of the study.

There was no significant difference in age between the five who dropped out and the 13 who completed training (t = 0.896(6.1), p = 0.404). A chi-square test was performed to determine whether any relationship existed between gender and completed training, but as 75% of cells had an expected frequency less than 5, Fisher’s exact probability was the appropriate test. This gave a p value of 1.00 for a two-tailed hypothesis and Cramer’s V was 0.09, indicating no relationship between gender and training completion. There may have been a relationship between ethnicity and whether or not training was completed (p = 0.031), with Black British and mixed race trainees more likely to withdraw. Although such small numbers deserve caution, future trainers may wish to consider this issue in more detail.

Attendance at training sessions was good; trainees attended between 8 and 12 sessions, with a mean of 10 sessions per trainee. Between 8 and 13 trainees attended each session, with a mean of 10 trainees. The support groups were less well attended, with people attending between 0 and 7 groups (of 9), and only attending 3 groups on average. There were between 2 and 6 people at each group, with a mean of 4 attendees of the 8 who went on to become active PSWs.

NPSTET Scores

Pre-training scores on the adapted NPSTET were high, with an average of 6 (of a possible 7) across all questions, indicating that even before the training, trainees tended to “agree” with most statements. There was no change posttraining; the average score remained 6 of 7, indicating that trainees still tended to “agree” with most statements. Eight peer support trainees’ overall scores increased (although none significantly), whereas five peer support trainees’ overall scores decreased (although none significantly).

Five trainees obtained significantly different scores between the pre- and posttraining questionnaires and another almost reached significance, but the overall difference between pre- and posttraining scores was not significant across trainees, t(12) = −0.508, p = 0.620). Three of those who scored significantly differently increased their scores in the posttraining questionnaire, and two decreased.

Focus Groups

The focus group interviews covered the PSWs’ experiences of providing peer support, the types of interventions provided, the personal impact of taking on this role, and their perceptions of how their input affected the service users they supported. These findings will be reported elsewhere in detail, but in general, PSWs reported very positive experiences, with the training and work experience combining to boost their self-esteem and confidence, generate feelings of pride, help develop new skills, and overcome challenges. The quality of relationships with their service user peers varied but most experienced productive, rewarding peer support interactions. Numerous examples of supportive emotional and practical therapeutic relationships emerged alongside evidence of constructive developments on the part of their peers. The PSWs themselves described an increased understanding of their own recovery processes and positive effects on their well-being, despite stresses associated with the new role. The biggest frustration was that the support period of 6 weeks was too short, a finding echoed by the service users receiving support.

When asked explicitly about the training and preparation they received, the PSWs identified the following key issues.

Training Covers Most Things/Can’t Cover All. The PSWs believed the training had covered most things and been very useful and there was an acknowledgement that it is not possible to cover everything and anticipate all eventualities. Quotes included:

  • “Really good, learning from the tutors and your peers. I reflected on the training and what peers said.”
  • “One tutor said it’s OK to have an off day; I remember his advice and use that when everything gets on top of me.”
  • “It covered 90+% of what to expect.”
  • “Certain things will come up and catch you unawares, no matter how well prepared [you are].”
  • “Training covered a lot, but as you go along things come up.”
  • “Focus in practice was different to the job description.”

Role-Plays Useful. Various aspects of the training were mentioned and recalled positively and many people spoke of it providing them with confidence. Role-plays in particular were seen as most useful, as noted in the following quotes:

  • “Role-plays helped me deal with things I was running away from.”
  • “[You gain] more insight into your own problems and the sort of problems you are likely to encounter with your peer.”
  • “It gives you confidence to deal with things you probably thought you wouldn’t be able to deal with.”

Insufficient Preparation for Emotional Reactions. Most of the PSWs did not believe they had been adequately prepared for the depth of emotions they would experience generally, and particularly in relation to the ending of the peer support relationship. Although this had been discussed in training and throughout supervision, the PSWs found it difficult having to end a relationship that had swiftly become meaningful and that was highly valued by the other person. Additionally, one PSW was deeply hurt by the death of someone she had recently supported, through an unrelated illness. Related quotes included:

  • “I found ending the relationship terribly hard, more help on endings and how to deal with people.”
  • “We trained a lot but not enough on endings…didn’t realize the emotional feelings that you’ll get.”
  • “Ending was difficult; I worried about my peer—where do they go from here?”
  • “Training was of limited relevance to experience of peer dying.”

The PSWs spoke of thinking about their peer a lot at evenings and weekends and often felt a great responsibility for them. The emotional attachment even after such a short period was strong. This was amplified when there was a long gap over the Christmas period or when contact was broken, as noted:

  • “Lost contact with peer—felt like she was rejecting me, but she wasn’t and I carried on seeing her.”
  • “I was worried when peer did not turn up, concerned something had happened.”
  • “What is going to happen when this stops?”
  • “My peer was discharged homeless, left me pretty frazzled emotionally and physically trying to find accommodation. I didn’t want to leave him on the street.”

Not Trained to Help Families. Several of the PSWs explained how their work had found them involved not just with the service user, but often, either directly or indirectly, with other members of the person’s family. They did not believe the training or their own expectations had prepared them for that:

  • “You’re not just taking on the peer but the whole family and their history, which I’d not thought about.”

More “Hands-On” Training. Most PSWs would have welcomed more “hands-on” training while undertaking the role, which would have provided opportunities to address learning needs that were emerging through undertaking their role:

  • “On the job training so you can do practical and theories.”

Some welcomed the addition of “breakaway” training, which not everyone had been able or willing to attend:

  • “Include breakaway training in main training.”
  • “Wish I’d done the breakaway training but thought it would be judo and martial arts—it frightened me.”

Supervision and Support. All of the PSWs were very positive about the support they had received from the PSC, who was described in positive terms, including “warm,” “flexible,” “easy to get on with,” “a nice person,” “approachable,” “great,” and “simply fabulous.” The importance of a supportive, pro-active PSC was recognized by all:

  • “Right approach—introduced us then left us to get on.”
  • “Keeps you informed.”
  • “Genuinely cares about us.”

The supervision with the PSC was also rated highly and provided a safe environment to discuss anything that was important to PSWs, whether directly related to their peer support role or more about their personal circumstances and emotional reactions to the work:

  • “In supervision explored personal as well as peer issues.”
  • “I felt there was nothing I couldn’t say.”
  • “She provides a safe space.”
  • “Supervision covered everything—that was really important.”
  • “She made you feel wanted, valuable.”
  • “When I was in hospital she gave me space—not rushed back; eased back in.”

Support Groups. Most of those who attended the fortnightly support groups found them helpful and liked the informal atmosphere, but some wanted more structure to prevent them from being dominated by one or two people:

  • “Support groups run well—I liked the informal atmosphere and you could talk privately.”
  • “The support group was helpful as we could find out what’s been happening with all the other workers.”
  • “I didn’t find them helpful as people were talking about their experiences too much.”
  • “One person dominated meetings.”

Future Possibilities. When asked whether they would be interested in continuing as PSWs in some guise if possible, most said that they would, either in a full-time employed capacity or in a part-time or even voluntary role. Some believed the voluntary aspect marked them out as separate from professional staff in the eyes of their peers and also provided them with more choice and flexibility about their working hours. Several spoke of seeking out additional training or educational possibilities as the experience had inspired them:

  • “I feel so lucky and privileged to be doing this; I’m looking into a future career and qualifications.”
  • “It has reinforced that I would like to be involved in mental health work to help others and it helps me.”
  • “I would like to continue being a PSW with a view to doing a course or something.”
  • “Love to do training in something or train other people.”
  • “Thinking about taking it further, going to college.”

Discussion

The overall view of the training by those who went on to work as PSWs was that it was a valuable, challenging, yet positive experience that provided them with a good preparation for the role. A key area where they believed they could have been better prepared concerned the strength of emotional involvement and feelings they would have for their peers and in particular, in regard to ending the support relationship.

The difficulties of ending peer-to-peer relationships that are more like friendships have been reported elsewhere (Repper & Watson, 2012a) and some of the tensions involved in asking people to work in a way that attempts to avoid the distancing often associated with professional therapeutic relationships are discussed. Further work to explore how best to negotiate engagement and boundaries would be valuable.

The PSWs also felt insufficiently prepared for the involvement and influence of family members and dynamics and would have welcomed more ongoing training and development as they undertook the role. Interestingly, such support was provided through the fortnightly support groups, but these were not well attended or utilized. Reflections by C.H. and S.J.H. suggest this may have been because of delays at the start of the project caused by difficulties obtaining criminal records clearance, which resulted in few PSWs being able to start work as planned, in turn resulting in few people attending the support groups. This perhaps set up a pattern that was difficult to change. Nonetheless, some PSWs had positive experiences of the support group. Clearly, the strength of the supervision and regular support and supervision provided by the PSC was valued greatly and seen as important in ensuring the peer support work was effective and safe for all parties. Such a finding is important for others considering introducing peer support and should not be ignored or taken lightly.

The overall positive experience of the training reported by the PSWs and the facilitators was not reflected in the scores on the questionnaires. This may have been for a number of reasons. First, the pre-training scores were already high, making improvement difficult or unlikely. It is also possible that the trainees completed the pre-training questionnaires over-enthusiastically in an attempt to show they were perfect for the role. Alternatively, the trainees were well selected for the role and already had many of the skills needed to make an excellent PSW. Second, the measure is unvalidated and was adopted and adapted from a measure designed for a different though similar training program and may not have been entirely suitable or sufficiently rigorous to measure the effect of the training. It is also possible that the training had no real impact on the way trainees felt about themselves or their ability to support a peer. Finally, the posttraining questionnaires were completed on the final day of training with all of their peers, trainers, and others around; it was an exciting day and responses may have been rushed. Whatever the reason, the other evidence suggests we have good reason to believe that the training provided a good preparation for the role, with a few caveats.

Nursing Implications

Mental health nurses may have a significant role to play in the further development of peer support roles. The challenges of working closely with people in mental distress is one that is familiar to nurses, as are the emotional demands of establishing and maintaining empathic, therapeutic relationships, and of terminating these meaningful encounters.

Other studies of peer support report challenges around role conflict and the maintenance of boundaries (Faulkner & Basset, 2012). Mental health nurses have knowledge and expertise in these areas that can be shared. But PSWs also have much to offer nurses, and any such learning needs to be within a reciprocal, mutually respectful relationship in which nurses show they are willing to listen and learn from their peer support colleagues. Together, mental health nurses and PSWs can discuss how to best work collaboratively with service users and focus on recovery and strengths not just symptoms, deficits, and illness. They can explore how to best negotiate the need for boundaries in relationships without becoming remote and uncaring. They can also explore alternatives to physical restraint and seclusion and how to work in ways that ensure the safety and well-being of service users, peers, staff, and the public.

Conclusion

In the United Kingdom, as is the case elsewhere, various peer supporter roles are being developed and introduced into the workforce, both within statutory health services and the charitable or voluntary sector (Faulkner & Basset, 2012). The introduction of PSWs into the workforce is now being advocated as central to the move to provide recovery-focused service delivery in England (Repper, 2013). Alongside this article, a number of publications have recently emerged describing some of the experiences and challenges of introducing peer support staff, including recruitment, preparation, and training experiences (Repper & Watson, 2012a); the peer support work undertaken with individuals (Gerry, Berry, & Hayward, 2012; McLean et al., 2009; Repper & Watson, 2012b); and the experiences of PSWs themselves (Watson, 2012). These provide useful information and suggestions for others about to embark on this journey.

Since completing the pilot trial, peer support is being further developed in East London and S.J.H. has been employed by the local service provider as PSC and continues to deliver PSW training and supervision and coordinates PSW input into local services. The other trainer, C.H., has been successfully developing a peer support initiative in Uganda (Hall, 2013).

References

  • Bluebird, G. (2008). Paving new ground: Peers working in in-patient settings. Alexandria, VA: National Technical Assistance Center, National Association of State Mental Health Program Directors. Retrieved from http://www.nasmhpd.org/docs/publications/docs/2008/Bluebird%20Guidebook%20FINAL%202-08.pdf
  • Clay, S. (2005). On our own, together: Peer programs for people with mental illness. Nashville, TN: Vanderbilt University Press.
  • Dulwich Centre. (n.d.) The Tree of Life: An approach to working with vulnerable children, young people and adults. Retrieved from http://www.dulwichcentre.com.au/tree-of-life.html
  • Faulkner, A. & Basset, T. (2012). A helping hand: Taking peer support into the 21st century. Mental Health and Social Inclusion, 16, 41–47. doi:10.1108/20428301211205892 [CrossRef]
  • Forchuk, C., Reynolds, W., Sharkey, S., Martin, M.L. & Jensen, E. (2007). Transitional discharge based on therapeutic relationships: State of the art. Archives of Psychiatric Nursing, 2, 80–86. doi:10.1016/j.apnu.2006.11.002 [CrossRef]
  • Gerry, L., Berry, C. & Hayward, M. (2012). Evaluation of a training scheme for peer support workers. Mental Health Practice, 14(5), 25–29. doi:10.7748/mhp2011.02.14.5.24.c8309 [CrossRef]
  • Hall, C. (2013) Into Africa. Mental Health Practice, 16(8), 9. Retrieved from http://rcnpublishing.com/doi/pdfplus/10.7748/mhp2013.05.16.8.9.s13 doi:10.7748/mhp2013.05.16.8.9.s13 [CrossRef]
  • Jones, J., Nolan, P., Bowers, L., Simpson, A., Whittington, R., Hackney, D. & Bhui, K. (2010). Psychiatric wards: Places of safety?Journal of Psychiatric and Mental Health Nursing, 17, 124–130. doi:10.1111/j.1365-2850.2009.01482.x [CrossRef]
  • Lawn, S., Smith, A. & Hunter, K. (2008). Mental health peer support for hospital avoidance and early discharge: An Australian example of consumer driven and operated service. Journal of Mental Health, 17, 498–508. doi:10.1080/09638230701530242 [CrossRef]
  • McLean, J., Biggs, H., Whitehead, I., Pratt, R. & Maxwell, M. (2009). Evaluation of the Delivering for Mental Health Peer Support Pilot Scheme. Edinburgh, Scotland: Scottish Government Social Research. Retrieved from http://www.scotland.gov.uk/Resource/Doc/291864/0089933.pdf
  • Meehan, J., Kapur, N., Hunt, I.M., Turnbull, P., Robinson, J., Bickley, H. & Appleby, L. (2006). Suicide in mental health in-patients and within 3 months of discharge: National clinical survey. British Journal of Psychiatry, 188, 129–134. doi:10.1192/bjp.188.2.129 [CrossRef]
  • National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. (2013). Annual report: England, Northern Ireland, Scotland and Wales. July 2013. Manchester, UK: University of Manchester. Retrieved from http://www.bbmh.manchester.ac.uk/cmhr/centreforsuicideprevention/nci/reports/AnnualReport2013_UK.pdf
  • 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]
  • Reifer, M. (2003). Georgia’s consumer-driven road to recovery: A mental health consumer’s guide for participation in and development of Medicaid reimbursable peer support services. Atlanta, GA: Division of Mental Health, Developmental Disabilities, and Addictive Diseases.
  • Repper, J. (2013). Peer support workers: Theory and practice. London, UK: Centre for Mental Health. 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]
  • Repper, J. & Watson, E. (2012a). A year of peer support in Nottingham: Lessons learned. Journal of Mental Health Training, Education and Practice, 7, 70–78. doi:10.1108/17556221211236466 [CrossRef]
  • Repper, J. & Watson, E. (2012b). A year of peer support in Nottingham: The peer support workers and their work with individuals. Journal of Mental Health Training, Education and Practice, 7, 79–84. doi:10.1108/17556221211236475 [CrossRef]
  • Simpson, A., Flood, C., Rowe, J., Quigley, J., Henry, S., Hall, C. & Bowers, L. (2013). Results of a pilot randomised controlled trial to measure the clinical and cost effectiveness of peer support in increasing hope and quality of life in mental health patients discharged from hospital in the UK. Manuscript submitted for publication.
  • Smith, J. & Firth, J. (2011). Qualitative data analysis: The framework approach. Nurse Researcher, 18, 52–62. doi:10.7748/nr2011.01.18.2.52.c8284 [CrossRef]
  • Watson, E. (2012). One year in peer support–Personal reflections. Journal of Mental Health Training, Education and Practice, 7, 85–88. doi:10.1108/17556221211236484 [CrossRef]
  • Woodhouse, A. & Vincent, A. (2006). Mental health delivery plan: Development of peer specialist roles: A literature scoping exercise. Retrieved from http://api.ning.com/files/HlNSKDUHnvz3QV1mFcfpznw-5wWriH-QhggVVu7FFO*d2qBcLubo4Jbdxle7*O93jpzXQIz6i40T11zhEtVnDBPyCHHZ-k3es/DevelopingPeerSpecialistRolesLiteratureReview.pdf

Peer Supporter Training Program Outline

Session Topic
1 Exploring Peer Support
2 Tree of Life
3 Recovery and Personal Recovery Plans
4 Recovery and Personal Recovery Plans (continued)
5 Confidentiality, Information Sharing, Exploring Boundaries
6 Active Listening Skills
7 Social Inclusion
8 Appreciating Differences
9 Responding to Distressing Situations
10 Revisiting Boundaries and Difficult Situations—Participants’ Choice
11 Preparing to be a Peer Supporter
12 Endings and Celebrations

Keypoints

Simpson, A., Quigley, J., Henry, S.J. & Hall, C. (2014). Evaluating the Selection, Training, and Support of Peer Support Workers in the United Kingdom. Journal of Psychosocial Nursing and Mental Health Services, 52(1), 31–40.

  1. The introduction of peer support workers (PSWs) is now being advocated as central to recovery focused service delivery in the United Kingdom and elsewhere.

  2. Available evidence shows there are minimal differences in consumer outcomes across a wide range of measures between consumer providers and professionals in similar roles; however, the available research base is limited at this stage.

  3. Preparing and supporting the PSWs for the role consisted of a 12-day training and required ongoing supervision and the appointment of a peer support coordinator.

  4. Most of the PSWs experienced productive and rewarding interactions with the service user peers and reported positive effects on their own recovery.

Do you agree with this article? Disagree? Have a comment or questions?

Send an e-mail to the Journal at jpn@healio.com.

10.3928/02793695-20131126-03

Sign up to receive

Journal E-contents