In recent decades, there has been an increase in the employment of peer workers in mental health and substance use settings (Gagne et al., 2018; Myrick & del Vecchio, 2016; Stratford et al., 2019). Peer workers represent a unique workforce employed to support others by using their personal experiences of navigating services and finding their own recovery. Peer work is based on principles of mutuality, hope and shared power (Austin et al., 2014). Peer workers are employed in a range of services and settings, including peer-operated services and multidisciplinary teams in government, non-government services, community, and clinical settings (Gagne et al., 2018; Mancini, 2018). The work includes, but is not limited to, advocacy, community linking, and the provision of social, emotional and practical support (Davidson et al., 2006; Gagne et al., 2018).

Peer support work has shown effectiveness in improving outcomes for people accessing services, including reduced hospitalizations, increased satisfaction with services, more autonomy, and greater hope (Corrigan et al., 2017; Davidson et al., 2012; King & Simmons, 2018; Rowe et al., 2016; Vayshenker et al., 2016; White et al., 2020). Employing peer workers also brings benefits for organizations by increasing contemporary service delivery priorities, particularly recovery-oriented values and practices (Austin et al., 2014; Dark et al., 2017; Mutschler et al., 2021; Walker & Bryant, 2013). The concept of personal recovery is characterized as a holistic approach, emphasizing hope, autonomy, informed choice, and connection (Anthony, 1993; Leamy et al., 2011). The effectiveness of peer support in facilitating more recovery-oriented service delivery reinforces the inclusion of peer roles in multidisciplinary settings (Kent, 2018; Mutschler et al., 2021; Vandewalle et al., 2016).

The recovery-oriented approach has been found to create tension with more traditional service approaches (Adams, 2020; Gillard et al., 2017). Embracing a recovery-oriented approach requires a radical culture shift from a medical orientation, towards valuing lived experience, personal recovery, and person-directed support (Byrne, et al., 2018a, 2018b; Mancini, 2018; Vandewalle et al., 2016). Peer values undergird a recovery-oriented approach, and the role of peer workers is described as one of change agents in driving a social change and recovery orientation in traditionally oriented services (Adams, 2020; Mead & Filson, 2017; Mead & MacNeil, 2005; Mutschler et al., 2021). As a consequence, effective peer worker integration within multidisciplinary organizations is linked to organizations adopting a recovery orientation (Gillard et al., 2015; Mancini, 2018; Moran et al., 2013; Mutschler et al., 2021), supporting the importance of an underpinning philosophical commitment to both recovery and peer support (Slade & Longden, 2015; Vandewalle et al., 2016).

Previous research has revealed a potential for resistance to peer workers and system change from traditional services (Adams, 2020; Byrne, et al., 2019a, 2019b, 2019c; Gordon & Bradstreet, 2015; Hurley et al., 2016; Moran et al., 2013; Mutschler et al., 2021; Stefancic et al., 2021). This reflects challenges in workplace culture impacting effective integration and reducing capacity for collaboration in multidisciplinary teams (Adams, 2020; Jones et al., 2020; Moran et al., 2013). Developing a favorable workplace culture includes a process of organizational readiness (Aarons et al., 2011; Byrne, et al., 2019a, 2019b, 2019c; Gillard, 2019; Ibrahim et al., 2019; Mutschler et al., 2021), including ensuring clarity and understanding of peer roles (Byrne, et al., 2019a, 2019b, 2019c; Gagne et al., 2018; Stefancic et al., 2021), and organizational training (Gates & Akabas, 2007; Mancini, 2018; Silver & Nemec, 2016; Stefancic et al., 2021).

Changes in organizational structures and strategies, including staffing structures, strategic priorities and policies and procedures, are also needed to facilitate a supportive workplace culture and combat resistance (Gillard et al., 2015; Mutschler et al., 2021). Specific organizational strategies that have been identified include creating senior peer roles (Byrne, et al., 2019a, 2019b, 2019c; Gagne et al., 2018; Gillard et al., 2015; Jones et al., 2020; Moran et al., 2013), providing peer supervision (Jones et al., 2020; Kent, 2018; Mancini, 2018), developing policies and practices that protect authentic peer practice (Cronise et al., 2016; Stefancic et al., 2021) and valuing diversity (Jones et al., 2020).

Although professional qualifications and credentialing have raised peer work credibility, certification has been fraught with inconsistencies (Gillard et al., 2015), role confusion and co-optation (Adams, 2020; Gates & Akabas, 2007; Gillard et al., 2014, 2015; Harrison & Health, 2017), restricting opportunities for dissenting voices and system change (Adams, 2020; Pilgrim, 2005). In the absence of effective strategies to embed peer workers, authentic peer work is compromised by potentially putting peer workers in “para-clinical” roles (Gillard, 2019, p. 342), diluting or eroding peer work (Adams, 2020; Gillard et al., 2015) and reducing the potential for sustained system change (Adams, 2020; Dierdorff & Morgeson, 2007).

While full inclusion of peer workers has long been identified as critical to effective peer work (Dixon et al., 1997; Gillard, 2019), the literature has focused on the effectiveness of the role of peer workers rather than the organizational change necessary for peer workers to work authentically and be effectively embedded (Lloyd-Evans et al., 2014; Mutschler et al., 2021; Repper & Carter, 2011; Watson, 2017). Attention has included desired peer worker characteristics (Solomon, 2004; Vandewalle et al., 2016), addressing concerns about boundaries (Asad & Chreim, 2016; Gillard et al., 2013; Rebeiro Gruhl et al., 2016) and pre-emptive risk planning (Chinman et al., 2010; Repper & Carter, 2011). Understanding and modifying behavior in organizations and workplace culture to support peer worker employment in multidisciplinary teams is less developed.

To identify organizational best practices and increase our understanding of the required qualities within a workplace culture that facilitate effective peer worker employment and maximize service benefits, research was undertaken in the United States to explore the perspectives of peers, non-peer staff and managers of multidisciplinary teams. Within this study, effective employment of peer workers refers to the workplace conditions and structures that support peer workers’ ability to enact their potential in contributing to individual and system change, using their unique perspective, skills, and knowledge. Using study findings, the authors present a working model for emerging best practice in peer work and organizational change in multidisciplinary teams.

Method

Participants

Participants included 132 people employed across five multidisciplinary organizations delivering mental health and substance use recovery services. These organizations were located in five geographically diverse States. Participant numbers from the five sites were as follows: 31 at Organization 1, 27 at Organization 2, 31 at Organization 3, 23 at Organization 4, and 20 at Organization 5. Organizations were of various types and sizes from medium (50–250 employees) to large (more than 250 employees) and included: two not-for-profit, one county-run, one under the umbrella of a managed care company, and one privately owned. The term multidisciplinary team is used to describe staff teams comprised of a range of disciplines, including peer and non-peer workers (e.g., nurses, psychologists, support workers etc.). The 132 participants included 32 non-peer workers, 47 non-peer managers, seven peer-designated managers, 38 peer workers, and eight ‘other’. Participants who chose the category ‘other’ were employed in human resource, administrative (e.g.: executive assistant) or ‘caregiver’ positions.

Procedure

An expert, twelve-member advisory group, provided consultation and assisted in identifying multidisciplinary organizations. Advisory group members were located in diverse states across the United States and were chosen for their peer workforce development history, commitment and expertise. Members were researchers, industry representatives and funders with a range of peer and non-peer perspectives. Advisory group members nominated numerous multidisciplinary organizations considered to employ peer workers effectively and to provide a rationale for their nomination. Criteria for selecting organizations were determined by the advisory group based on expert opinion in a modified Delphi process. This process involved iterative feedback and aggregation of group responses of potential criteria and benchmarking until a consensus was reached (Boulkedid et al., 2011). Criteria included integrity/role clarity of the peer role, identified strategies to support peer roles, robust and appropriate supervision, financial sustainability of the service model, understanding of the peer role among non-peer staff, potential career mobility for peers within the organization and capacity of the organization to meet the diverse whole-person needs of the people who use the services. Organizations were short-listed according to the criteria and rationale provided, then from that list organizations with the most nominations were contacted for participation.

Prior to study commencement, executive management provided a signed letter confirming their organization’s participation. Information regarding the study and an invitation to participate was distributed via existing organizational email lists to all employees at each organization. Participants self-selected to attend a semi-structured individual interview and/or focus group by responding directly to the research team. All participants provided written consent prior to study commencement, and all participation was voluntary.

Each interview and focus group began with the same initial questions, in accordance with grounded theory (Birks & Mills, 2015). These broad questions, formed in consultation with the advisory group, were related to participants’ understanding of what defines peer work; how peer workers are employed in their organization; what in their opinion allows peer workers to be effective in their roles and what organizational strategies aid employment of peer workers. In line with grounded theory, questions were extended and developed as interviews and focus groups proceeded, and participants mentioned different concepts.

Fourteen focus groups were conducted and attended by 124 participants. Eight participants chose to participate in an individual interview. Separate focus groups were conducted for non-peer workers, management, and peer-designated employees. Peer managers had the option to attend either the peer worker or management focus group, with two peer management participants opting to join peer worker focus groups and the remainder choosing individual interviews. Representation from peer and non-peer perspectives were obtained at all sites to provide a range of perspectives across diverse multidisciplinary environments. Four sites had three focus groups, one for each participant group (designated peer roles, non-designated roles and management positions), while the remaining site had focus groups for management and non-designated roles, with peer workers at this site opting to participate in interviews. Interviews and focus groups were conducted at four of the five sites, with participants at one site opting for focus groups only. Most interviews and focus groups were conducted face-to-face, with one interview and one focus group via video call. All focus groups and interviews were audio-recorded and transcribed verbatim.

IRB approval was granted by (blind) University. Neither organizations nor individual participants received any payment. To maintain confidentiality, individual names and organizations were given codes, and city/state locations are not included in reporting. To provide additional confidential options, participants were offered the choice of individual interviews as well as focus groups.

Design and Analysis

Interviews and focus groups of this qualitative study were coded using a grounded theory method (Corbin & Strauss, 2015). De-identified transcripts were coded using QSR International’s NVivo 12 software, 2018. The second author conducted open (line-by-line) coding of verbatim transcripts. When the coding was completed, the first author (and interviewer) research notes and memos were compared with the line-by-line coding and discussed by the research team to refine and confirm concepts. The research notes and memos were not shared with the second author until after coding was complete to reduce inadvertent influence. Codes were then linked relationally and clustered to form key concepts and categories (Corbin & Strauss, 2015). Findings in existing literature were cross-checked to test trustworthiness and generalizability in the development of a working model for best practice in peer work employment.

Results

The analysis revealed perceptions of workers concerning factors involved in the effective employment of peer workers, as presented in Table 1.

Table 1 Distribution of themes per site
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These findings are presented as major categories and subcategories that either facilitate or inhibit effective peer employment and form the interactive components of a working model for best practice in peer employment. While differences existed in the employment of peers among the sites, there was consensus in the perception of what was needed for effective peer work. The working model included below, brings together the key elements from this study to form a model for effective employment of peer work (Tables 2, 3).

Table 2 Strategies for effective peer employment
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Table 3 Challenges to effective peer employment
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Organizational Commitment to Embed Authentic Peer Work

Effectively employing peer workers begins with organizational commitment. Organizational commitment was a major category involving whole-of-organization commitment and both philosophical and financial commitment. This commitment was evident when peer workers were valued, seen as essential and embedded within organizations.

Peer Work is Valued and Seen as Essential

Organizational commitment represented a long-term philosophical commitment to peer work, and peer work values were central to organizational work. There was a fundamental belief that peer work needed to be seen as essential rather than optional:

I’d like to think it's woven into pretty much everything we do here and … if all that intentionality wasn't there it wouldn't hold up. -Site 3 Focus Group: Management

So, it's [peer work is] a given. It is a founding tenet of this clinic to make sure that peer support was included. -Site 1 Focus Group Peers

This was reflected in peer work positioned as part of the mission statement and manifest in organizational culture and strategies. The mission statement and organizational values were described by some participants as being referred to overtly and often, with a clear translation of ideas into action:

I think in every staff meeting or every meeting, no matter whether you’re here or in the group living environments or whether it's senior leadership or nursing or whatever, at the start of every meeting, there's always a reading from the mission statement and reflecting on how it was applied in your role. –Site 5 Focus Group: Non-Peer Workers.

Whole-of-Organization Commitment: Top-down and Bottom-up Championing

Organizational commitment involved top-down and bottom-up championing within the organization. Participants noted top-down leadership and ‘buy-in’ as contributing to whole-of-organization commitment:

It's both. I think you have to have leadership who believe, or is at least willing to try something different, and then I think you have to have staff, somebody closer to the ground who’s been able to push up the value of peers. So, it's both- a top-down and a bottom-up. –Site 2 Focus Group: Non-Peer Workers

Financial Investment

Organizational commitment also included financial investment in peer roles, including employing adequate numbers of peer staff and senior peer positions.

They [organizations] wanna put their money where their mouth is as far as actually trying peer services. There needs to be more than just one poor person [peer] thrown into the thing and say “make it work”. -Site 1 Focus Group: Non-Peer Workers

Organizational Culture

Features of organizational culture were identified by participants that reinforced effective peer work. These included transparency, openness to change, meaningful collaboration and a commitment to a learning process and working through challenges.

Transparency

To embed peer work, all sites spoke about having an open and transparent organizational culture:

It’s being open, transparent and that's also what helps us to maintain recovery, is that honesty and the willingness to talk about the problems and talk about the successes. –Site 1. Interview: Peer Manager

Openness to Change

Participants also described organizations as being willing to take calculated risks, being open to change:

There's an element of allowing people to try something out… there's some value, I think on a little bit of liberty to just be like, "Maybe that'll work, give it a shot, let's see". –Site 3. Focus Group: Management

Commitment to Learn Through Challenges

Similarly, organizations planned to undertake peer work for the long-term and were prepared to work through and learn from challenges:

There’s a fostering of “we grow from our experiences, good and bad”. I think that’s what helps us to continue to sort of move forward. –Site 2 Focus Group: Non-Peer Workers

Meaningful Collaboration

Traditional workers and peers at all sites talked about the value of collaboration and effective communication in working together:

So, to me, it’s been beneficial to have that connection and that collaboration because it's two different worlds being combined. -Site 4 Focus Group: Non-Peer Workers

Mutual Respect

Both traditional workers and peers recognized that successful collaboration relied on mutual understanding and respect:

There has to be an understanding of both roles. There has to be mutual respect. And that can be difficult to achieve, but I do think it’s crucial. -Site 4 Focus Group: Management

I’ve never one time working here have felt like I was looked down upon or my opinions were disregarded... when it comes together for working for a peer [person accessing services] it's all of us; we're that person's tribe. -Site 1 Focus Group: Peer Workers

Organizational Strategies

Several strategies were identified that were needed to facilitate a supportive workplace culture and to combat resistance. These included senior peer roles, workplace preparation and training, recruitment strategies, policies and procedures, peer supervision and peer specific training.

Peers in Senior Positions of Authority

Participants identified the importance of peers in senior positions at multiple organizational levels, including management and executive level roles, as central to guiding workforce development and influencing organizational culture:

We've got a large organization, and we have the peer roles going up all the way to the vice president level and we have the support of our chief executive and our medical director as well as a number of other people…. -Site 5 Focus Group: Peer Workers

We have a hierarchy of peer supervisors, peer managers. So, our organization I think, is fortunate to have a very strong peer culture. –Site 1 Focus Group: Non-Peer Management

These positions were considered instrumental in guiding peer workforce development and maintaining peer role authenticity and providing a “buffer” between non-peers and peers:

I also am attending those different management meetings, committee meetings, advisory meetings, planning meetings and being able to weigh in on what they’re doing within the system to plan services and looking through the peer lens, I can look at all of those things and then advocate so we don't create barriers for peer support… I'm really given great latitude to be able to speak and share all kinds of very cutting edge, radical, peer lived experience. -Site 1 Interview: Peer Manager

Conversely, a lack of peer positions at different levels in the organizational hierarchy created barriers to peer career pathways along with implied lower confidence in peer perspectives:

…when it comes to the managers’ position it's [lived experience] always ‘preferred’ and they can never just go and say, ‘that's a peer designated role’… part of me is like ‘do they feel like they won't find someone worthy of both?’-Site 3 Focus Group: Management

However, senior peers were seen to be under considerable pressure and at times described feeling exposed, unsupported, [and] not understood:

It gets to be too much, especially when I wasn't supported to get where I am and I have nobody to lean on. -Site 3 Focus Group: Peer Workers*

*Note: this focus group included people employed in peer management roles as well as face-to-face delivery roles

Workplace Preparation and Whole-of-Workplace Training

Workplace preparation and whole-of-workplace training was essential to increase understanding of peer work and gain acceptance from colleagues in traditional roles:

We all came together as a large group to take a look at each other’s fears and expectations and discuss them as a larger group… it was a process, and it took months; it wasn't a week or a few days. -Site 1 Interview: Peer Manager

Introducing peers and peer concepts at orientation for all staff was also seen as key in establishing peer values:

The role of peer specialists comes I think, from that training which is a new hire orientation training. So, I think it [valuing and understanding peers] starts right from the get-go. -Site 5 Focus Group: Non-Peer Workers

That level of exposure, when it’s put through the organization, helps us have a better understanding, and through that understanding, the patience, the respect, the challenges that are faced. –Site 4 Focus Group: Management

Without whole-of-organization training to tackle the wider workforce culture there was a risk of disconnection between peer work and recovery concepts:

If the whole agency isn’t supporting the notion and providing education to the whole agency staff about the philosophy and purpose of peers, then there's a lot of disconnects and that misunderstanding stuff happens. -Site 1 Focus Group: Non-Peer Management

However, training in isolation was seen to have a limited impact if the wider workforce culture wasn’t accepting of peers:

They've done training… but if you go [from training] to a culture that doesn't support it, it doesn't matter what you read, it doesn't matter what you learned… there's nothing you can really do about it. -Site 3 Focus Group: Peer Workers

Importantly, training was seen to be most beneficial when it was ongoing and revisited rather than one-off:

Every year we do a refresher on [the] peer support role. -Site 4 Interview: Peer Manager

Effective Recruitment Processes

An effective peer workforce was seen to be fostered by role clarity supported by meaningful recruitment processes, effective supervision including peer supervision, and appropriate training for peers. Management and HR understanding of authentic peer work was important in developing meaningful recruitment processes. These were seen to include skillful use of questions and knowledge of what peer work involved. In terms of assessing the appropriateness of applicants, participants talked about the need for peers to contextualize their personal experiences within the broader peer movement, particularly in senior or peer management positions:

What do people know about the history of the movement? What do people know about how it's distinct: how peer support has come to be? How it's distinguished from regular direct service delivery? -Site 3 Interview: Peer Manager

Similarly, the role of HR was significant in understanding the peer role and choosing the “right” person for the job based on existing skills, shared values, connection and fit in the workplace culture. The emphasis on workplace culture and values important for non-peer staff as well, including hiring staff in non-peer roles who were accepting and supportive of peer work and willing to collaborate with peers:

It has become most important that you match on a value level… we need you, if you are going to join our team, to understand that's the culture here. The culture is that peer services are extremely important, and we all believe in it. –Site 1 Focus Group: Non-Peer Workers

Peer Work is Embedded Within Policies and Processes

Participants raised the importance of policies and processes being adapted to preserve the integrity/authenticity of peer roles:

Even policies and procedures are slightly shifted for the peers so that they can be authentic in their role and continue to do what they're doing rather than jumping and becoming the next [clinical role name removed]. -Site 1 Focus Group: Non-Peer Management

Peer Supervision

Effective supervision was also emphasized as important to maintaining authenticity and role clarity. Peer supervision, in particular, was stressed as an effective means of supporting authentic peer work and limiting ‘role drift or co-option.

it's absolutely important that people understand what the role is; otherwise, you get the role drift. -Site 4 Interview: Peer Manager

Some participants recommended peers in mainstream organizations being employed by peer-run services for reporting and supervision while being physically located in the multidisciplinary workplace. This was a way of ensuring accurate guidance and role clarity as well as peer support and mentoring at the peer-run service:

I encourage people all over the country, contract with a peer-run organization because at least they can then provide that supportive environment for people [peers]. –Site 1 Focus Group: Non-Peer Management

Participants in traditional clinical roles with peer supervisory responsibilities at times expressed that they didn’t understand peer roles very well and felt lost when trying to provide role clarity:

In supervising peers I found myself hearing how they approached working with program participants on an issue, and I was like "That's different than I would've done based on my training" and I feel like I've had to do a lot of learning on how to understand folks who've done actual peer certification, what they learned and where we're gonna not see eye to eye, how I can adjust my understanding and provide good consultation and supervision based off of the framework of training they [peers] have, it's been a huge blind spot. –Site 3 Focus Group: Management

Training in peer work concepts and practice for people employed in traditional management positions to assist in providing effective peer supervision was also raised by peers:

I believe truly that supervisors should have ongoing training the same as peers. I’m a firm believer in that. Because there's a certain way that I feel I need supervision and the way that I get it often is not meeting my needs.” –Site 1 Focus Group: Peer Workers

Training and Professional Development for Peers

Peer training was another means of addressing and ensuring role clarity. In all but one of the states where organizations were situated, Certified Peer Specialist accreditation was mandatory. However, training was variable:

Even in our own state, we have a lot of curriculums that are certified trainings and meet the same core competencies but have very different philosophies. -Site 1 Focus Group: Non-Peer Management

Training for effective use of personal story was also seen as highly desirable and evident as sharing personal stories to strengthen connection/relationship, validate the experience of the person accessing the service, or provide hope. As one peer manager stated:

Sharing from your scars and not your wounds. And not talking about things that are still kind of raw for you. -Site 2 Interview: Peer Manager

Intentional Peer Support (IPS) was frequently cited as supportive in helping peers understand uniqueness of peer roles and maintain integrity in their work. Other training included emotional CPT and WRAP (Wellness Recovery Action Plan):

In terms of like practical strategies, what can an organization do to aid the employment of peers? Like, what's your top ten basically? Well, IPS. –Site 1 Focus Group: Non-Peer Management

Outcomes of Best Practice

Peer workers were often seen to promote ongoing service change either formally or informally. These services were perceived as becoming more recovery-oriented and person-directed in their service delivery.

Services Become More Recovery-Oriented and Person-Directed

At four sites, peer workers were described by both traditional workers and non-peer management as contributing to a greater recovery orientation:

I have more hope that recovery’s possible. So, I think working alongside peers every day; there's something that just happens to clinicians in my opinion. –Site 1 Focus Group: Non-Peer Management

Non-peer participants also identified changes to their perspective as a result of interactions with peers:

I really learned from them [peers] in terms of how you use yourself, how do you bring yourself into the situation, to really connect with people. –Site 3 Focus Group: Management

Being ‘‘housed” in multidisciplinary services rather than peer-run services provided peer presence and influenced workplace culture in the wider service delivery environment, increasing hope and challenging prejudicial attitudes.

I think a lot of our clinicians ended up sort of having a different kind of hope for the work that they do with and for the folks that we see. –Site 1 Focus Group: Non-Peer Management

Additional Challenges

Challenges were also identified that constrained effective employment of peer workers and inhibited the potential of peer workers to contribute to positive changes within services.

Lack of Cultural Diversity

Participants raised the need to address cultural diversity and inclusion within the peer workforce. For peer participants from culturally and linguistically diverse backgrounds, they recognized the importance of peers of color providing authentic, culturally aware connection:

I would say as a woman of color in this field, I’ve definitely been able to connect more, I guess, with other folks of color. -Site 3 Focus Group: Peer Workers

Unequal opportunities, particularly in relation to language, exclude many people of color from peer roles with the result that people of color do not receive needed support:

One of the challenges we have in working is language barriers. People [accessing services] have English as their second or third language, it can get in the way of how to really connect and communicate with each other and then, of course, things get misinterpreted for cultural reasons. –Site 3 Focus Group: Peer Workers

People from the Deaf Community also experienced challenges in relation to communication and understanding:

I feel like communication is an ongoing constant barrier because there's not enough interpreters to meet the demand and so just getting communication access to what other hearing peer specialists are talking about so that I can participate in my own team and be involved in my own team is hard. I feel left out, for lack of a better word. I feel left out a lot of the time. -Site 5 Focus Group: Peer Workers

Addressing an awareness of white privilege was noted, and a process of learning about and understanding diverse cultures and perspectives was seen as essential:

And where is the support system for that culture in your environment, and are you really willing to do the work to have cultural humility when you bring somebody on? Because if you’re gonna bring in culture or diversity or any other protected class member, you have to be knowledgeable, and if you're not knowledgeable, then they're [people from diverse cultures] just something that looks good on paper. -Site 2 Interview: Peer Manager

Leadership roles for people representing diverse cultures and perspectives were important to ensure organizational commitment to diversity:

When we’re talking about career trajectory and where to go and how to do things a little differently and how to be seen and be visible, because I feel like there are sometimes seats at the table but the people who are getting them look like the people who already have them. -Site 3 Focus Group: Peer Worker

Funding

Challenges in effectively embedding peer roles included challenges with funding not being renewed and changes to funding guidelines which had created negative consequences and affected morale for two sites. Challenges with funding demonstrate that even when organizational commitment and strategies for best practice are observed, good work can be undone by changes to funding and funding cuts:

I think some of the frustration from staff is because we value the peer roles so much… we had this solid, consistent thing [peer presence] and then from unforeseen circumstances [funding cuts] kind of been cut back a bit and so that’s been kind of tough. -Site 5 Focus Group: Non-Peer Workers

Tension also resulted from funding bodies not understanding peer work and creating funding rules that made it difficult to do authentic peer work:

Here’s a situation where we have a program fully funded. I mean an excessively funded program, and where we had alignment that peers were a critical component of connecting and engaging. And still we weren’t able to plug into the resources. –Site 4 Focus Group: Management

Medicaid reimbursementFootnote 1 was contentious, with some praising and others critical. Participants further described Medicaid reporting as potentially risking the authenticity of roles as peers were required to provide concrete outcomes from a setlist that didn’t reflect peer practice:

I mean, did they [peers] help with assertiveness and self-advocacy, and what we can we bill for? Did they give stress reduction, symptom management, all those lines you know that we have to check for billing purposes. I’m not sure I mean, maybe we could put the STR code stress reduction because they were here at that 'everybody knew their name' [place] just the environment itself is something of a comfort and relief to people who come to respite, but how is that billable that's the big question? Cos when it comes down to it, that's what they want, billable hours. -Site 3 Focus Group: Peer Workers

Conversely, one participant was adamant that rather than the reason being Medicaid guidelines, it is actually the organization mandating unhelpful reporting requirements:

People think that Medicaid somehow makes it (documentation standards) not recovery or peer oriented, but it’s technically not true. -Site 4 Interview: Peer Manager.

Medicaid reimbursement was also seen as a way for organizations without a genuine commitment to peer work, potentially employing peers simply to gain additional funding. Participants questioned how meaningfully peers were included in service design and delivery when the inclusion incentive was primarily financial:

But the fact of the matter is, everyone, jumping on the free dollars that Medicaid is offering for peer services." –Site 3 Focus Group: Non-Peer Workers

Discussion and Implications

This study obtained a clearer understanding of effective peer inclusion and organizational change from the perspectives of peer workers, non-peer staff and management in multidisciplinary mental health and substance use recovery services. These findings yield a working model of best practice for peer employment in these settings. The working model represents effective peer employment as the interactivity of whole-of-organization commitment to authentic peer work, organizational change reflected in organizational culture and strategies, and transformation towards more recovery-oriented service delivery. Consequently, the working model emphasizes the interrelationship between the effective embedding of peers within multidisciplinary environments and a process of organizational transformation. The working model and additional table of challenges and strategies have value and practical application in guiding organizations employing peers.

Participants described the organization itself as changing—synthesizing the combined workforce, rather than ‘fitting’ peers into the already existing structure, philosophy, and processes. According to study participants, integrating peers into a pre-existing paradigm is not sufficient. This is consistent with wider peer literature that highlights the role of peers as ‘change agents’ (Gillard et al., 2014; Mead, 2003; Mead & MacNeil, 2005). As peer work differs substantively from traditional clinical practice (Gillard, 2019), the change agent aspect can be controversial and poorly understood (Gillard et al., 2015). Organizational commitment to embedding authentic peer work appeared to support the peer role as change agent, contributing to service transformation.

As part of service transformation, participants noted the positive impact of peers on more recovery-oriented, person-directed approaches (Bradstreet & Pratt, 2010). Organizations adopting a recovery approach are also reportedly more likely to employ a peer workforce (Bass et al., 2008; Slade et al., 2014; Vandewalle et al., 2016). Given the strong understanding and valuing of peer work by participants in all demographics, it is concluded that when peers are empowered to work authentically and are accepted and considered valued colleagues, person-directed and recovery-informed service delivery increases. These findings support earlier work suggesting a peer leadership role in guiding organizational recovery orientation (Byrne et al., 2015).

Previous work (Gagne et al., 2018; Jones et al., 2020; Philadelphia Dept. of Behavioral Health & Intellectual Disabilities Services & Achara Consulting Inc., 2017; SAMHSA, 2018; Wolf et al., 2010) identified inter-relationships among organizational culture, commitment, and practice. This study demonstrated a deeper and more nuanced understanding of the interrelationships between adding a new role (peer employees) and concomitant organizational change. Effective peer employment occurred as peer roles were valued, taken seriously, and supported and promoted by colleagues at every level of the organization. In comparison, previous studies highlighted the importance of "top-down" support for peers (Byrne, et al., 2019a, 2019b, 2019c), this study suggests that top-down support is not enough, with the whole of workforce—including bottom-up support and acceptance, also essential. The highly collaborative nature of this work, particularly in multidisciplinary environments (Mancini, 2018), may contribute to the significance of the need for whole of workforce acceptance. Further, professional isolation has previously been identified as a challenge for the peer workforce (Happell, 2008; Mancini, 2018; Moran et al., 2013), with unwillingness from people in more traditional service roles to accept the peer workforce cited as a barrier to collaboration and effective peer employment (Asad & Chreim, 2016; Gates et al., 2010). With championing from numerous organizational levels, widespread understanding, and valuing of peers and whole of workforce acceptance are more likely.

The mental health and substance use recovery sector has been described as typically risk averse. Seeming to buck this trend, organizations in this study were described as willing to take risks, learn and work through challenges, to be transparent and open to change. This ethos is more consistent with peer values, particularly in relation to “positive risk” (Scott et al., 2011) and seeing opportunity in crisis (Mead & Hilton, 2003). Peers appear to flourish in organizations with a leadership culture naturally aligned with peer principles.

As with any significant change management endeavor, to embed peers, participants suggested multi-layered and ongoing strategies to facilitate a better understanding, mutual valuing, and authentic collegial collaboration. The organizations in this study had made an active, long-term, and financial investment in peer workforce development. All employed sufficient numbers of peers to influence workplace culture. Additionally, peers were employed both in face-to-face delivery roles as well as in executive management roles throughout the organization. Participants emphasized the importance of peer management roles with authority, informed by and connected to the wider peer movement. Previous research has indicated the critical role of peers at higher levels of authority in assuring peer priorities are addressed and role authenticity protected (Byrne, et al., 2019a, 2019b, 2019c).

In addition to the need for peers in positions of authority, the findings also note challenges faced by senior or management peers. Some management peers felt isolated and poorly understood. The relative rarity of peer management positions and the growing but still emergent understanding of peer value and credibility by non-peers may contribute to peer managers’ feelings of isolation. While the need for peer access to effective networks and other peer-led supports is frequently identified (Bateman et al., 2016; Carlson et al., 2001; Shepardson et al., 2019), and is increasingly being addressed for peer roles generally (Philadelphia Dept. of Behavioral Health & Intellectual Disabilities Services & Achara Consulting Inc., 2017), additional attention to peers in management positions is warranted.

Workplace culture has increasingly been identified in recent years as key to effective peer involvement (Jones et al., 2020). Study participants highlighted workforce preparation to reduce still-common assumptions and prejudices towards peers (Byrne, et al., 2019a, 2019b, 2019c). Recognizing the value of appropriate training for peers (Ahmed et al., 2015; Moran et al., 2013), this study also emphasizes whole of workforce training about peers. Previous research has advocated for peer leadership in all peer workforce training (Byrne, et al., 2018a, 2018b) and is also recommended by participants of this study. Formal commitment and valuing of peers and lived experience in mission statements and other policies was also highlighted to underpin ongoing positive workplace cultural change.

Congruent with previous studies (Ahmed et al., 2015; Byrne, et al., 2018a, 2018b), findings suggest HR personnel and management involved in hiring staff need to understand peer work, support the effectiveness and authenticity of the role and help choose the “right” person for the job (Byrne, 2014; Jacobson et al., 2012). Consistent with prior work on peer supervision (Kuhn et al., 2015), this study found peer supervision important in assuring role clarity and protecting role authenticity. Study findings suggest the effectiveness of peers may be enhanced through employment in peer-run agencies while assigned to traditional, multidisciplinary organizations (Byrne, et al., 2019a, 2019b, 2019c). Funding prioritized to build administrative infrastructure in peer-run organizations may be beneficial.

Significant barriers limit employment and retention of peers from culturally and linguistically diverse backgrounds, including people of color and people from the Deaf community. Language-related barriers, divergence in cultural mental health concepts, and a lack of organizational commitment to workforce diversity are common. Likewise, there are few peers of color from diverse cultural backgrounds in leadership positions. Greater emphasis and understanding of intersectionality is key to growth in workforce diversity because people with lived experiences have various identities that are salient to their lives such as culture, LGBTQ+, Deaf etc. A lack of cultural inclusion and diversity in the peer workforce also corresponds with previous research showing a lack of diversity among peer research participants (Cabassa et al., 2017).

To work towards greater diversity and equity in peer employment, it is recommended organizations commence pro-active recruitment of people from diverse cultures and backgrounds as well as whole-of-organization training in cultural capacity building (Molefi et al., 2021). For organizations, there are practical and specific ways to address barriers to access and advancement of Black, Indigenous, People of Color (BIPOC) and people who are Deaf or hard of hearing within peer work. These include greater intentional outreach to BIPOC and Deaf communities to engage people from these communities into peer support work, and provide training that addresses Diversity, Equity and Inclusion (DEI) and anti-racism directly. In addressing the lack of diversity, it is essential to acknowledge that there are many BIPOC leaders that can provide support and training. It is further recommended that organizations develop HR policies that are culturally respectful and take into account the additional responsibilities many bear when working in representative roles for their culture and community (Byrne et al., 2021). Specific policies to aid inclusion also assist to encourage the employment of people who identify as LGBTQ + and/or having other diverse experiences and backgrounds (Byrne et al., 2019a, 2019b, 2019c).

Funding appeared to be the greatest remaining challenge. Even with significant philosophical and financial investment, organizational championing and whole of workforce acceptance, funding changes can undermine the uniqueness of peer approaches. Orienting funding bodies to peer principles and practice might assist in designing funding that supports rather than inhibits peer work. Adding peers to funding body decision-making, funding design, and allocation may also be beneficial (Fig. 1).

Fig. 1
figure 1

Model of best practice for effective employment of peer workers

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Limitations

This study has a large key participant sample size for qualitative research (n = 132). It is limited by having been undertaken in only five organizations in five states in one 50-state country, the United States. It is noted that potential bias may be present due to participants’ self-selection to take part in the interviews and focus groups. Cultural representation and transferability are also limited. However, this study’s data informed two Australian based policy documents: 'Queensland Lived Experience (peer) Workforce Development Framework' and the 'National Guidelines for Lived Experience (Peer) Workforce Development'. Both projects used quantitative methods to test and validate the findings through extensive consultation throughout the multidisciplinary Australian mental health workforce including management, clinicians and peer workers. These findings therefore, have established credibility beyond the limitations of this study alone and provide confirmation from an international perspective.

Conclusion

Study findings indicate, for effective employment of peers, a whole-of-workplace approach is necessary, with peer inclusion and values integral to organizational policy and practice. When peers are accepted and considered full colleagues, can work authentically, and organizations are open to and welcome change, person-directed, recovery informed care naturally develops or evolves further. The working model based on these findings offers multi-layered and ongoing strategies for effective peer employment and organizational change.