Introduction

Peer support is a natural human response to any number of issues and circumstances. When a person is considered to be different from others, there is a need to feel that they are not alone and that others are capable of understanding them through shared experiences. Peer support takes place when two or more people (peers) share a common problem or concern and together they provide emotional support to each other and develop ways to effectively manage the issue and personally grow (Davidson et al. 1999). Among those with mental illness, an important part of coping and recovery is the unique understanding and support provided by peers. (Deegan 2006; Mead et al. 2001; Mead and MacNeil 2006).

At this time, over 30 states within the United States have developed training criteria for “peer specialists” and at least 16 states have achieved Medicaid reimbursement for Certified Peer Specialist services delivered in the mental health system (Daniels et al. 2010; Davidson and Rowe 2008). Medicaid reimbursement refers to payments service providers receive for providing services to patients that are covered under the Medicaid program (a government funded health program for persons with low incomes). This integration of Certified Peer Specialists (CPSs) into the mental health system has the potential to create synthesis, collaboration and a greater understanding helpful in providing well rounded support and services to those who are recovering from mental illness. However, there isn’t a great deal of consistency in delivery of Certified Peer Specialist Services. What constitutes a Certified Peer Specialist activity can vary from state to state as well as from one setting to another (Daniels et al. 2010).

In order for CPSs to be a successful addition to the mental health system of care, this new role must be integrated within current mental health system practices. Many employees experience feelings of uncertainty when beginning new positions (Teboul and Cole 2003). These feelings are likely intensified when the position itself is new to the organization with few role models and a lack of established norms for that position. New employees in general are concerned with violating formal and informal rules, living up to standards, and being labeled as incompetent or difficult (Teboul and Cole 2003). In addition to the fears associated with being a new employee, CPSs also face the stigma associated with having a mental illness in a professional setting that exclusively treats mental illness.

Considering that the role of CPS is new in the mental health system, and the guidelines for services provided by CPSs are not finite but are open for interpretation by each workplace, it is important to identify the services provided by the CPSs. In this study, we investigate what job activities and services are provided by CPSs, how often these activities are being performed and if these activities are specific to the CPS role. In addition, we study the embedding of CPSs into the Kansas mental health system by assessing (a) workplace integration; (b) job satisfaction; and (c) organizational support which are considered important elements for employee retention (Slattery and Selvarajan 2005; Armstrong-Stassen and Templer 2004; Teboul and Cole 2003 Wayne et al. 1997; Chernis and Egnatios 1978).

Methods

Participants

Fifty-nine people who are currently working as CPSs and who attended the five day CPS training program held by Wichita State University between 2007 and 2009 participated in this research. The sample was obtained through convenience sampling. The sample was comprised of two groups: 35 people who had held a position at the mental health center prior to becoming a CPS and 24 people who had not worked at the mental health center before they became a CPS.

Measures

Job Activities and Services

Job activities and services were measured with a 10 item scale developed specifically for this research project and included the aspects of the CPS job description as defined by the state of Kansas. Participants who were currently working as a CPS were asked to rate how frequently they engage in each job-related activity. Sample questions from this scale include “Share my personal story of recovery with consumers” or “Help consumers gain support from others”. Participants rated these items on a six point scale ranging from: (1) “not at all” to (6) “all of the time”. The scale was found to have high internal validity (Cronbach’s alpha = 0.85).

Workplace Integration

The level of integration into the mental health center was assessed by the Workplace Integration scale. The Workplace Integration Scale was developed for this research and consisted of 14 statements such as “I fit in at the mental health center” or “I am part of a team at the mental health center”. Participants were asked to rate how much they agreed with the statement on a 6 point likert scale ranging from (1) “strongly disagree” to (6) “strongly agree”. The Workplace Integration scale was found to have high internal validity (Cronbach’s alpha = 0.91).

Job Satisfaction

The participant’s satisfaction with their employment at the mental health center was determined by responses on the Indiana Job Satisfaction Survey (IJSS) (Resnick and Bond 2001). The 32 item questionnaire was developed specifically for employees who have mental illness (Resnick and Bond 2001). The IJSS is comprised of 6 subscales, (1) General Satisfaction; (2) Pay; (3) Advancement and Security; (4) Supervision; (5) Coworkers; and (6) How I Feel On This Job. Questions were answered using a 4 point Likert scale ranging from (1) “Strongly Disagree” to (4) “Strongly Agree”. The Indiana Job Satisfaction Survey was found to have high internal validity (Cronbach’s alpha = 0.90).

Organizational Support

The participant’s perceived level of organizational support was measured with the 8 item version of the Survey of Perceived Organizational Support (SPOS) (Rhoades and Eisenberger 2002) derived from the original 32 item SPOS (Eisenberger et al. 1986). Examples of items from this scale are “The organization values my contribution to its well-being” or “The organization would ignore any complaint from me”. Questions are answered on a 7 point Likert scale which ranges from (1) “Strongly Disagree” to (7) “Strongly Agree”. This Survey of Perceived Organizational Support has been shown to have high internal validity (Cronbach’s alpha = 0.97) (Eisenberger et al. 1986).

Procedure

Interviews

All measures were completed in a structured interview format. Participants were asked to participate in an interview about their experiences being a CPS. Interviews took approximately 30 min to complete. At the beginning of the interview, consent was read to the participant. Upon agreement, the interview was conducted. Researchers read the interview questions to the participant and recorded the participant’s responses on a paper copy of the interview. All scales in the interview relied on self-reported information from the CPS. In addition to completing the interview, participants who had worked in the mental health center in a different position prior to becoming a CPS were asked to respond to the interview section about job activities a second time to report how often they engaged in the same job related activities during their previous appointment at the mental health center. Participants received 10 dollars (check by mail) for completing the interview. This study was approved by the Institutional Review Board at Wichita State University.

All authors approved this manuscript and certify responsibility for the research.

Results

Demographic Characteristics of CPS

The gender composition of Certified Peer Specialists participating in this study was 68 % female (n = 40) and 32 % male (n = 19). Their race/ethnicity was 81 % Caucasian, 12 % African American, 2 % Hispanic, 2 % Asian and 3 % identified as belonging to a racial/ethnic category that was not listed. Average age of CPSs was 47 years old (SD = 11.02 years), ranging from 22 to 67 years of age. Highest level of education was reportedly 21 % high school diploma (n = 12), 4 % G.E.D. (general equivalency diploma received in lieu of a high school diploma) (n = 2), 5 % technical school (n = 3), 40 % some college (n = 23), 23 % college graduate (n = 13), and 7 % graduate degree (n = 4). The demographic composition of the CPS is similar to that of social workers, counselors and other community workers on the dimensions of gender, age, race and education (National Association of Social Workers 2003; U.S. Department of Labor, 2008). It is worth noting that although post high school education is not required of CPSs, the majority (75 %) have education beyond a high school level. These results show that demographically CPSs were more similar to their coworkers than different.

Job Activities and Services

Those who were working as a CPS were asked to report how frequently they provided CPS specific services. The overall mean for the scale was 3.69 (SD = 0.81) with 4 equaling “Frequently” and 3 equaling “Some of the Time”. The activities that were performed most frequently were “Help a consumer make independent choices” (M = 4.51, SD = 1.37), “Share my personal story of recovery with consumers” (M = 4.20, SD = 1.11), and “Help a consumer work on the objectives of their treatment plan” (M = 3.98, SD = 1.69). The CPS service and activity scale demonstrated that the CPSs were performing the 10 activities identified by the Kansas training entity as central to the role of CPS “frequently”.

Of this sample (n = 59), thirty-five people worked at the mental health center in another position prior to becoming a CPS. Using the same scale, this sub-group was asked to answer how frequently they had performed the same activities during their previous appointment at the mental health center. The overall mean score for this scale was 3.14 with 3 equaling “some of the time” (SD = 0.81). A two-tailed t test was conducted comparing the mean activity score while working as a CPS (M = 3.90 SD = 0.85) to the mean activity score during the previous position held at the mental health center (M = 3.14, SD = 0.81). A statistically significant difference was found, t (34) = 4.67, p < 0.01, Cohen’s d = 0.92.

Workplace Integration

Overall mean score on this 6 point scale was 4.80 (SD = 0.89) with 4 equaling “somewhat agree” and 5 equaling “agree” indicating a moderately high level of integration into the workplace. The highest indicators were “I look forward to coming to work each day” (M = 5.14, SD = 1.11) and “My coworkers think highly of me” (M = 5.10, SD = 0.89). The lowest indicators were “It is difficult to get questions answered” (reverse scored due to negatively worded question) (M = 4.31, SD = 1.48) and “Being a Certified Peer Specialist is stressful” (reverse scored due to negatively worded question) (M = 3.46, SD = 1.49).

Job Satisfaction

The mean for the IJSS was 3.45 (SD = 0.56), indicating a high level of satisfaction with the job. Subscale scores are as follows: General Satisfaction M = 3.69, SD = 0.52; Pay M = 2.57, SD = 0.74; Advancement and Security M = 3.15, SD = 0.69; Supervision M = 3.56, SD = 0.66; Coworkers M = 3.57, SD = 0.49; How I Feel M = 3.38, SD = 0.43. These results were similar but somewhat more positive than the sample of 71 mental health consumers who were working in a psychiatric rehabilitation facility upon which this survey was normed (Overall scale M = 3.18, with Pay being the lowest, M = 2.66 and General Satisfaction being the highest, M = 3.39) (Resnick and Bond 2001).

Organizational Support

Items on the SPOS were answered on a 7 point scale ranging from 1 “strongly disagree” to 7 “strongly agree”. The overall mean score on the SPOS was 5.69 (SD = 1.28) indicating a high level of organizational support. The highest indicators were “The organization shows very little concern for me” (M = 6.08, SD = 1.19) (reverse scored due to negatively worded question) and “Even if I did the best job possible, the organization would fail to notice” (reverse scored due to negatively worded question) (M = 5.80, SD = 1.57). The lowest indicators were “The organization really cares about my well being” (M = 5.50, SD 1.82) and “The organization cares about my general satisfaction at work” (M = 5.44, SD = 1.64).

Discussion

The Certified Peer Specialists who participated in this study indicated they were well received into the workplace. They reported high levels of workplace integration, job satisfaction and organizational support. These results are very encouraging, showing that the mental health system of care is receptive to these innovative services.

Job Activities and Services

The activities identified as specific to the CPS role were reportedly performed frequently by the CPSs. The CPSs were likely using the skills from the CPS training and appeared to be adhering to the job description of a CPS in the mental health center. This also indicates support from mental health centers for these activities. When asked the same activity and service scale, the CPSs who had held a previous position at the mental health center reported performing the activities substantially less in their previous roles. We believed it was important to compare the reported frequency of activities deemed specific to CPSs in the current role to that of prior positions held to ensure that CPSs were, in fact, performing a unique service, rather than billing the same services of the previous position under the new Medicaid reimbursable title of CPS.

Some aspects of the CPS position may be similar to other positions in the mental health center such as Attendant Care or Mental Health Technician, but the primary aspects of CPS are significantly different. The frequency of all identified CPS activities increased in the CPS role. Activities with the greatest change were assisting a consumer in making independent choices, teaching strategies to independently manage psychiatric symptoms, and helping a consumer to identify precursors or triggers that result in functional impairments. These three activities were prime examples of putting the consumer in control of their own recovery (a central tenant to the CPS philosophy).

Workplace Integration

The overall score on the Workplace Integration scale shows that CPSs were being successfully integrated into the workplace. Indicators of integration which received high agreement from the CPSs included: “feeling like part of a team”, “feeling supported at the mental health center” and “feeling like other staff at the mental health center did not look down on them”. Considering the stigma associated with mental illness and that state and federal policy mandated that mental health centers hire CPSs, it was encouraging to find successful integration into the existing mental health center culture.

Job Satisfaction

The responses to the Indiana Job Satisfaction Scale allowed more insight into the satisfaction CPSs have with the particular aspects of working at the mental health center. The total score on the scale indicates satisfaction with the CPS position overall. The scores on General Satisfaction, Satisfaction with Coworkers and Satisfaction with Supervision subscales were all high, which is consistent with the findings of the Workplace integration scale. The subscales that had the lowest scores were Satisfaction with Pay and Satisfaction with Advancement and Security. As the professional role of the CPS is new to the mental health system, there is uncertainty about advancement opportunities as no such structure has been developed. In fact, there were really no other jobs for which a CPS could be promoted to at this time.

Additionally, a higher degree of uncertainty regarding the future was found with the national economic crisis beginning in 2008. Many of the concerns were about possible budget cuts that could affect their position. Some shared that they believed their position was in jeopardy because it was new and that state budget cuts could eliminate Medicaid funding for the CPS position. These concerns were not unwarranted or unique to mental health.

Organizational Support

CPSs believed they were supported on all dimensions of organizational support measured by the SPOS. This scale was normed on groups of employees who worked in a variety of settings including postal clerks, financial trust employees, high school teachers, law firm secretaries, bookstore employees, telephone line workers, white collar workers, secretaries in manufacturing, and credit bureau clerical workers. Their scores ranged from 2.88 (postal clerks) to 5.67 (white collar workers and secretaries) (Eisenberger et al. 1986). CPSs reported a comparatively high score (5.69) which is a powerful finding especially considering the context of mental health centers in which a new role is instituted from outside that can only be filled by a mental health consumer. Mental health centers are not easy environments but most mental health professionals care deeply about their work and for those they serve, and it appears they were accepting and supportive of the CPSs.

Future Research

The CPSs in this study reported being well received and supported in their mental health centers; being that only CPSs from Kansas were included in this study, it would be beneficial to conduct a larger scale study to better understand the generalizability of these results. Also examination of the inter-relationships between the variables included in this study, or perhaps the inclusion of different, uncorrelated measures would be useful in creating a better understanding of the CPS climate. Future research needs to be conducted on the satisfaction and outcomes of those CPS’s serve. Further, conducting natural and controlled experiments to formally assess the outcomes related to peer support are needed to best understand how to successfully implement peer services in and outside of mental health centers.

Conclusion

Certified Peer Specialists are being trained and hired to provide peer support in mental health centers. The results of this study show that the CPSs were being well received and were given the support need to do their job. CPSs are diverse in age, race and education, with many of them having at least some college course work. CPSs are providing new services and engage in new activities that are unique to the role of a CPS and were not offered at mental health centers previously. Overall, CPSs show high levels of integration into the workplace, high job satisfaction, and strong perceived organizational support. The high levels on these important factors will serve as a buffer against burnout and job turnover, but more immediately show a high level of acceptance of CPSs by their co-workers who previously were their case managers and therapists. This research is encouraging in that the results represent a powerful step in evolving the mental health centers into an organizational and therapeutic culture based in recovery.