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Open Access

Peer-reviewed

Research Article

What support do frontline workers want? A qualitative study of health and social care workers’ experiences and views of psychosocial support during the COVID-19 pandemic

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft

* E-mail: [email protected]

Affiliation Division of Psychiatry, University College London, London, United Kingdom

Roles Formal analysis, Investigation, Project administration, Validation, Writing – review & editing

Roles Conceptualization, Validation, Writing – review & editing

Affiliations Division of Psychiatry, University College London, London, United Kingdom, Traumatic Stress Clinic, Camden & Islington NHS Foundation Trust, London, United Kingdom, National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom, University College London Hospitals NHS Foundation Trust, London, United Kingdom

Affiliations Division of Psychiatry, University College London, London, United Kingdom, Department of Community Mental Health, University of Haifa, Haifa, Israel

• Jo Billings, 
• Nada Abou Seif, 
• Siobhan Hegarty, 
• Tamara Ondruskova, 
• Emilia Soulios, 
• Michael Bloomfield, 
• Talya Greene

• Published: September 2, 2021
• https://doi.org/10.1371/journal.pone.0256454
• Peer Review
• Reader Comments

The COVID-19 pandemic has placed a significant burden on the mental health and wellbeing of frontline health and social care workers. The need to support frontline staff has been recognised. However, there is to date little research specifically on how best to support the mental health needs of frontline workers, and none on their own experiences and views about what might be most helpful.

We set out to redress this research gap by qualitatively exploring UK frontline health and social care workers’ own experiences and views of psychosocial support during the pandemic.

Frontline health and social care workers were recruited purposively through social media and by snowball sampling via healthcare colleagues. Workers who volunteered to take part in the study were interviewed remotely following a semi-structured interview guide. Transcripts of the interviews were analysed by the research team following the principles of Reflexive Thematic Analysis.

We conducted 25 interviews with frontline workers from a variety of professional groups working in health and social care settings across the UK. Themes derived from our analysis showed that workers’ experiences and views about psychosocial support were complex. Peer support was many workers’ first line of support but could also be experienced as a burden. Workers were ambivalent about support shown by organisations, media and the public. Whilst workers valued psychological support services, there were many disparities in provision and barriers to access.

Conclusions

The results of this study show that frontline health and social care workers are likely to need a flexible system of support including peer, organisational and professional support. More research is needed to fully unpack the structural, systemic and individual barriers to accessing psychosocial support. Greater collaboration, consultation and co-production of support services and their evaluation is warranted.

Citation: Billings J, Abou Seif N, Hegarty S, Ondruskova T, Soulios E, Bloomfield M, et al. (2021) What support do frontline workers want? A qualitative study of health and social care workers’ experiences and views of psychosocial support during the COVID-19 pandemic. PLoS ONE 16(9): e0256454. https://doi.org/10.1371/journal.pone.0256454

Editor: Vincenzo De Luca, University of Toronto, CANADA

Received: March 10, 2021; Accepted: August 8, 2021; Published: September 2, 2021

Copyright: © 2021 Billings et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data supporting the findings of this study have not been made generally available due to the personal and sensitive content of the frontline workers’ accounts, in line with the requirements stipulated by the UCL Research Ethics Committee. Data can be made available upon reasonable request to the corresponding author (JB) or to the UCL Research Ethics Committee: [email protected] , 2 Taviton St, London WC1E 6BT.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

On March 11 th , 2020, the World Health Organisation declared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19, to be a worldwide pandemic [ 1 ]. In the UK, healthcare workers braced themselves, as news from around the world described healthcare workers overcome by the requirement to treat rapidly growing numbers of patients affected by the virus. Many NHS services in the UK did subsequently report themselves to be overwhelmed, whilst other services mobilised to respond to additional demand never reached expected capacity. Other groups, such as care home staff, were overwhelmed in ways never anticipated.

Early quantitative research emerging from the UK [ 2 – 4 ] and around the world [ 5 , 6 ] has demonstrated a significant mental health burden experienced by frontline workers in response to COVID-19, with elevated rates of depression, anxiety, post-traumatic stress disorder (PTSD) and suicidality reported. In the UK, it has been estimated that 45–58% of the frontline health and social care workforce met criteria for clinically significant levels of anxiety, depression and/or PTSD shortly following the first wave of the pandemic [ 2 , 3 ]. This is amongst a workforce already under considerable strain pre-COVID-19, as evidenced by the growing incidence of stress, burnout, depression, drug and alcohol dependence and suicide across all groups of health professionals, worldwide [ 7 ].

The need to support the mental health of frontline staff during COVID-19 has been recognised [ 8 ]. However, this pandemic has also highlighted a paucity of research on the mental health needs of frontline health and social care workers, and a lack of evidence-based guidance about what psychosocial support might be most effective in helping them. What guidance there has been issued during the COVID-19 crisis has tended to come from expert opinion and be extrapolated from other professional groups, such as military personnel. In a rapidly escalating pandemic, such top down ‘command and control’ guidance has been of value. However, health and social care workers are a unique workforce, living alongside their work, not deployed into time-limited situations of crisis, nor with any allocated time to decompress [ 9 ]. We require specific evidence on how best to support the mental health needs of this population, during a pandemic and beyond, and this evidence-base must necessarily be underpinned by the workforce’s own views and preferences.

So far, there has been very little qualitative research exploring frontline workers own experiences and views of working on COVID-19. What qualitative research has been published so far has tended to be on small samples, limited to doctors and nurses, and of poor to moderate quality [ 10 ]. No research to date has considered health and social care workers’ own opinions about psychosocial support. We set out to redress this gap by asking frontline health and social care workers about their own experiences and views about psychosocial support during the pandemic, and in so doing, aimed to amplify the voices and views of frontline workers themselves. This collaborative contribution is vital as we face further waves of COVID-19 in the UK and need to ensure that we can maintain the wellbeing of the health and social care workforce and sustain the services they provide to the UK population.

2.1 Study design, participants, and procedures

All procedures were approved by the University College London Research Ethics Committee (Ref. 18341/001).

We recruited frontline health and social care workers purposively through social media (Twitter and Facebook) and by snowball sampling via healthcare colleagues, asking them to pass on details of the study to potential participants. We invited any health and social staff who had been working directly to treat patients affected by COVID in any UK based health or social care organisation. We excluded health and social care workers not working in direct COVID related roles or other non-health or social care frontline workers. We deliberately sought a wide range of participants, including different professional groups, career stages and geographical locations, to access a diverse range of experiences and views.

Potential participants were invited to contact the first author via email. They were then sent the study Participant Information Sheet and Consent Form by return email. As all interviews took place remotely, participants were asked to return the electronically signed consent form to the allocated interviewer in advance of the interview. All interviews were completed by four graduate students in Clinical Mental Health who received training from the first author. Written informed consent was obtained from all participants prior to taking part in the interviews.

Interviews were arranged at a mutually convenient time between the interviewer and the frontline worker and took place by telephone or online video call. The interview guide (see S1 Data ) was drafted collaboratively by the research team, in consultation with our Expert Reference Group, comprising NHS service leads, Wellbeing officers, and clinicians with lived experience of mental health difficulties. All the interviews were audio recorded and then transcribed verbatim by the interviewer who conducted the interview. All potentially identifying information about the participant and their place of work was removed from the interview transcripts to protect participants’ anonymity. Pseudonyms are used for illustrative quotes.

The wellbeing of our participants and our research team was of paramount importance throughout this study. If any participant reported significant distress, they were signposted to local and National sources of psychological support. The research team were supported by regular supervision from the first author.

2.2 Analysis

We followed the principles of reflexive thematic analysis [ 11 , 12 ], underpinned by a critical realist epistemological stance, throughout this study. In keeping with thematic analysis, we sought immersion in the data by reading and re-reading all the transcripts, reflecting on the interviews and discussing emerging themes in research team meetings. JB and the four interviewers independently coded two transcripts each, to derive an initial list of potential codes. This coding frame was reviewed and agreed through discussion in the team. All transcripts were then imported into NVivo Pro V12 and coded into the provisional coding frame, which was further extended and refined with the coding of subsequent transcripts. All coding was inductive, derived from the data, and not pre-determined by any pre-existing theories. A final set of themes was then developed from the coded data and revised with feedback from participants, health and social care worker colleagues and our Expert Reference Group.

The concept of ‘data saturation’ is not considered consistent with the values and assumptions of Reflexive Thematic Analysis and its underlying non-Positivist ontology [ 13 ]. Therefore, we drew on an ‘information power’ approach [ 14 ], considering the research aims, sample specificity, established theory, quality of dialogue and analysis strategy to guide our decisions about how many participants to interview. Ultimately, we sought a sufficient sample size of health and social care workers to offer a pragmatic balance between breadth, and depth, of analysis, as advocated by Braun and Clarke [ 13 ] the founders of Reflexive Thematic Analysis.

2.3 Reflexivity

Reflexivity is an important component of all qualitative research, enabling the reader to consider the validity of the analysis by better understanding the research team who have produced it. This team is made up of a diverse group of researchers, including different career stages, clinical specialities, genders, and cultural groups. JB is a Consultant Clinical Psychologist and Associate Clinical Professor with over 20 years of experience of working in the NHS. She has particular expertise in the mental health and wellbeing of high-risk occupational groups. NAS, SH, TO and ES are all MSc graduates in Clinical Mental Health Sciences. All volunteered to work with the team during the COVID-19 pandemic. It is worth noting that all the interviewers who conducted the interviews are female. MB is an Honorary Consultant Psychiatrist and Principal Clinical Research Fellow. He has 19 years’ experience of working clinically in the NHS. TG is a Senior Lecturer specialising in research on psychological responses to mass traumatic events. The research team was an ethnically diverse group, including White British, Arab, White Irish and White European backgrounds. As a team we brought a range of different perspectives and experiences to this topic.

2.4 Quality and validity

We have adhered to the highest standards for conducting and writing up qualitative research throughout this study. We have drawn on existing frameworks for quality in qualitative research: including the Standards for Reporting Qualitative Research Framework (SRQR) [ 15 ] and specific guidance for quality practice in reflexive thematic analysis [ 16 ].

In qualitative research, we are less concerned with reliability and generalisability but attend more to validity, transferability and trustworthiness [ 17 ]. To increase the validity of our results, we included multiple researchers in the processes of data collection, coding and analysis; challenging our own assumptions and identifying potential ‘blind spots’ that any one of us might have had with regards to this topic. We met regularly throughout the course of the research to discuss emerging observations and all members of the research team were actively involved in developing the written report of this study. We also presented our preliminary findings to both mental health colleagues and health and social care workers in a variety of forums to discuss the face validity of our emerging themes. Two healthcare workers who took part in the interviews provided feedback on our analyses as a form of member checking.

In this study, we have not sought to achieve a representative sample of participants with the intention of generalising our results to all health and social care workers in the UK. However, we deliberately tried to include as varied a group of participants as possible in order to explore the diversity of experiences and views of support during the pandemic, to increase the potential transferability of our findings.

To increase the trustworthiness of our interpretations, we have sought to be transparent about the research team conducting the study and the lenses through which we have viewed this data. Below we provide quotes from participants to illustrate and evidence our analyses.

Twenty-five frontline health and social care workers volunteered and took part in the study. The gender, roles, settings and geographical locations of participants are shown in Table 1 .

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https://doi.org/10.1371/journal.pone.0256454.t001

Interviews took place between June 1 st and July 23 rd , 2020; and lasted between 30 and 77 minutes. Ethnic origin was not recorded at the point of recruitment, although several participants described themselves as being from minority ethnic groups during the interview.

Experiences and views of psychosocial support during the pandemic were organised into six domains according to potential sources of psychosocial support. These domains are not themes per se but were areas identified by the workers when asked about what sources of support were important to them. Within these domains, we identified a number of pertinent inductive themes (see Table 2 ), which are described below and illustrated with quotations.

https://doi.org/10.1371/journal.pone.0256454.t002

This category describes how workers sought to support themselves during the pandemic.

3.1.1 Just getting on with it.

The predominant narrative amongst the frontline workers when they spoke about how they coped during the pandemic was one of “just getting on with it”. This mentality was attributed to being a positive person, being part of the job, or simply not having a choice.

“ yeah , you just get on with it” , it’s your job . ” Ella , ICU nurse “ I have to say , it was tough , yes . But there isn’t anything I could have done about it really . I just had to get on with it . ” Nick , Healthcare assistant

Finding purpose and meaning in the work they were doing helped many of the frontline workers to cope and maintain motivation.

“ I’d try and draw on the positives that were happening through this , people being discharged , people surviving this against so much past medical history . That was really positive and reassuring to hear” . Katerina , OT

This focus on “just getting on with it”, for some however, led to them failing to recognise or subjugating their own needs. Yara, an A&E nurse told us:

“ I cried a lot . Felt rubbish about going to work . But to be honest , I think I just buried it all because I had to . ”

Staff sought opportunities to engage in existing coping strategies where possible, such as exercise or spending time with family, although several acknowledged that they were not able to engage in previously enjoyable activities as much as before, due to working extra hours, being too tired, or not being able to access them due to lockdown and social restrictions. Many workers commented on not having been able to take time off work or use annual leave during the pandemic and several acknowledged increasing alcohol consumption in the absence of other mechanisms to relieve stress.

3.2. Family and friends

Participants described how family and friends could be an important source of support, but also engendered feelings of worry and responsibility. They also felt that family and friends were often unable to relate to what they were going through.

3.2.1. Competing demands.

Some participants commented on having the opportunity to spend more time together at home with family during lockdown which they valued. For others, trying to manage the competing demands of work and family commitments was a source of stress. Most participants had additional caring responsibilities and talked about juggling childcare with working spouses, not being able to use grandparents for support and often having to take on extra tasks for vulnerable family members who were shielding. Amy, a physiotherapist in ICU told us:

“ Seeing the patients wasn’t the emotional bit- we’re used to seeing poorly patients- actually having to then deal with your home life and the change to your home life , I think that impacted on it hugely and that was probably more stressful for me than actually working in the acute hospital”

Similarly, Daniella, a mental health worker described:

“ On my days off I was getting more exhausted because the shopping was taking… I was doing shopping for my household , my partner , my mother , his mother and for work . ”

3.2.2 Separation and sacrifice.

Many workers expressed concerns about contaminating their families. Participants talked about keeping their families away from other people, and even keeping themselves away from their own families.

Katerina, an OT in London, told us about her fears of contaminating her vulnerable partner who was shielding, leading her to live in a caravan on their driveway for 14 weeks during the peak of the pandemic.

“ It felt like that was the right thing for us to do to try and protect him , because if he was going to get it , it would be only through me…and the thought that he could’ve caught that from me was just overwhelming , so that was the thing that I could do , was to help and keep working , but also protect him at the same time . ”

As a result, several workers talked about feeling isolated, although perceived this as a necessary precaution.

“ I still don’t feel very comfortable going to visit my family or any of my friends because I don’t want the risk of them having anything and giving it to me and me passing it to the home , or anyone in the home having anything and then me passing it to my family . I feel very–quite a bit , like , isolated from the world , and more isolated than people that aren’t working on the frontline , because we have a lot of weight on our shoulders of the places where we have to be . ” Joy , Carer , Dementia Care Home .

3.2.3 Not in our boat.

Many participants talked about the importance of keeping in touch with friends and family, often online. Some valued having the opportunity to talk to people outside of health and social care about things that were not work related. Workers valued the support of family and friends, both emotional and practical.

Many participants, however, acknowledged that it was often hard to talk to friends and family who might not be able to relate to what they were going through–who were “not in the same boat”.

Olivia, a Physiotherapist told us:

“ Nobody really understands what it was like . I can come home and kind of explain it to my husband , but he doesn’t work in a hospital , he doesn’t really know what it is like working in intensive care anyway , and so , you couldn’t really come home and tell him what it was like , cause nobody ever really can accept what it’s like unless you are working there as well . ”

Workers also did not want to burden others. Ester, a Nurse, described trying to talk to her daughter:

“ I tried to talk to her once , but then she said she had her own anxieties and problems with Uni work , and exams and things like that . So , I tried to talk to her once , but she got so upset , that after that I can’t put this on her as well . ”

3.3. Colleagues, peers and teams

For the most part, participants spoke positively about their experiences of support from colleagues and peers, united through shared experience. However, this was not straightforward, and peers were not always a source of support.

3.3.1 In the same boat.

Participants described a strong sense of camaraderie and peer support. In contrast to family and friends, workers felt that colleagues could relate to their experiences.

“ We all support each other , because we’re all in the same boat , we’re all sort of going through the same emotions . ” Joy , Carer , Dementia Care Home .

Workers valued being able to talk to someone who could understand and relate to what they were going through. When asked who she found it most helpful to talk to, Olivia a Physiotherapist said:

“ definitely the colleagues that I worked with , being able to share that experience with them and talk it through , was really , really helpful . Because , obviously , they really understood how you felt , because 99% of them felt exactly the same way . ”

Workers particularly valued colleagues knowing and understanding the unique demands of their role and would often seek their support over more formal sources.

“ I personally , I would probably rather , I’ve had a few colleagues that I’ve used as confidants rather than speaking to somebody outside my circle . I know there are well-being apps and things being rolled out to people free of charge which were suggested to me , but I’ve not used them , in all honesty . ” Michael , Doctor .

Workers appreciated colleagues for being able to normalise and validate emotional responses and appreciated the opportunity to share decision making. They also particularly valued support from colleagues and peers as it was usually easily accessible and timely at the point of need.

3.3.2 Tensions and transitions.

Relationships between colleagues were not, however, always straightforward or supportive. Whilst many groups were brought closer together by shared experience, others were separated, and divisions were observed between those perceived as doing more and those perceived as doing less. Resentments brewed between those who accepted redeployment and those who were not asked or who refused. As some groups bonded, fractures were amplified between different teams, departments and wards.

Many staff were redeployed into new roles and/or new locations during the peak of the pandemic and this was a particular source of frustration and tension.

“ I got moved to a different team of people to work with that I didn’t know and they didn’t really know me or my skills or my background or whatever… they didn’t know what I was able to do and not do , and then I wasn’t being used effectively . That was quite frustrating . Or you know , they would change the times they’re having meetings and stuff and I wouldn’t really be updated…I felt like I wasn’t being taken care of by their team . Particularly when like , I don’t normally do this , I’m already out of my comfort zone a bit here…We were kind of the outsiders , and it still is…I feel like an outsider . ” Alice , Physiotherapist .

Several redeployed staff talked about being “outside of their comfort zone” leading them to look for more support from new colleagues, but not always finding it.

“ you go for a break you didn’t know anybody , so it was quite lonely on your breaks . So , you kind of just sit there and saw people talking to each other and ranting . But I did not have anybody , because I did not know anybody . ” Ester , Nurse .

On returning to previous teams, support was still not always necessarily forthcoming, as Ester went on to tell us.

“ The week I finished my redeployment , I came back to my normal role , and had a bit of a breakdown , because there was nobody here . My colleague went home for annual leave , I couldn’t find my managers . ”

3.3.3 Burden of responsibility.

Workers also described a sense of burden in caring for others. Several worried about being a burden when they were working in a new role or environment. Some talked about feeling burdened by colleagues. Others described feeling a burden of responsibility to look after others.

Workers worried about whether they were doing the right thing and giving the right advice to colleagues. They also noted how it was harder to support others when they themselves were feeling depleted.

“ You felt responsible for the nurses that were there on the first shift . On top of everything , you had the added pressure of , you know , you felt responsible making sure that they were okay , when you yourself were not 100%” . Ester , Nurse .

Similarly, Megan, an A&E nurse described how workers did not want to burden colleagues further when everyone was going through the same stresses:

“ We’re a really close team but because everybody is in it , there isn’t that support around you because everybody needs to be for themselves . It is a time when everybody needs to be quite selfish but that means that there isn’t anybody there really asking how you are because everybody is asking themselves how they are . ”

Later, Megan spoke about this as a barrier which prevented workers from seeking peer support from designated colleagues:

“ There are posters in changing rooms and things , saying like ‘if you need someone to talk to…’ and there are the named people who have put themselves forward for if you want to talk to them , but you almost feel like they are in this job as well and I’m going to come to them with something they are doing as well and it’s hard , you almost feel like I don’t want to bother them with a problem when they are going through it as well . ”

3.4. Organisational support

3.4.1 practical needs..

Staff valued organisational responses which addressed their basic human needs during the peak of the crisis. This support was appreciated both on a practical level but also in that it conveyed value of the workers themselves. Workers spoke about free meals, access to free parking and areas to rest and recover being important.

“ They provided free parking which I think staff really valued and they also provided free meals… and little things like that have really helped because it just makes people feel more appreciated . ” Amy , Physiotherapist .

This kind of practical support was prioritised by many during the peak of the pandemic. As Anna, a Consultant in A&E said:

“ We appreciate the basic things done well…making sure that we get our breaks , that we have access to hot food in our department . Simple things like that are actually really important…I don’t think that putting on meditation or resilience training are necessarily the best way to help and support staff . I think that making them feel like their basic needs are helped and they are valued , are probably the most important things . ”

Whilst this practical support was important, some pointed out inconsistencies in messaging, for example, free food including many sugary and unhealthy snacks. And whilst staff appreciated these resources, they often noted that in reality, having the time during their busy shifts to access them was impracticable. A couple of participants also commented on how resources were positioned, for example, how a rest area being labelled a “wobble room”, could perpetuate stigma, as staff did not want to be seen as someone “having a wobble”.

Whilst these forms of additional support were appreciated by the workers, when they were subsequently taken away, staff felt de-valued, which was reflected in lower morale.

“ The free snacks and the free coffees go away and everyone’s sort of like oh , back to business as usual , people have forgotten that actually , the rest of the time we’re all trying to do a really good job and help people , I think that’s when everybody’s going to need a bit of a morale boost . ” Alice , physiotherapist

Workers appreciated flexibility in their working patterns, especially when they had other caring responsibilities or were vulnerable members of staff who needed to shield. Staff valued opportunities to take breaks, although many commented that they had not been able to take time off work and use annual leave.

“ I haven’t had a lot of time off . The whole annual leave situation [laughs] not to bag on my trust and my hospital but that was non-existent for a period of time . I haven’t had annual leave , I am due to have it so that is fine but I know that more than ever in my life , I am hanging out for a bit of time off because I do feel exceptionally burnt out . ” Alyssa , Doctor , London

Workers also shared concerns about patients who were not being treated during the peak of the pandemic and the burden of growing waiting lists. This as well as increasing rates of COVID compounded the sense expressed by many of having had insufficient time to recover.

3.4.2 Information, communication and consultation.

Workers sought consistent information and clear guidance. They especially wanted clear communication around PPE and safety procedures, but noted that recommendations changed daily, leading to confusion and inconsistencies.

“ The trust was very good in that they had their message that they were filtering down but they didn’t filter it down consistently and that was a big level of frustration so it was one day oh , you need to be doing it this way , the next day it was some other way , and everyone interpreted what they meant differently . ” Amy , Physiotherapist

Workers talked about problems with communication within and between teams. They noted that many methods of communication were problematic, with staff rarely having time to check emails. Not all staff had equitable access to information, with agency and contractual employees not having access to NHS email accounts, via which information was often disseminated.

Workers wanted communication to be two-way and wanted to be consulted in the process of decision making. Some gave examples of feeling listened to and involved, more spoke about their views not being invited or taken into account.

“ It has been a bit frustrating I think we feel from an A&E point of view that we haven’t been that involved . There are these task force that we should we have some representation at , and we haven’t been involved . So , I think that we have been expected to respond to things but without being involved in the strategic management . ” Anna , Consultant , A&E

At worst, the workers felt like their views were silenced and invalidated by organisational and governmental responses.

“ They should listen to the people on the frontlines , that was the major problem because there was a massive mismatch between what the government kept on saying , what the NHS bosses kept on saying and the people on the front lines saying ‘no , we don’t have that . We don’t have what we need to keep us safe’ and the government were trying to silence the people who were working on the front lines…they were treating us like we were stupid like making us doubt our memory like ‘did this really happen ? You’re saying we had all the equipment , why is it we don’t have it then ? Why are we getting ill ? ’” Alex , Agency Nurse .

3.5. Media and the wider public

Participants described mixed feelings about support offered by the media and the wider public. On the one hand, they appreciated the recognition and value of their work. On the other, they felt such support was often short-lived and many-times unhelpful.

3.5.1 Recognition and awareness.

Healthcare workers appreciated media coverage of their work when it raised awareness of important issues in realistic ways. For example, participants from allied health professions, such as physiotherapy and occupational therapy, told us that they valued coverage of their professional roles in healthcare settings which they felt were previously poorly understood by the public.

The media was also valued for its role in raising awareness of the challenges that NHS workers were facing and advocating for resources such as personal protective equipment (PPE).

“ I think that what the media has done is a good thing because it has said look , we need to have this recognition that the NHS as a whole , it can’t handle something like this , and they do struggle , and this is going to be a massive knock back for the NHS , like , they’re going to struggle to come back from it a lot . I just feel like the media portrayed it well in saying , there needs to be more help , there needs to be more PPE , stuff like that . ” Will , Paramedic .

Participants did, however, also highlight groups of workers who they felt were forgotten by the media and largely absent in their representations, but equally affected by the pandemic, including care home workers, porters, cleaners and mortuary workers. Several participants commented on resentment harboured towards healthcare staff by other keyworkers or furloughed employees who felt overlooked by the media and public.

3.5.2 A double edged sword.

Whilst workers appreciated positive media coverage and public gratitude, most expected that this would be short-lived. Participants expected that they would soon be “forgotten” or worse, anticipated that a “backlash” would inevitably follow.

Zahra, a junior doctor told us:

“ I’m worried there’s gonna be a backlash when people are seeing that now we have to put all the cancer treatment on hold , and all this stuff , all these really sick people that haven’t been coming in , and GPs are gonna be completely on their knees after this , and its already been impossible . So , then the backlash is gonna be big because it’s gonna be OUR fault that nobody can be seen . ”

Megan, an A&E nurse, captured the double-edged sword of the media portrayal of health care workers:

“ I think that we’re the heroes when people want us to be and we’re the villains when people want us to be . We are the scapegoat for everything aren’t we so , we’re the national treasure when we want to show off to the rest of the world but it’s not long until we are back to being slated . ”

Many workers also went on to talk about the hypocrisy of public and media support. For example, Katerina, an OT, said:

“ The clap for carers , I really liked it at the beginning , I felt it was something really positive that the community felt they could do to show their appreciation…but then , as time sort of went on , and we saw more and more people out in the parks , it almost became a little bit of an insult . My team felt like when we would go outside and see people just hanging around in groups , it was just…are you the people that are clapping for us and then also going off to do that ? It really just seemed contradictory . ”

3.5.3 Unhelpful heroic narratives.

Several participants commented that media portrayals were inaccurate, tending to glorify healthcare workers’ roles and present a positive media story.

“ It just showed the glory of things , you know , people ringing a bell as they left the ward and things like that but it didn’t say how many nurses had to move out of their own houses and how many had to cut contact with their children as some people had to . I don’t know , I don’t think it showed maybe the weight on the shoulders of all of us and yeah , I do feel like the clapping was widely broadcast and showed how lovely everyone was being but I don’t think anybody is talking about what it really means to support the NHS and frontline workers” Megan , A&E Nurse

Similarly, Michael, and A&E doctor told us:

“ I think most of the things that I’ve seen have tried to be a bit upbeat and I don’t think all of the negatives have come through . I don’t think the fact that hospitals were literally like war zones with all of the chaos that was going on has necessarily come out in the media . ”

Heroic narratives were seen as particularly unhelpful and were not welcomed by any of the workers in our sample. Several described this as “over the top” when they perceived themselves to just be doing their jobs; jobs they did all year round, not just during the pandemic. Many participants felt that such narratives detracted from debates about adequate pay and protection.

“ It makes me feel really uncomfortable , with people clapping and all that stuff , when really , you know , what would’ve been a lot more helpful is PPE and some proper staffing to begin with . ” Zahra , Junior Doctor “ Being called a hero or an angel is deemed to be sufficient reward for managing down salaries…it is very easy to say you’re doing a fab job , you know…but it’s about how you support your staff in a consistent and meaningful way . So , the notion of heroes and angels , I don’t think is one that I have found particularly valuable or helpful . Appreciation is nice , but it’s not heroism , it’s doing the job that you are paid to do . ” James , Nurse , Scotland .

For many, this appeared to serve the function of perpetuating a view of health and social care work as a vocation, and a sacrifice that workers were willing to make, akin to military personnel.

“ The Thursday night clap was always very , really like , angering and made us just so frustrated…made us feel like “ok , so you think that will be enough for us ? Don’t give us safe working conditions and hazard pay” , but instead , they brought in this idea of heroes , like militarising the whole response , like our death would be seen as a sacrifice rather than absolutely due to inadequate response from the employer , from the government . That made us so angry . The glorification of the NHS worker , instead of giving us what we need which is proper protection . ” Alex , Nurse

Furthermore, some workers also observed that such narratives devolved responsibility from the wider public.

“ Placing nurses as heroes devolves responsibility from others…we’re not heroes , we’re all just doing our part … but everybody has their part to play in this . ” Katerina , OT .

3.6. Psychological support services

Support from psychological therapy services, when available, was largely valued, and those who had accessed them, or knew others who had, spoke positively about them. However, there appeared to be large disparities in what was available and significant barriers to access.

3.6.1 Awareness.

There was a striking variety of experiences amongst the workers in our sample. Some felt psychological support services were well advertised and available, although notably not many of these participants felt that they themselves were in need of them. Many others were unaware of what psychological support was available.

Some participants highlighted a lack of recognition of mental health issues in the first place.

“ I think firstly , there needs to be a way of recognising it because everyone has been so involved that it has been hard to recognise that people are falling apart , one of the people went off with an acute psychotic episode and actually in retrospect we should have picked that up earlier and one of my other colleagues has gone off with very bad depression in the last week and the signs were there but it’s a matter of how you try and spot that . ” Michael , Consultant .

A few participants who had received wellbeing or Psychological PPE training early on in the pandemic valued this; some others thought this desirable, but for most, this was not something they had experienced.

Communication about what psychological support services were available was often unclear and inconsistent, leaving staff uncertain about what support was available and confused about how to access it.

“ There hasn’t been psychological support available . Or at least I didn’t have time to look for it . And if it was there , I didn’t see it . It wasn’t made available , it wasn’t visual … I certainly haven’t seen anything . ” Grace , ICU Nurse “ Lip service is given to numbers you can call and things like that . But I wouldn’t know how to access it . I don’t know their numbers; I wouldn’t know who to contact . ” Jasser , Consultant

3.6.2 Accessibility.

Even when staff were aware of support being available, they often seemed to feel that this was quite remote, irregular and not easily accessible. When asked what mental health support was available, Ester, a redeployed nurse, told us “they just said that the wellbeing team is available and to contact them if we had any need of it” . Anna, a Consultant in A&E also described:

“ We didn’t have regular access to a psychologist in the department . They were kind of infrequently coming and touching base with us . I don’t know how great the uptake would be if they had come down regularly…I was hoping we would be able to have some support on a regular basis . ”

When staff did try to seek help, they were not always able to access it. Yara, an A&E nurse told us:

“ We were told if we wanted to speak to someone , we could phone occupational health . But every time you tried to phone occupational health it was engaged . ”

Similarly, Anna, Consultant in A&E, talked about problems accessing counselling services in her hospital:

“ People have tried to take up these interventions , but they haven’t managed to actually get through to anybody . It’s just that the phone lines are busy , or they have been unlucky in terms of when they are trying to call…So , although technically the provision is there , I haven’t actually spoken to anyone who has managed to speak to one of the counsellors . ”

There were also many practical and structural barriers to accessing psychological support services. Workers commented on services usually only being available in working hours, Monday to Friday, which did not correspond with the shift patterns that most staff worked during the pandemic. Many staff commented that they were too busy during their shifts to be able to take time out for such appointments, and understandably did not want to attend after the end of long shifts, or to come in to work on their time off.

“ There were a couple of things set up like one was to drop in and have a cup of tea and a chat about how people are feeling but I don’t think people ever realised like we are not going to be able to just pop in and have a cup of tea in the middle of the day . They were good ideas and people meant well but in reality , nobody wants to stay at the end of a shift to talk…nobody is going to get to talking because there just isn’t time when people are at work . ” Megan , A&E Nurse

There also appeared to be striking inconsistencies in the provision of mental health support across services, as noted by several workers when they moved between locations and specialties. There were particular barriers to access for staff who were not employed by the NHS, restricting access to many NHS based services for social care staff and agency staff not on NHS contracts.

Redeployed staff also found it especially hard to access services when transitioning between services and line managers, often key points of access to support services.

“ I felt isolated and left on my own … and then my manager said : ‘Once you’re redeployed , I’m not your manager anymore . It’s the COVID-19 centre that manages you . ’ It’s very difficult to navigate around the system and find who actually is managing you . ” Ester , redeployed nurse .

3.6.3 Not for me–reluctance and stigma.

Most of the staff we interviewed had not accessed any psychological support services themselves. For several participants, this was because they perceived that they did not need this, or preferred to seek support from colleagues, friends and families. However, many of the participants in this study did describe feeling very distressed by their experiences of working during the pandemic. Strikingly, several commented that the interview was the first time they had had the opportunity to talk about and reflect on their experiences and they found this helpful. Some said that more mental health support would have been helpful for their teams but tended to dismiss this for themselves. This highlights a potential gap between need and engagement.

Some staff groups seemed to hold the perception that such services were not intended for people like them. For example, some doctors and allied health professionals perceived the services as only applicable to nurses. Others pointed to more explicit stigma as a barrier to seeking help. Joseph, A&E Healthcare Assistant said:

“ I think there’s a huge stigma with mental health . Maybe not as much as it used to be . But I think there’s definitely still a stigma . Probably more so for men…People feel that they can go but it might affect how people perceive them as a person . How they’re perceived as being a strong individual or something like that . ”

Similarly, Nathan, a Junior Doctor told us:

“ The problem with healthcare is that mental health is slightly stigmatised in healthcare workers and people don’t want to admit that there is a problem…they stress a culture of resilience and I don’t think anyone wants to be seen as being unable to cope with anything . ”

3.6.4 Value of expertise.

Whilst many of the workers in our sample sought support from colleagues and peers who could relate directly to their experiences, others, at other times, valued the expertise, neutrality and confidentiality of being able to speak to a mental health specialist.

Several participants commented that informal and reflective team sessions facilitated by a mental health professional had been beneficial. Workers worried about saying the right thing or giving appropriate advice, so seemed reassured when sessions were facilitated by someone with psychological expertise. In a traditionally hierarchical health system, some participants specifically desired advice from the experts most qualified to give it.

“ My view…is that it [psychological support] should be a clinical psychologist . Because that’s just , you know , I do the type of surgery I do because that’s what I do , and no one else could do it . And you guys do what you do . So , I think it should be a consultant clinical psychologist leading a service . ” Jasser , Consultant .

Workers valued dedicated time to talk and be listened to, which they did not think they could expect from colleagues and peers. The also particularly valued a confidential and non-judgement space in which to talk, and several commented that they did not think it always appropriate to speak to supervisors and line managers about how they were feeling.

“ I think it’s important that the other person isn’t directly associated with your job and then you can just have the opportunity to express really openly without anything getting back to your team or you bosses about how you really feel . ” Nathan , Junior Doctor .

For most, accessing psychological support services in their own hospital was most desirable and convenient. However, there were a couple of notable exceptions, where mistrust in their organisation and management had been fostered, some workers preferred to be able to access a service that was outside of their immediate organisation.

Several workers also talked about access to individual sessions being important, in addition to group and team support, as they did not always feel able to talk openly in front of colleagues or had experienced certain individuals in groups dominating.

“ I just think it’s difficult to express how you really feel , if you are with peers you might not want to open up or display any kind of sign of weakness . ” Nathan , junior doctor

Several participants in this study spoke about the benefits of formal mental health support being appreciated after the peak of the crisis. Workers recognised that during the peak of the pandemic they tended to focus on the work at hand and be “running on adrenaline” . After the peak of the crisis had past, they acknowledged that they had more time to reflect, and for many, this was when they recognised the greatest impact on their mental health.

“ Now is the time that people are developing some of the problems . At the time when everybody was immersed and working , there were a few people developing problems , but actually I think that the PTSD and the aftereffects are coming now . ” Michael , Consultant .

Several participants also commented on a longer-standing lack of psychological support, and that such support should be made available in the longer-term, not just during the crisis.

4. Discussion

In this study we sought to better understand frontline health and social care workers’ experiences and views about psychosocial support during the COVID-19 pandemic. We have deliberately considered the full breadth of potential sources of psychosocial support in this paper, including individual, team, organisational and societal aspects, as these were raised by workers when asked about what sources of support were important to them.

The results of this qualitative thematic analysis found that workers’ experiences and views about support were complex and nuanced. Workers for the most part tended to adopt a “just get on with it” attitude which often led to them not recognising or subjugating their own psychological wellbeing. They valued emotional and practical support from family and friends but often worried about them and felt they could not relate to their experiences as they were “not in the same boat”. They valued the shared experience with colleagues who were “in the same boat” and often looked to peers as their first line of support. However, peer relationships could also be complicated, and many staff did not want to burden, or be burdened by, colleagues. Workers were ambivalent about support shown by organisations, media and the public. Whilst they valued psychological support services, there were many disparities in provision and barriers to access. These findings have important clinical and research implications for better supporting the psychological wellbeing and mental health of the frontline health and social care workforce.

4.1. Peer and family support

Colleagues and peers were most workers’ first line of support. They valued talking to peers in the first instance as they could relate to each other’s experiences and support was usually easily and immediately accessible. However, there were several caveats to this, and peer support was certainly not straightforward.

Peer support was sometimes experienced by workers as a burden. They worried about burdening, and being burdened by, colleagues, who were by definition going through the same stressors as they were. The mutuality of shared experience could bring workers together, but empathy for others’ distress has also been well established as a risk factor for vicarious traumatisation [ 18 ]. Therefore, whilst peer support may be an important component of psychosocial support for health and social care workers, [ 19 ] the results of this study show that it is likely best embedded in a wider system of support, including peers, organisations and mental health professionals, so as not to place too much additional pressure on peers, at a time when their emotional resources may already be depleted.

The results of this study also showed that whilst certain groups bonded through shared experience, other teams and services experienced fractures and conflict. Social psychology has made us aware that the strong formation of an “in-group” necessitates greater distancing and rejection of the “out-group” [ 20 ]. This was particularly apparent during COVID-19 with conflicts between wards, services and localities. This made it particularly difficult for staff who were redeployed during the pandemic, who did not always feel included in their new ingroup but were no longer part of their old ingroup and could be left without clear lines of management support. Other quantitative research [ 3 ] has shown that being redeployed was a significant risk factor for health and social care workers developing PTSD in the context of the pandemic. Additional psychosocial support for redeployed staff is therefore likely to be of paramount importance.

The practical and emotional support of family and friends was valued by health and social care workers but could also engender feelings of worry and responsibility, and for many, family life brought with it additional competing demands for childcare and care-giving. Workers often believed that family and friends could not relate to what they were going through and sought not to burden them. The experiences of family members of workers in high-risk occupational roles have received little research outside of a military context [ 21 ] and would warrant further research in order to better understand how to support the families and friends of health and social care workers.

4.2. Mental health awareness

Staff often did not attend to the state of their own, and their colleagues’, mental health, indicative of a lack of awareness of mental health issues in some physical healthcare settings. Mental health awareness training could facilitate better recognition and prioritisation of their own and others’ psychological wellbeing and has a demonstrable impact on improving healthcare worker wellbeing and burnout [ 22 ].

Greenberg and Tracy [ 23 ] have advocated for supervisors to be trained in having “psychologically savvy conversations”. This could certainly go some way to mitigating the lack of awareness of mental health issues in the health and social care workforce. However, the workers in this sample talked rarely about supervisors and managers as sources of support. Several also talked about deliberately wanting to access support that was outside of their line management structure. We cannot assume that this means supervisors are not important, but nor does it mean that we can assume that they are. It may therefore be equally, or even more important, for mental health awareness training to be made available to all staff.

Furthermore, awareness of mental health issues alone is unlikely to lead to behaviour change and several participants in this study spoke about enduring stigma associated with transparency around mental health difficulties. Stigma about mental illness amongst healthcare professionals has previously been well-documented and noted as a workplace culture issue and a barrier to help-seeking [ 24 ]. It is likely that top-down encouragement, role modelling by senior staff and cultural change will be necessary to increase psychological safety and subsequently workers’ willingness to talk about mental health in the health and social care workplace.

4.3. Organisational, media and public behaviour

Workers appreciated public support and felt valued by gestures of media and organisational support. However, heroic narratives were unhelpful and were in contradiction to the professionalism of health and social care roles, detracted from debates about pay and protection, and at worst, created a barrier to staff seeking support. After all, heroes do not struggle; angels do not get PTSD.

Workers desired clear and consistent information from government and organisations, and this appeared to mitigate anxiety and stress. They also wanted to be consulted and collaborated with more, but few had experienced this. Consultation and co-production with frontline staff is going to be essential in establishing systems of support which are likely to be most effective, acceptable, and sustainable.

Workers felt gestures of practical support conveyed value of the workers themselves. However, when resources were taken away, this had a deleterious effect on mental health and left workers feeling de-valued and demoralised. An example of this which has previously been seen was when doctors’ messes; hubs for rest, refreshments and social interaction amongst physicians, were discontinued, leading to demoralisation and disaffection amongst medical staff who felt that one of the final vestiges of their wellbeing had been dismissed [ 25 ].

Several participants in this study acknowledged that staff morale after the peak of the pandemic was very low. This is consistent with the findings of a recently published Royal College of Nursing survey [ 26 ] of 42,000 nurses, which found that pay and feeling under-valued were nurses’ primary concerns. Subsequently, 35% of the sample stated they were considering leaving the profession.

Significant steps need to be taken to improve the psychological wellbeing and morale of the UK health and social care workforce and to ensure that the services they deliver to the UK population are sustainable, during the COVID-19 pandemic and beyond. Resources for support need to be made consistently available, and easily accessible to all staff. However, systemic and cultural barriers to access need to be addressed to ensure that accessing such resources is not inadvertently stigmatising. Access to resources also needs to be equitable, within different teams and localities and across the health and social care workforce.

4.4. Psychological support services

Workers valued psychological expertise and found sessions facilitated by mental health experts reassuring, as they were often worried about saying the wrong thing. They valued being able to access a confidential and independent space, with less burden placed on health and social care peers. Any effective and acceptable mental health support for frontline workers is therefore likely to need to be flexible and accommodate different preferences, including group and individual support, peer and expert led interventions and in-house and external support services.

The results of this study lend support to emerging evidence that psychosocial support may be most acceptable and effective when delivered in a phase-based way [ 10 ], although this warrants evaluation. Mental health awareness training, health promotion and ill-health prevention are likely to be most helpful in advance of crises with practical resources, peer support and informal psychological support most valued at the peak. Formal psychological support is likely to be vital in the early recovery and subsequent period, requiring more assertive follow up of workers, early detection of mental health problems and signposting to evidence-based treatment. Effective screen and treat programmes may be required to identify staff in greatest need.

There also needs to be equitable access to support services for all staff, as many staff groups are not employed directly by the NHS so have fallen outside of support being offered by it. This risks perpetuating systemic injustice in support provision, as those from ethnic minority groups, single parents and those on lower incomes are likely to be over-represented in agency and contractual work [ 27 , 28 ].

There were notable disparities in provision and barriers to access to psychological support services. Staff were often uncertain about what psychological support was available and how to access it. When support was available, it was often not easy to access or unavailable at convenient times. This highlights that psychological support needs to be made available within working hours and time protected to attend. To not do this communicates to staff that their mental health is not a work priority.

The findings of this study also suggest that communication about psychological support needs to be more coherent and consistent. Mental health practitioners are likely to have to more assertively engage health and social care staff to make them more aware of services available and overcome stigma in attending. Research with mental health professionals who were surged to provide psychological support for frontline health and social care workers during the pandemic [ 29 ] showed that much of the mental health care workforce had received no prior training in the needs of health and social care staff and there has been little research into what psychological interventions are most effective in supporting them. This highlights the need for further training and CPD for mental health care providers, as well as the need to develop an evidence base of effective psychological interventions specifically tailored to the unique needs of the health and social care workforce.

Since the initial peak of the COVID-19 pandemic in the UK, NHS England and NHS Improvement announced an investment of £15 million to fund rapid mental health assessment and treatment for NHS staff [ 30 ], including piloting of a number of specialist ‘Wellbeing Hubs’. This builds on the commitment outlined in the NHS People Plan 2020–21 published in July 2020, to provide a more supportive working environment for staff in the NHS [ 31 ]. However, in the early stages of delivery, many psychological wellbeing services have focused on offering training in “psychological resilience” to individuals. Whilst such primary prevention measures have their virtues, we need to be cautious that such messages do not inadvertently perpetuate stigma about mental ill-health and being seen as “not resilient”. We also need to make sure that we do not place more burden on individual health and social care workers to “be more resilient”, but rather need to address the culture, systems and structures identified in this study which present very real barriers to their wellbeing.

Finally, all psychological support services will need to be adequately resourced and financed, not just in the short term but also in the long run, in order to protect the mental health of the health and social care workforce, and in so doing, maintain the health and wellbeing of the UK population.

4.5. Clinical implications

• ■ There is a need to increase mental health awareness for all staff in health and social care settings
• ■ Top-down encouragement, role modelling by senior staff and culture change are needed to increase willingness to talk about mental health in the health and social care workplace
• ■ Staff who are redeployed or who transition between teams and services are likely to need additional support
• ■ A combination of peer, organisational and professional support, which accommodates flexibility and personal preference is likely to be most acceptable and effective
• ■ Systems of support need to be coherent, consistently communicated and easily accessible
• ■ Staff need protected time during working hours to access wellbeing resources and psychological support services
• ■ More assertive outreach is likely to be needed to engage staff with psychological support and identify those most in need
• ■ Structural and systemic barriers to accessing support need to be addressed, not just individual resilience
• ■ Equity of access to support needs to be ensured between different teams, services and localities, as well as across the health and social care sector
• ■ Psychological support services need to be adequately and sustainably resourced and funded, and not just made available during crises

More collaboration, consultation and co-production of support services, and their evaluation, with health and social care staff is needed

4.6. Strengths and limitations

The results of this study should necessarily be considered within the context of its strength and limitations. The analysis of this qualitative data was rigorous, with all steps taken to maximise the validity and trustworthiness of the findings. We deliberately sought to include a varied group of participants from across the UK, including diverse professional groups at different career stages, in order to explore the diversity of experiences and views of support during the pandemic and increase the potential transferability of our findings. Our research team was diverse with considerable clinical NHS experience. Health and social care workers’ perspectives were included in the design, delivery, analysis and write up of this paper.

Nevertheless, this study has a number of limitations. Despite our best efforts to include them, we were only able to recruit one non-medical care home worker and no participants from outside of a direct healthcare role, such as administrators, cleaners or porters. More assertive outreach is needed to engage these groups in future research. We also did not record the ethnic origins or ages of our participants. Whilst several workers identified themselves in their interviews as from black and minority ethnic groups, and were from a variety of career stages, this does limit the potential diversity of our sample. Only one participant from Scotland took part and none from Wales. Workers in these settings might have had different experiences in these different healthcare systems. Further research is needed to extend these questions to these groups and allow their voices to be adequately heard. The roles that health and social care workers undertook during the pandemic were multifarious and therefore have not been categorised quantitatively in this study. This study took place over seven weeks in the early post-peak phase of the first wave of the pandemic in the UK. It is likely that workers’ needs change over time. Therefore, there needs to be ongoing dialogue with health and social care workers about their needs and preferences.

5. Conclusions

This study provides an in-depth analysis of frontline health and social care workers’ views, which elucidates many complexities about their relationship with different domains of psychosocial support which were hitherto poorly understood. The results of this study show that a “one-size fits all” approach to providing support is unlikely to be helpful, and that rather a systematic approach to support including peers, organisations and professional support is warranted. Nevertheless, these systems of support need to be coherent, consistently communicated and easily accessible. More research is needed to fully unpack the structural, systemic and individual barriers to accessing psychosocial support. The views of workers from minority professional and ethnic groups need to be assertively included in future research. More collaboration, consultation and co-production of support services and their evaluation is warranted.

Supporting information

S1 data. interview guide..

This is the interview schedule which was used to guide the semi-structured interviews.

https://doi.org/10.1371/journal.pone.0256454.s001

Acknowledgments

We would like to thank all the frontline health and social care workers who gave up their time to take part in this research. We would also like to thank our Expert Reference Group and our health and social care colleagues who provided invaluable guidance on the design, delivery and analysis of this study.

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• Open access
• Published: 01 June 2022

The impact of working as a peer worker in mental health services: a longitudinal mixed methods study

• Steve Gillard 1 ,
• Rhiannon Foster 1 ,
• Sarah White 2 ,
• Sally Barlow 1 ,
• Rahul Bhattacharya 3 ,
• Paul Binfield 3 ,
• Rachel Eborall 4 ,
• Alison Faulkner 5 ,
• Sarah Gibson 2 ,
• Lucy P. Goldsmith 2 ,
• Alan Simpson 6 ,
• Mike Lucock 7 ,
• Jacqui Marks 2 ,
• Rosaleen Morshead 2 ,
• Shalini Patel 8 ,
• Stefan Priebe 9 ,
• Julie Repper 10 ,
• Miles Rinaldi 8 ,
• Michael Ussher 2 , 11 &
• Jessica Worner 12  

BMC Psychiatry volume  22 , Article number:  373 ( 2022 ) Cite this article

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Peer workers are increasingly employed in mental health services to use their own experiences of mental distress in supporting others with similar experiences. While evidence is emerging of the benefits of peer support for people using services, the impact on peer workers is less clear. There is a lack of research that takes a longitudinal approach to exploring impact on both employment outcomes for peer workers, and their experiences of working in the peer worker role.

In a longitudinal mixed methods study, 32 peer workers providing peer support for discharge from inpatient to community mental health care - as part of a randomised controlled trial - undertook in-depth qualitative interviews conducted by service user researchers, and completed measures of wellbeing, burnout, job satisfaction and multi-disciplinary team working after completing training, and four and 12 months into the role. Questionnaire data were summarised and compared to outcomes for relevant population norms, and changes in outcomes were analysed using paired t-tests. Thematic analysis and interpretive workshops involving service user researchers were used to analysis interview transcripts. A critical interpretive synthesis approach was used to synthesise analyses of both datasets.

For the duration of the study, all questionnaire outcomes were comparable with population norms for health professionals or for the general population. There were small-to-medium decreases in wellbeing and aspects of job satisfaction, and increase in burnout after 4 months, but these changes were largely not maintained at 12 months. Peer workers felt valued, empowered and connected in the role, but could find it challenging to adjust to the demands of the job after initial optimism. Supervision and being part of a standalone peer worker team was supportive, although communication with clinical teams could be improved.

Conclusions

Peer workers seem no more likely to experience negative impacts of working than other healthcare professionals but should be well supported as they settle into post, provided with in-work training and support around job insecurity. Research is needed to optimise working arrangements for peer workers alongside clinical teams.

Peer Review reports

Introduction

Peer support is what many people do when they recognise a shared experience of adversity and choose to support each other [ 1 ]. While people might share many things in common, relating to experiences, interests, personal identity or to community [ 2 ], some shared experience of mental distress or of using mental health services is core to mental health peer support [ 3 ]. Within mental health services, peer support is increasingly provided by people trained and paid – as peer workers – to make use of their own experiences of mental distress in supporting others with similar experiences as part of their mental health care. Peer workers are employed in a range of roles: paraclinical roles such as healthcare assistants or community support workers; providing structured support for self-management; or in a more loosely structured capacity as part of a more personal recovery process [ 4 ]. There is increasing evidence of the benefits of one-to-one peer support in mental health services, with a recent systematic review and meta-analysis of data from 19 trials of one-to-one peer support indicating a significant improvement in self-reported recovery and sense of empowerment for people offered peer support compared with care as usual [ 5 ].

A number of studies also point to benefits for peer workers, while at the same time stressing caution about potential negative impacts. An early scoping review of the literature on peer support in mental health services suggested that peer support might enhance personal recovery for peer workers, but could also be a source of stress, with mental health professionals voicing concern that the peer workers they work alongside might relapse and be hospitalised because of the stresses of the role [ 6 ]. A review of qualitative research about peer workers’ experiences of peer support indicated improvements in confidence, self-esteem and social contacts for peer workers [ 7 ]. A qualitative interview study with 31 peer workers, working in a variety of mental health services, suggested that benefits included improvements in mental illness management and general health, emotional and spiritual wellness, enhanced interpersonal relations, vocational recovery and professional development [ 8 ]. A review of qualitative research focused on the impact of peer support on peer workers indicates that peer workers experience enhanced personal recovery relating to improved knowledge about their mental health and a new positive sense of self relating to the role, but these improvements can be undermined where acceptance, value and support for the role is absent within the clinical team [ 9 ].

A wider literature explores the impact of implementation issues and organisational environment on peer support in mental health services [ 10 ], suggesting that the potential benefits – for people offered peer support - can become diluted where key aspects of how peer support is put into practice are poorly defined [ 11 ]. Notably, it has been identified that a clear peer worker role description [ 12 ], role specific training and support [ 13 , 14 ], preparation for clinical teams working alongside peer workers [ 15 ], and shared expectations of the peer worker role across peer workers and their clinical colleagues [ 11 ] all facilitate successful delivery of peer support. Poor quality implementation, in particular in relation to the role of the peer worker as part of the multi-disciplinary clinical team, has also been shown to impact outcomes for peer workers. A qualitative interview study based in an inpatient setting in Germany showed that peer workers experienced pressure to succeed as pioneers in a new role, had to negotiate identity issues with existing professional staff - as colleague, rival or patient – and had to navigate unfamiliar issues around information sharing, boundaries and professionalism [ 16 ]. In Canada, Voronka [ 17 ], an experienced peer worker and researcher, writes of the demands on peer workers of having to perform a marginalised, experiential identity while at the same time following professional rules and regulations – to pass simultaneously as both normal and disabled – echoing research from the UK [ 18 ]. A qualitative interview study with 23 peer workers and 11 ‘non-peer’ mental health workers in the US suggests that levels of job satisfaction among peer workers are contingent on role clarity, a sense of autonomy in the role and acceptance by non-peer co-workers [ 19 ].

While much of this research is qualitative and focuses on an experiential perspective, efforts have been made to quantify the impacts of working as a peer worker. A survey of 84 peer workers working in a range of mental health services in one state in the US found that peer workers experienced difficulties including poor financial compensation, limited employment opportunities, work stress, the emotional stress of helping others and in maintaining personal wellness, with 44% reporting having a relapse in their mental health while working as a peer worker [ 20 ]. Another survey of 253 peer workers in the US indicated benefits of working in the role as increased self-efficacy and self-esteem, enhanced recovery, better communication and sense of belonging, as well as a new sense of meaning in life, with negative impacts related to poor pay and workplace opportunities [ 21 ]. Development of a scale to measure job satisfaction for peer workers indicates intangible and tangible factors of satisfaction, with intangible benefits including relational aspects of work, sense of self-efficacy and accessible work environment, and tangible benefits comprising payment, promotion and educational opportunities [ 22 ]. A survey of 597 peer workers across the US found that over half were very satisfied with their work (with another third somewhat satisfied), and that feeling respected, being given responsibility, having sufficient training and support, and opportunity to use skills were all significant predictors of satisfaction [ 23 ].

Burnout in the workplace - characterised by emotional exhaustion, depersonalisation and a diminished sense of personal accomplishment [ 24 ] – has been identified as an issue effecting a higher proportion of mental health workers than other healthcare professionals [ 25 ], with the implications of burnout including increased staff turnover and absences as well as poorer job performance [ 26 ]. A small number of studies have compared burnout and other employment-related outcomes for peer workers with those of other mental health workers. A longitudinal study of burnout among 152 peer workers in veterans’ mental health in the US indicated that levels of burnout were similar to other mental health workers and that, while levels of burnout increased in the first 6 months of employment, this increase was not observed over the first year of employment [ 27 ]. A recent survey of 67 peer workers in one state in Australia indicated that job satisfaction, burnout and turnover intention for peer workers was not significantly different to other mental health workers [ 28 ]. In contrast, recent benchmarking data from the UK, among 862 peer workers in National Health Service (NHS) mental health services, indicated substantially higher levels of staff absence and turnover than in the NHS workforce as a whole [ 29 ]. While the assumption that peer workers are inherently vulnerable in the work place and will inevitably spend more time on sick leave than other workers has been challenged as a myth [ 30 ], this range of findings suggests that differential working environment might be associated with outcomes for peer workers.

We note a growing body of evidence describing the impact of peer working on a range of outcomes for peer workers, with many studies considering employment-related outcomes as well as outcomes relating to mental health, personal recovery and other psychosocial outcomes. While much of this research is qualitative, more recent quantitative studies begin to explore the relationship between employment outcomes and working conditions for peer workers. However, these studies are almost exclusively cross-sectional and there are no studies that combine quantitative and qualitative enquiry in order to understand how the way in which peer support is implemented into practice in mental health services impacts on employment-related outcomes for peer workers. This study aims to address that knowledge gap and so contribute to research informing best practice in supporting peer workers in their role. The paper addresses the follow research questions:

What is the impact of working as a peer worker on employment-related outcomes and wellbeing, and how does this change over time?

How do peer workers experience the impact of peer working on their work and wellbeing, and how does this change over time?

This is a mixed method, longitudinal study using standardised measures of outcome, structured questionnaires, and semi-structured qualitative interviews. All methods were carried out in accordance with relevant guidelines and regulations. The study was informed by experiential knowledge of mental health and peer support [ 31 ], as well as clinical and academic knowledge, with service user researchers on the research team - many of whom had a range of experiences of giving and receiving peer support - playing a key role in developing interview questions, conducting interviews and analysing data.

The study took place in seven NHS mental health services in England. Services were study sites in a large randomised controlled trial of peer support for discharge from inpatient to community mental health care (trial registration: https://doi.org/10.1186/ISRCTN10043328 ). Peer support was provided by peer workers, recruited and trained specifically to provide peer support for discharge. A detailed description of the peer worker role, training provided and the support and supervision they received in post is given in the study protocol [ 32 ]. In brief, people admitted to psychiatric inpatient care were offered at least one meeting with a peer worker while in hospital, prior to discharge, and then weekly meetings for 10 weeks in the community following discharge and a further three fortnightly meetings. Peer support principles [ 33 ] underpinned a peer support handbook and training programme, the development of which was coproduced by peer workers, service user researchers and a Lived Experience Advisory Panel alongside other academics on the research team, and clinical staff in study sites [ 34 ]. The training provided guidance and practice for peer workers on building a relationship based on shared experiences, using their experiential knowledge in the role, a range of ‘strength-based’ tools that they could use flexibly with the people they supported, and enabling people to make and strengthen connection with community resources. Peer workers were supervised and supported by a peer worker coordinator (PWC), an experienced peer worker with team leadership expertise. Peer workers were based in a dedicated peer support team at each site, working across inpatient and community mental health services, with approximately two full-time equivalent roles shared between two to five part-time peer workers per site. A full-time equivalent peer worker provided support to up to eight people through the discharge process at any one time, with face-to-face contacts lasting for up to 2 h supplemented with telephone contacts as necessary. Other duties included a weekly team meeting, administrative tasks associated with the role, any ongoing training provided by the service provider, and meeting with clinicians as agreed with the people they were supporting.

Sample and recruitment strategy

All 32 peer workers who provided peer support in the trial were given information about the study and invited to give written, informed consent to take part by a member of the study team.

Data collection

Interviews took place at three time points: after training and induction into the role (T1); after 4 months in post (T2); after 12 months in post (T3). At T1 only, the interview included structured questions collecting socio-demographic data. At T1 and T3 structured questions were asked about each participant’s use of mental and physical healthcare services for the preceding 3 months using a modified version of the Client Services Receipt Inventory (CSRI) [ 35 ]. At all three time-points participants were asked to complete the following standardised measures:

Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) [ 36 ] – a well validated, self-report scale designed to measure positive mental health;

Job Satisfaction Measure [ 37 ] – a self-report scale developed for community nurses, including subscales of personal satisfaction, workload, professional support, salary and training;

Interdisciplinary Team Process and Performance in Long-term Care [ 38 ] – a scale assessing experience of healthcare team working including domains of leadership, communication, coordination, conflict management, team cohesion and perceived team effectiveness, demonstrating a high degree of reliability and validity across care settings;

Maslach Burnout Inventory [ 39 ] – a well-validated and reliable self-report scale used in mental health services [ 40 ], demonstrating inverse correlation with job satisfaction, and positive correlation with absenteeism, lower productivity and staff turnover [ 24 ].

Data on days absent from work and length of employment on the peer support for discharge project for each peer worker was collected from the PWC at each site. Data on number, length and type (face-to-face or telephone) of contact with each person supported by each peer worker was collected from an online contact log completed by peer workers after each contact.

Peer workers completed a qualitative interview, lasting about an hour, with a service user researcher on the study team at each timepoint (see supplementary material). Interviews at T1 explored peer workers’ experiences of recruitment to the role and training received, how well they thought training and induction had prepared them for the role, and initial experiences of being part of a peer worker team. Interviews at T2 and T3 explored peer workers’ experiences of providing peer support, reflection on how training helped them prepare for the role, challenges and rewards of the role, experiences of team working and working alongside clinical teams, experiences of support and supervision, and reflections on staying well at work. The interview at T3 also considered future work aspirations and opportunities. Qualitative interview schedules were developed using the available literature (cited above) and the expertise of the study team, including the experiential knowledge of service user researchers and team members involved in developing and delivering peer support. Input from the study Lived Experience Advisory Panel and peer workers involved in the pilot trial [ 32 , 34 ] also helped inform the development of research questions.

Ethical approval

Approval was granted by the UK National Research Ethics Service, Research Ethics Committee London - London Bridge on 10 May 2016, reference number 16/LO/0470. Written, informed consent was given by all research participants.

Quantitative data analysis

The socio-demographic characteristics of the peer worker sample are described, with frequencies and percentages for categorical variables, and mean and standard deviation (SD), and minimum and maximum values for continuous variables. Count data only are provided for service use given low numbers of participants. Outcome measures are summarised by mean and standard deviation (SD), minimum and maximum values, and reported alongside representative normative data. Normative data were chosen to reflect either the general population (wellbeing) [ 41 ] or a large sample (greater than 500) of healthcare professionals from the UK (job satisfaction [ 42 ] and burnout [ 43 ]) or USA (interdisciplinary team working [ 38 ]). Comparison of the outcomes for peer workers to normative samples was by inspection rather than tested statistically. To examine change in outcomes over a year, paired t-test analyses were conducted comparing T1 to T3 data and T1 to T2 data. Results are reported by mean differences (change) and 95% confidence intervals (CI), the p -value and the effect size (ES) (calculated by the mean difference divided by the T1 SD for the respective measure). If a subscale of a measure had more than one item missing it was set to missing. All statistical analysis was conducted in IBM SPSS Statistics v26.

Qualitative data analysis

Qualitative data analysis proceeded in stages, first generating a largely descriptive coding framework that organised and made sense of peer workers experiences of the role, and second, a more explicitly explanatory analysis that sought meaning in those experiences [ 44 ]. Given that peer support is predicated on the use and sharing of experiential knowledge of mental distress [ 45 ], we sought to integrate the experiential perspective brought by service user researchers in the team throughout the process, alongside the clinical and academic perspectives of other team members [ 46 ].

In the first stage, members of the research team each undertook a preliminary coding of one or two interview transcripts. We then held an interpretive workshop, with each team member sharing and explained emerging analytical ideas from their preliminary coding. Analytical ideas were explored by the team, with ideas integrated as potential codes where they were meaningfully similar (idiosyncratic ideas remained as separate codes) to produce a provisional coding framework. A second round of preliminary coding of new transcripts combined deductive and inductive approaches [ 47 ]. The provisional framework was applied, deductively, to transcripts to explore the fit between data and codes, with transcripts also analysed inductively to allow new analytical ideas to emerge. In a second interpretive workshop, team members again presented their preliminary analyses and, through discussion as a team, existing codes were modified where necessary and new codes added to refine the coding framework. Service user researchers on the team then used the refined framework to code the full set of peer worker interviews using NVivo qualitative analysis software.

In the second stage, two members of the team (RF and SG) first wrote interpretive memos around the data within each code of the framework before, through rounds of discussion, exploring and identifying a smaller number of themes that offered explanation [ 44 ] of how and why peer workers were impacted by their work. Emerging themes were shared with the full team and refined through further discussion.

Data synthesis

We adopted a Critical Interpretive Synthesis approach to data synthesis, as has been widely used to synthesise quantitative and qualitative evidence in systematic reviews [ 48 ] and the development of evidence-based practice [ 49 , 50 ]. In this approach findings of different analyses (i.e. descriptive analysis and hypothesis testing of quantitative data, and thematic analysis of qualitative data) are mapped onto a grid that explores how those analyses interface. This enables the development of synthesising arguments or propositions that offer explanatory insight into study findings as a whole and inform applied learning from the research. Synthesis was initially undertaken by SG and RF and then refined through discussion with the full team.

Sample characteristics

Thirty-one peer workers employed in the ENRICH trial competed a baseline interview. One further peer worker completed data at T2 only so their socio-demographic and outcome data has been used at T1. Participant characteristics are reported in Table  1 .

Peer workers comprised 21 (66%) women and had a mean age of 42.9 (standard deviation 9.0) ranging from 26 to 59. Twenty-five out of the 30 peer workers (83%) who reported their ethnicity were of white ethnicity. Eight out of 25 peer workers (32%) were graduates and seven out of 25 (28%) were married or in a relationship.

The 32 peer workers were in post for 17.7 months on average, ranging from 6.1 to 31.6 months. Two of the peer workers were employed as bank (causal) staff so had no contracted hours or recorded sick leave. For the 30 peer workers who were contracted the mean number of hours worked per week was 17.8 hours, ranging from 10 to 30 hours per week. Twelve of the thirty peer workers (38%) had no recorded sick leave, with mean sick leave for all peer workers of 7.7 days. The remaining 18 peer workers had a median number of sick days of five, ranging from 0 to 55 days.

Two of the 32 peer workers did not record their contacts with peers. The 30 peers with recorded contacts were assigned a mean of 9.7 people to support, ranging from one to 39 people supported by individual peer workers. There was a wide range in the number of completed face-to-face contacts for each peer worker, from two to 273, with a mean of 56.1 contacts. Peer workers conducted 1682 completed face-to-face contacts over the course of the study.

Use of mental and physical health services 3 months prior to T1 was characterised by routine care, with no peer workers reporting an inpatient psychiatric admission or use of crisis or emergency care for their mental health (see Table  2 ).

Quantitative analysis

Measures of outcome.

Data were available for 20 peer workers at T2 and 21 at T3. Table  3 reports descriptive statistics of all outcome measures at each time point. Wellbeing of peer workers remained fairly constant over the year, marginally lower than the general population norm. Job satisfaction subscales and overall score mean values appeared higher than the norm sample apart from satisfaction with pay and prospects subscales. Interdisciplinary Team Scale subscales were higher than the norm values across the three timepoints apart from team effectiveness and workplace resources. Mean scores on the Maslach Burnout Inventory subscales indicated lower levels of burnout and depersonalization, and slightly higher levels of personal effectiveness than norms.

Change in service use

While it was not possible to estimate the effect of working as a peer worker on mental and physical healthcare use because of low numbers of participants, a similar pattern was observed in the 3 months to T3, compared to the 3 months to T1 with continued emphasis on routine rather than acute or emergency mental health care (Table 2 ).

Change in outcomes

Change in outcomes from T1 to T2, and T1 to T3 is reported in Table  4 . Between baseline and 4 months follow-up there was a statistically significant decrease of nearly 4 points in wellbeing, a medium effect size, 0.56. However, over the course of the year there was no significant change in wellbeing.

With respect to job satisfaction there was a statistically significant decrease in the following subscales at the 4-month follow-up; personal satisfaction (medium effect size, 0.50), satisfaction with workload (small effect size, 0.31) and satisfaction with prospects (small effect size, 0.33). This decrease in satisfaction with prospects continued over the year with T1 to T3 scores reducing by 0.45 points, a statistically significant change (small - medium effect size, 0.43). Over the course of the year there was also a statistically significant decrease in satisfaction with training (small - medium effect size, 0.46).

There was no statistically significant change in any of the Interdisciplinary Team subscales at four-month follow-up or 1 year. Of note however is the relatively large effect size for a drop in the Communication subscale score, 0.38 to T2 and 0.86 to T3.

Examining the Maslach Burnout Inventory, there was a significant increase in depersonalization at both T2 and T3, the increase occurring in the first 4 months and seemingly maintained to T3 (small-medium effect size to T2, − 0.48).

Qualitative analysis

Our descriptive analysis produced a coding framework with 18 codes from which we derived three explanatory-level themes reflecting positive, negative and complex experiences of impact. Our thematic analysis is presented below with illustrative data from interview transcripts. Participants are identified with an identifier comprising site number (e.g. S1 = site 1), participant number for that site (e.g. PW01 = peer worker 1) and timepoint for the interview (e.g. T1 = timepoint 1).

Feeling valued

Peer workers described a sense of feeling valued as an important impact of taking on the role, of finding meaning, as an individual, through using their experiences of mental health and what they offered as a peer worker in supporting others:

For me it was about having the opportunity to be able to help others and to be able to realise that I was a human being who was valued … So then when I started realising that I am a valuable person and I’ve got skills and I can contribute back to life and lead a meaningful, fulfilling life and I learnt about this through the peer support … (S6-PW01-T1).

… being out of a job, out of work for a long time and feeling very hopeless about one’s future and experiencing high levels of mental distress oneself and thinking ‘God am I ever going to’, you know ‘what is the point of all this’, it’s just been a bit of a revelation I suppose that one can use it in a constructive way, that it hasn’t all been for nothing. … just knowing that one can understand probably more than many people … just trying or managing to make a small difference has been really helpful to me just for one’s own self-esteem really. (S4-PW02-T2).

Peer workers described a personal sense of reward from seeing the positive results of their peer support:

I think ultimately the real buzz of it is when you help people and then see the results and realise you have actually improved people’s quality of life either a little bit or a lot. (S4-PW05-T3).

I’ve found it rewarding. I’m really enjoying the job actually. I’m finding talking to people is really all I wanted to do and being such a people person I think this is the best job for me. I’ve learnt a lot from this role, it’s made a difference to my life. So it’s not only made a difference to the peer’s life but it has also made a difference to me. [S4-PW03-T2].

Proper remuneration for the role was symbolic of the value and recognition attached, by others, to the support that peer workers were providing:

… our peer coordinators explained to us that some of the Trusts have been just paying people on an as-and-when needed basis for this role whereas our is like a proper contracted permanent role. (S6-PW02-T2).

This has been my first paid job in probably 8 years I think … It’s been the most fantastic experience, I’ve absolutely loved it. (S1-PW05-T3).

However, that sense of value could be undermined where peer workers felt their role was misunderstood or not acknowledged by the clinicians they worked alongside:

I think it’s a mixed bag to be honest … I haven’t had any adverse things but sometimes I feel that they don’t understand the role and sometimes I think they can belittle it a bit. I don’t think sometimes people get how difficult it is to use your lived experience on a daily basis. [S2-PW06-T2].

Whenever I got a new service user I’d email their CPN or care coordinator, I’d send them a link even to the trial to give them more information about it and nobody apart from I think one person got back to me. So that’s been quite challenging not really having any communication or contact really with the mental health teams that are working with the service users that’s been a bit challenging and quite disheartening really as well in a way. [S6-PW03-T3].

Over time, peer workers hoped that the value of their work would be further recognised through ongoing employment (most of the peer workers in the study were on short term contracts for the duration of the research):

Well I just want to carry on … I’m glad to carry on as I’m doing at the moment and hopefully this will be a very long-term job to have. (S1-PW04-T2).

I’m hoping that once our contracts are up or not furthered or whatever more opportunities will come. (S3-PW05-T2).

For some, that sense of value or self-worth found in the role could be challenged when peer workers felt they were unable to offer enough support to people, or where the people they were supporting chose not to engage in peer support:

I think it’s disappointing when you have a limited time that you can spend with somebody. I’m surprised at how much I worry. I’m a worrier in any case but I really worry about my peers and how they are and I want to have more contact than just say an hour and a half or 2 h a week or however long it is. So, that for me is difficult. (S2-PW05-T3).

How to deal with non-engaging clients and you just, it is frustrating because you want to help them. You think the person would benefit … It feels frustrating that some of the clients I’ve worked with won’t say ‘right, yes I don’t want to take part, can I withdraw?’ And then that would free up a space for somebody else. (S5-PW02-T2).

One peer worker found it difficult to explain their role in social situations outside of the workplace where they did not feel comfortable disclosing their mental health difficulties, perhaps undermining the specific value of working in a peer support capacity:

… it does have a negative aspect in terms of outside of work when I have to explain my job to friends or strangers or whatever I kind of get that they don’t really understand what it is … their faces go really confused and … then having to explain it is another thing. I try and avoid saying using lived experience because then they’ll go down the route of ‘what do you mean, do you have a mental health?’ because I don’t want to expose myself and say that I have a mental condition or whatever … (S4-PW03-T1).

Feeling empowered

Many peer workers described a transformational impact of being a peer worker, acquiring a sense of purpose and providing opportunity for personal growth:

I think in the beginning there was just masses of self-doubt, am I doing this right, is that person thinking this of me, have I helped them, what if I’ve made them? Like loads of loads of anxieties, which I had to work quite hard to keep them small and not them grow. I think after I’d seen the full month through one or two times with different people, just when I think back now I’ve changed in so many ways I really have … (S1-PW03-T3).

It’s actually helping me to fit things in the rest of my life because it’s given a purpose, something that I want to do, something that I like doing and I know is going to create change in the future. So, it feels purposeful and I think that that is something that you learn through mental health as well, or mental illness, that to maintain happiness on a level there has to be a purposefulness there. (S2-PW05-T1).

… it was an empowering experience to be able to now be in a position to contribute and have a meaningful fulfilling role in life again by supporting others. (S6-PW01-T1).

Empowerment was found in being able to openly make use of experiences of mental health in the peer worker role:

I feel really empowered and hopeful, when I go into work I feel confident whereas in my last job those things weren’t there and really I felt, my last job didn’t know about my mental health and they had no idea about it and I felt like I … was putting that hat on where I had to be someone else. (S4-PW03-T1).

One peer worker reported, over time, how that personal development manifested first as aspiration for career development, and then to securing a new job:

The sky is the limit isn’t it. Anything is possible. I’d like to be able to achieve more, I mean I don’t know what the next level is in terms of becoming, once you are a peer support worker obviously maybe gain some more experience, maybe go on to a more senior role or managerial role. I’d like to do some training development for my own personal growth. And maybe go on to peer training. (S4-PW04-T1).

… the more I’ve continued on with this role my self-esteem and confidence has increased. So, I feel like I’m more how I used to be and I’m a lot more assured and assertive now than I was before, which brings me to the point that it’s given me the encouragement to be able to apply for other opportunities, which I have done, and I’m happy to say I’ve been successful … (S4-PW04-T3).

They indicated how the role had enabled them to acquire a wide range of skills and knowledge that might lead to opportunities beyond peer working:

… it’s taught me not just being a peer support work but also given me the opportunity to be able to train and deliver courses. It’s also given me the opportunity to learn other roles … it just has built up my knowledge base, skills and experience where now I’m in the hospital working within the mental health unit and I’m also still out in the community as well. (S4-PW04-T3).

The contribution of peer support training to an awakening sense of self-belief was also noted:

The training was giving me skills that I already had but that were lying dormant. The training supported that transformative process. So, the training in a way had a transformative impact on me in terms of empowering me and having more belief in myself. (S6-PW01-T1).

For one peer worker this transformational impact was articulated as a resilience against future adversity:

I started to get empowered by doing the stuff where I was learning from the peer support work and I thought, do you know what, they ain’t going to break me because I’m getting strong now and I’ve not learnt all these new skills and I’ve not learnt to get better just for my support network, which will be taken away, that they’re going to crush me because that ain’t going to happen now because I’ve changed. (S6-PW01-T1).

However, peer workers were clear that these positive impacts were only realised where balance in the demands of the role were achieved. One peer worker contrasted the current role with previous work that had been too demanding, while others described a process of establishing boundaries between work and personal life as they settled into the current role over time:

… so previously when I was at [name of service] they were very long days and it’s a crisis service so it’s extremely busy and you just don’t stop all day so I was tired. But this role, because it’s completely different, it’s good for me, it’s pushing me and I think it’s having a better impact on my wellbeing. (S5-PW03-T1).

I was so exhausted because I was getting so involved in doing all this work and doing this, that and the other and I wanted to do a good job and do extra little things, like I said to you I’m always working on my days off … I am slowly realising that, you know, that I’ve got to take some time for me … as stressful as it was at the time I’ve learnt a lot and I’ve learnt maybe what I should do next time … I think it’s a positive overall, I’m still enjoying it and I still enjoy seeing new peers so I think that says it all. (S2-PW07-T2).

Feeling connected

Feeling connected to others on a number of different levels was also a potential positive impact of working in the peer worker role. Peer workers described discovering a rewarding sense of connection through working with people in mental health services:

It was incredibly emotional because as soon as I walked on the ward … I was like, ‘I want to be back here on the ward with all these people’, and that was just in the back of my head. Obviously, I don’t want to go back in that way as a patient … I had to digest and reflect and see how I felt about that and that was a deciding factor for me because that was really important. Since I’ve been back it’s getting better and better, there’s no other way to describe it, it is actually the more I’m around, every time I come into work the more I’m around people, the times I go to the ward, it’s just like I’m on a complete high, happiness, I can’t believe this is so great. It’s just so positive. (S2-PW01-T1).

… it is a people role so it’s very communicative, it’s very social. So you can benefit from the reward of talking to someone else yourself. (S4-PW05-T3).

Peer workers described how they learnt from connecting with the people they were supporting, as well as from colleagues and professionals around them:

I like the interaction with the peers, I like the fact that I’m learning so much and it’s an ongoing learning process [and] experience … I like the people that I work with because I’m learning a lot from [Occupational Therapists], having interactions with the other clinicians etc. that work with the peers as well. (S4-PW04-T2).

I find it very interesting … to be able to meet people, fellow service users, that have struggled with mental health issues, it’s been pleasurable learning from them really because I learn from them as much as they learn from me. (S6-PW03-T3).

Another peer worker described how connecting with their colleagues as peers enabled them to better connect with their own experiences:

We really bonded so well because there was the ability to be open about our mental health and how it’s affected and to be able to listen to that. It’s quite traumatising to hear it from somebody else with your own story you … say for instance if I was speaking to a consultant or something I’d talk about my mental health like it’s happening to a different body. It was quite strange. And you become detached from it and this is about re-attachment to it. It opens your eyes because it puts you back in touch with what you experienced and you have those feelings right there raw, but it was such a safe place to do that. In way a comforting and in a way traumatising. (S2-PW05-T1).

However, this close connection, through peer support, with people who might share similar challenges to their own mental health was demanding for many peer workers:

It can be a bit of a challenge sometimes listening to people’s traumatic trust stories because of my personality disorder I feel quite emotional anyway. I don’t sit there crying in front of the service users but I can really feel their pain sometimes and that can be a bit difficult. (S6-PW03-T3).

One peer worker described how they needed to modify their work, with their manager, in order to address those demands:

I like connecting with people in life. So that’s why when I was feeling this intensity I said there was a burnout … and my manager said ‘what would help you’ and I said ‘I still need to continue to connect with people, I don’t want time off, but I just don’t want to connect as intensely as I was doing’. So, they needed someone to promote the project so me going out now and doing presentations was a win-win situation for the project and for me at this moment. So, it’s helped my mental health in those ways … I think I would like to do this maybe two or 3 days a week maximum. I think that’s probably the most healthy thing for me and do other things. (S2-PW04-T2).

Others found supervision or training on boundaries useful in helping them not to over-connect with the people they were supporting in their work:

To be honest I kind of switch myself off, I have to try and switch myself off. Supervision has taught me to do that … because I think sometimes you do tend to take your work home and you worry about things because you’ve built up such a rapport and a relationship with the peers it’s hard to detach yourself and walk away from it because you are concerned as any other person would be. But I suppose you are more emotionally attached as well because the nature of the role … if you’ve been through similar challenges then it’s even more difficult to let go of it as well. Our supervisor has been really good at enabling us to recognise those things and to reflect and say, ‘OK it’s alright to leave it on the table until next week’ … (S4-PW04-T3).

… the boundaries and relationships sessions that we did. I think boundaries has been vital really in this line of work … in terms of my boundaries, what I need to do to keep myself well and also be able to communicate and to, I think, limit sometimes the effect of something quite difficult that might be going on for that person and its effect for me maybe after work, so that switching off thing once I’ve dealt with that particular difficulty. (S4-PW01-T2).

Importantly, a supportive sense of connection was found through supervision (with the peer worker coordinator) and, mutually, with the peer worker team:

Supervision has been a really nice way to end the week because we all come together and we discuss ideas and issues and explore ways to make things better to improve our practice. I do enjoy working with my other peer workers as well, they’re really nice. We get on really well and I think having the people that you surround yourself with at work and a good work environment is really essential to your mental health … I would raise something that’s worrying me with my supervisor. So being able to share that is very helpful because then my supervisor will know what’s going on for me and might also say ‘OK I’m not going to give you a load of allocations when you’ve got some very difficult things going on for you’. So, part of that is also communicating to a supervisor or colleague what is going on is helpful because then you can get that support or support someone else. (S4-PW01-T2).

I think that was quite an apprehensive time for myself to know who I was going to be working with. But, yes, I get on really well with them, the people I did the training with I think we’ve built some good friendships there, some good trusting relationships. We feel quite comfortable to confide in one another which I think is key when you are doing a job like this. [Our supervisor] as well I think she’s very approachable, she was absolutely brilliant at the training and I think I’ve built some lasting relationships there which was, not surprising, but a nice addition to the training. (S5-PW01-T1).

The value of building relationships and developing a strong sense of team through the peer workers training was more widely recognised:

… we’re very, very supportive of one another. Inside and outside work. I think it’s probably because we all did the training together so we got to know each other over a period of time … It’s an ongoing relationship which has just become stronger as the time has gone by. So we give each other good advice, if there are any problems we share and air it out. If we can help each other in any way we tend to do that via email or a text or phone call. Yes, we share a lot of our resources … I guess we’re an extension of one another is the best way of describing it. [S4-PW04-T2].

Conversely, another peer worker noted a higher than expected level of independent working in the role, and having to manage working in isolation at times:

Well the level of responsibility and the level of freedom has surprised me. In a good way predominantly but it does have its moments. I think remote working is quite difficult or can be. It works both ways so it’s great to have the freedom and creativity and flexibility and whatever but on the other hand you can feel left with quite a lot of difficult feelings. The isolation is quite hard at times because you can feel like you are working a lot alone and having a lot of responsibility at times can feel too much. People say things which are challenging at times or slightly nerve wracking at times and you’ve got to manage that. (S4-PW02-T2).

Part of the transformative impact of peer support was a knock-on effect, enhancing connection to others, including family:

… it’s massively, massively improved my wellbeing. It’s been transforming. Everybody has seen a difference … like my family, I’ve been able to talk to my mother. There was a time when I was not able really to talk to my mother and I don’t think she’s long for this world, but the thing is she is so happy, and she’s seen the changes in me and now we’re able to stay in the same room and have a conversation without it turning into a row or an argument … I’ve been able to make contact with people who ... didn’t want to know me before. … getting this role has transformed myself in terms of how I see myself and how others see me. (S6-PW01-T1).

… it definitely has helped me in my personal life because it’s actually changed how I talk to my children and specifically my 14-year-old, my first child. I hadn’t been listening, I had just been in mum role and just giving orders and stuff. Our relationship has changed since I’ve been [working as a peer worker] and he actually has started telling me more things and opening up and telling me things that I had no idea was even going on. With my mum as well that’s changed, with my best friend. (S2-PW01-T1).

Finally, while the sense of connection within the peer worker team was experienced as good, a number of peer workers reported a relative lack of connection, or tension with the clinical teams who were providing care with the people they were supporting, impacting on the quality of support they were able to provide:

… it’s been a bit blurred about what our role is as peer support workers [when] there hasn’t been a care coordinator or other support workers involved with a particular peer that you are working with. I think sometimes you are a little bit forced into helping with things like accommodation … and that’s not your role. So that can sometimes be a bit difficult if they are not getting the contact with particular other people as often as they want. (S4-PW01-T2).

… what you find is sometimes having that engagement, that rapport with them [clinical teams] is actually very supportive of one another and sometimes that’s what you need to be doing because it’s not about working against anyone, it’s about working together and it’s not about stepping on anyone’s shoes either whereas you’re coming in and you’re taking over and perhaps your rapport is better than the clinicians and other key workers or care coordinators or support workers that are involved. … I do believe that has happened and it’s not meant to be like that because we’re all supposed to be reading off the same page. (S4-PW04-T2).

Quantitative and qualitative data were synthesised as described above, resulting in five main synthesising propositions. These are presented in Table  5 and used to inform the discussion that follows.

This study aimed both to measure the impact of working as a mental health peer worker on wellbeing and employment-related outcomes, and to explore the experience of impact through in-depth interviews with peer workers. We note that the focus of our enquiry was concerned more with understanding and evaluating the demands, rewards and sustainability of the peer worker role, rather than asking if being a peer worker has a positive impact on the mental health of individuals taking on the role. Thus, while we observed a small downward trend in many of the outcomes we measured, changes were largely non-significant over the course of a year and scores remained as good or better than those for comparable populations (and qualitative experiences were often positive). We consider our findings in that context.

We observed levels of wellbeing among peer workers comparable to the general population when they came into the role and remaining so over the course of a year. The construct of wellbeing as measured here [ 36 ], comprised components focused on subjective experience of happiness and life satisfaction, and on psychological functioning and self-realisation [ 51 ]. Our analysis of qualitative interview data suggested that the positive impacts of working in the peer worker role – of feeling valued, empowered and connected – broadly reflected that construct. On the one hand, peer workers experienced a ‘buzz’ and ‘excitement’, as well as strong sense of achievement in the role, and on the other a transformative sense of personal growth alongside increased confidence and self-esteem. Peer workers felt empowered by the role and that it had brought a new meaning and purpose to their lives, aspects of wellness associated with peer support work found in other research [ 8 , 9 , 13 ]. While measuring somewhat different constructs, this positive sense of wellbeing was reflected in scores in the ‘personal achievement’ burnout subscale [ 24 ] that were higher than normative data, and high levels of job satisfaction [ 37 ], also at starting work and for the most part remaining so over the next year. Elsewhere, high levels of satisfaction with being a peer worker have been associated with pay and working conditions alongside enjoyment of the work [ 22 ], with peer workers in our study responding positively to being paid on substantive, rather than casual contracts. On a more functional level, peer workers did not access acute or emergency mental healthcare during our study, while sickness absence was comparable with that across mental health staff in the NHS in England [ 29 ]. As such, peer workers were well when they came into role and largely remained that way, challenging views voiced by some mental healthcare professionals that peer workers might inevitably become unwell when faced by the stresses of peer work [ 6 ]. Research has also indicated the importance of taking care in recruiting people who are ‘ready’ to take on the role [ 11 ].

The peer worker benchmarking exercise in England estimated sickness absences from work for peer workers in 2019 at 22% [ 29 ], considerably higher than levels of absence across the mental health workforce. Noting the possibility that peer workers were largely compared, in that exercise, to established professionals in more secure, better supported posts, this was not the case in our study, reflecting similar findings from Australia [ 28 ]. This variation in absence rates suggests that other factors, perhaps relating to working conditions [ 52 ] or the organisational support and training provided for peer workers [ 53 , 54 ], might be impacting absence and turnover. Qualitative data in our study strongly suggested that supervision and support from the peer worker team were crucial in managing the demands of the role, with above norm scores also reported in almost all subscales of the multidisciplinary team measure [ 38 ]. Some peer workers did report finding the work both emotionally draining and practically demanding, at least in the period immediately following starting work, reflected in a drop in wellbeing scores, and some burnout and job satisfaction subscale scores at 4 months. We note that this drop in scores was not, on the whole, maintained at 1 year, and a US longitudinal study with peer workers in veterans’ mental health services similarly observed an initial increase in burnout (at 6 months) that was not maintained at 1 year [ 27 ]. Data in our study suggested that initial high scores, perhaps buoyed by optimism at taking on a new role, were tempered somewhat as the realities of the job sank in, but that as peer workers became further accustomed to the role there was no sustained decline at 12 months. Qualitative data supported that explanation, with peer workers reporting at 4 months having had to adjust to the responsibility they had taken on and needing to better manage their workload, finding ways to cope with the intensity of connecting with people as peers with the support of their supervisor. A recent systematic review of literature exploring factors shaping the implementation of peer support in mental health services identified the importance of appropriate supervision as highlighted across multiple studies [ 10 ]. The implication of these findings for practice is that organisations employing peer workers need to be aware of this potentially challenging time for peer workers in the first few months after coming in to post, ensuring that support and supervision, both practical and emotional, is in place to enable peer workers to successfully adjust to the demands of the role [ 18 ]. Nonetheless there were two areas where satisfaction with the role did drop – employment prospects and access to training – with the optimism around future employment (either within or outside of peer support) that peer workers initially expressed starting to wane as fixed term contracts came towards to an end and ongoing job security became less certain for some. The wider peer support literature has indicated the importance of continued, on-the-job career development support, including advancement and promotion in the role [ 19 ].

Our qualitative data indicated clearly how peer workers experienced an enhanced sense of connection through peer working, derived to a large extent through a supportive experience of being part of a peer worker team. In contrast, earlier research had noted how a lack of opportunities to network with other peer workers hindered the successful implementation of peer support in mental health services [ 55 ]. Peer workers in our study also spoke about a greater sense of connection with self, realised in part through interacting with, and learning from the people they were supporting. This reflects the idea of reciprocal learning that has been identified as core to the concept of peer support [ 56 ] and embraced as a core value underpinning peer support as it was implemented in this study [ 33 ]. Scores on the depersonalisation subscale of the burnout measure [ 24 ] were considerably lower (less burned out) for peer workers in our study compared to a normative sample of mental healthcare workers, again reflecting this experience of peer support as enabling self-growth through reciprocal connection. In contrast, both our qualitative data and scores on the communication subscale of the interdisciplinary team measure [ 38 ] suggest that connection with the clinical team was not as strong. While tension with clinical team members has been identified as inimical to successful implementation of peer support [ 16 , 18 , 57 ], research has shown that peer workers have felt more integrated into teams as clinicians began to appreciate the value of peer support and attitudes changed [ 55 , 58 ]. It is important to note that in the ENRICH peer support approach, peer workers were managed within their own peer support team, working across inpatient and community mental health services as necessary, rather than being embedded as part of the complement of the ward or community multidisciplinary team. Our findings suggest that this organisational arrangement contributed to a strong, positive, supportive sense of (peer worker) team, potentially circumventing many of the challenges associated with integrating into the multi-disciplinary team that have been identified as an additional source of stress for peer workers [ 16 , 17 ]. However, the drawback of this arrangement was that peer workers might not have had the opportunity to build that shared understanding of their role with clinicians [ 13 ], in their view, potentially hampering their ability to provide the best possible support. While other research has identified that peer workers make a distinctive and highly valued contribution to the multi-disciplinary mental health team [ 59 ], more research needs to be done in order to establish an organisational model that optimises the potential for peer support either alongside or within the clinical team.

A strength of this study was its longitudinal nature and the use of both quantitative measures and qualitative data exploring peer workers experiences of working in the role, a first study in the field of this design. In particular, having an interim time point allowed us to identify challenges at a point when peer workers had started providing face-to-face peer support but did not yet feel established in the role. Qualitative data allowed us to make further sense of how changes in outcome might be associated with working conditions and the support peer workers received, and also extended the scope of the enquiry, enabling us to explore, for example, how of a sense of connection with self and others, through peer working, affected positive impact of the role. However, our sample was small and outcomes data were often incomplete at follow up, limiting the power of our analyses and our ability to explore possible associations between outcomes. In addition, the standardised outcome measures we used, although demonstrating good face validity, have not, to the best of our knowledge, been formally validated for use with peer workers. Similarly, our data on peer worker absences from work was not collected in a similar way to the mental health workforce data and lacked information on reasons for absence and so on. Prospective research would make more reliable comparisons. A future study might also seek to assess how impacts identified in the qualitative study, of feeling valued, empowered and connected, are associated with the quality of support that peer workers are offered.

In conclusion, our study finds that peer workers largely stay well and experience a positive sense of self and growth in their work, including in demanding roles based in acute mental health services, where they are well supported and valued in that capacity. We note that particular attention needs to be taken to providing appropriate support for newly employed peer workers as they accustom themselves to the emotional and occupational demands of the role (including supervision focused on these early challenges). As peer workers continue in post, in-work training that builds on a basic peer support training, and efforts to improve job insecurity are important so that the positivity peer workers bring to their work is not undermined. Finally, we note that basing peer workers within a dedicated peer support team is experienced as highly supportive by peer workers but might hamper the optimal provision of peer support where connection to clinical teams is not also supported.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge the important role played by members of our Lived Experience Advisory Panel in the development and conduct of this research.

This study was funded by the UK National Institute for Health Research (NIHR), Programme Grants for Applied Research funding programme (grant number RP-PG-1212-20019). This paper presents independent research funded by NIHR. The views expressed are those of the authors and not necessarily those of the UK National Health Service (NHS), the NIHR or the Department of Health and Social Care.

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SG, RF, SW, SGib, AS, ML, JM, RM, SP, SPr, JR, MR and MU made substantial contributions to the conception and design of the work. RF, SB, LG, JM and RM were involved in the acquisition of the data. SG, RF, SW, LG, AS, ML, JM, RM, JR and MR were involved in the analysis and interpretation the data. SG, RF and SW drafted the work and substantively revised it. SW prepared the tables. All authors have approved the submitted version of the paper and are accountable for their own contribution to the research.

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Gillard, S., Foster, R., White, S. et al. The impact of working as a peer worker in mental health services: a longitudinal mixed methods study. BMC Psychiatry 22 , 373 (2022). https://doi.org/10.1186/s12888-022-03999-9

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The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review

• Ruth E. Cooper 1   na1 ,
• Katherine R. K. Saunders 1   na1 ,
• Anna Greenburgh 2 ,
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• Karen Machin 6 ,
• Tamar Jeynes 6 ,
• Phoebe Barnett 2 , 3 , 4 ,
• Sophie M. Allan 2 , 5 ,
• Jessica Griffiths 1 ,
• Ruth Stuart 1 ,
• Lizzie Mitchell 6 ,
• Beverley Chipp 6 ,
• Stephen Jeffreys 6 ,
• Brynmor Lloyd-Evans 2 ,
• Alan Simpson 1 , 7 &
• Sonia Johnson 2 , 8  

BMC Medicine volume  22 , Article number:  72 ( 2024 ) Cite this article

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Peer support for mental health is recommended across international policy guidance and provision. Our systematic umbrella review summarises evidence on the effectiveness, implementation, and experiences of paid peer support approaches for mental health.

We searched MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration, and The Cochrane Database of Systematic Reviews (2012–2022) for reviews of paid peer support interventions for mental health. The AMSTAR2 assessed quality. Results were synthesised narratively, with implementation reported using the CFIR (Consolidated Framework for Implementation Research). The protocol was registered with PROSPERO (registration number: CRD42022362099).

We included 35 reviews (426 primary studies, n  = 95–40,927 participants): systematic reviews with ( n  = 13) or without ( n  = 13) meta-analysis, or with qualitative synthesis ( n  = 3), scoping reviews ( n  = 6). Most reviews were low or critically low (97%) quality, one review was high quality. Effectiveness was investigated in 23 reviews. Results were mixed; there was some evidence from meta-analyses that peer support may improve depression symptoms (particularly perinatal depression), self-efficacy, and recovery. Factors promoting successful implementation, investigated in 9 reviews, included adequate training and supervision, a recovery-oriented workplace, strong leadership, and a supportive and trusting workplace culture with effective collaboration. Barriers included lack of time, resources and funding, and lack of recognised peer support worker (PSW) certification. Experiences of peer support were explored in 11 reviews, with 3 overarching themes: (i) what the PSW role can bring, including recovery and improved wellbeing for service users and PSWs; (ii) confusion over the PSW role, including role ambiguity and unclear boundaries; and (iii) organisational challenges and impact, including low pay, negative non-peer staff attitudes, and lack of support and training.

Conclusions

Peer support may be effective at improving some clinical outcomes, self-efficacy, and recovery. Certain populations, e.g. perinatal populations, may especially benefit from peer support. Potential strategies to successfully implement PSWs include co-production, clearly defined PSW roles, a receptive hierarchical structure and staff, appropriate PSW and staff training with clinical and/or peer supervision alongside safeguarding. Services could benefit from clear, coproduced, setting specific implementation guidelines for PSW. PSW roles tend to be poorly defined and associations between PSW intervention content and impacts need further investigation. Future research should reflect the priorities of providers/service users involved in peer support.

Peer Review reports

Peer support in mental health care is a recovery-orientated approach delivered by individuals who have lived experience of mental health difficulties (as service users, carers, parents or supporters). Peer support workers (PSWs) are employed to draw on these experiences to support mental health service users or carers of people with mental health conditions [ 1 , 2 ]. As such, PSWs are uniquely positioned to facilitate recovery through empathic engagement with service users and their support networks. The success of peer support is thought to be based in the sharing of lived experiences and mental health knowledge and through interpersonal connection [ 3 , 4 ]. Across diagnoses, peer support may promote recovery through the modelling of coping strategies, and by providing hope and an example of recovery to those dealing with mental health difficulties [ 5 ].

Peer support has been utilised across various populations and types of service, for example in services for early intervention in psychosis [ 6 ], for people with co-occurring substance abuse and mental health difficulties [ 7 ], and in community interventions to reduce mental health inpatient admissions [ 8 ]. The format of peer support varies across services, for example it may involve one-to-one or group sessions, online or face-to-face delivery, unstructured open-ended conversations or more structured manualised support, or activities such as walking groups [ 9 , 10 ]. Peer support may be delivered by trained peer support staff or on a more ad hoc basis among peers [ 11 ]. Peer support for mental health takes place within mental health services in both statutory and voluntary sector settings [ 11 ]. Although PSWs may be paid or unpaid [ 6 , 12 ], paid roles have become increasingly available in mental health care settings [ 13 ]. Professionalising PSW roles as paid demonstrates the value of the role and appropriately rewards work done, should ensure formal training, supervision and management, and may help to clarify the boundaries of the role [ 14 ].

Service user networks and researchers in relevant fields have strongly advocated for provision of peer support [ 14 , 15 ], and peer support is now recognised and recommended across international mental health policy guidance, reflecting an increased understanding of the value of embedding lived experience support in formal mental health services [ 16 , 17 , 18 , 19 , 20 ]. In the UK, peer support is currently being expanded in the NHS [ 16 ].

There have been many reviews of the peer support literature separately evaluating the efficacy, implementation, and experiences of peer support from a variety of different perspectives (e.g. [ 21 , 22 , 23 , 24 ]). Given the numerous and sometimes inconclusive results from existing reviews on this topic, our research group, the NIHR Mental Health Policy Research Unit, agreed with policy makers in England to conduct an umbrella review of peer support to provide clinicians, policy makers and researchers with an overall assessment on the evidence available, comparing results between reviews, while taking the quality of these reviews into account [ 25 , 26 ]. The aim of this systematic umbrella review is to collate, synthesise and summarise the available evidence from published reviews to address the following research questions:

What is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health?

What influences the implementation of peer support approaches for mental health?

What are the experiences of peer support approaches for mental health (e.g. of acceptability) from the perspective of PSWs, healthcare practitioners, service users, carers?

This umbrella review was conducted by the NIHR Mental Health Policy Research Unit (MHPRU), based at King’s College London and University College London, which delivers evidence to inform government and NHS policy in England, agreeing a programme of rapid research with policymakers.

Study design and protocol

We conducted a systematic umbrella review following guidance from Fusar-Poli et al. [ 27 ] and Cochrane [ 28 ]. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (see Additional file 1 : Appendix 1 for the PRISMA checklist) [ 29 ]. The protocol was registered with PROSPERO (registration number: CRD42022362099) [ 30 ]. One amendment was made to the protocol after registration. We amended the ‘intervention’ section to state that reviews were excluded if the majority of interventions did not meet eligibility criteria, e.g. because we found that reviews often included paid and unpaid peer support interventions and did not report results separately.

Lived experience researcher involvement

Members of the MHPRU Lived Experience Working Group (LEWG), who collectively have substantial experience of delivering or receiving peer support, contributed extensively to this review, including protocol development, study selection, data extraction, quality appraisal, data synthesis, drafting the manuscript and lived experience commentary, and attending working group meetings.

Eligibility criteria

The eligibility criteria are detailed in full in the protocol [ 30 ]. In summary, we included:

Study designs : Published, peer-reviewed systematic, scoping or realist reviews which synthesised quantitative or qualitative data (narratively or formally using, e.g. a meta-analysis or meta-synthesis) that examined outcomes or experiences relevant to our research questions.

Intervention : We defined peer support as ‘involving a person who has lived experience of mental health condition(s), or caring for those with mental health conditions, being employed to use and draw on their experiences and empathy to support service users who have mental health conditions or carers or parents of people with mental health conditions.’ Eligible peer support approaches were paid, meaning that the PSW was paid for their work, and delivered face-to-face or remotely, for people with mental health conditions or for carers of people with mental health conditions, across any mental healthcare settings. Peer support approaches were ineligible if the PSWs were not in a dedicated peer support role, if they were primarily for physical health, or automated (i.e. peer support ‘bots’ or avatars). We excluded reviews where over 50% of primary studies in the review did not meet eligibility criteria, e.g. if the majority of people delivering the interventions were unpaid.

Population : Children, young people and adults with a mental health condition (including substance use disorders), carers, paid PSWs and mental healthcare practitioners working alongside PSWs. We excluded service users with a primary diagnosis of an organic mental disorder (e.g. dementia), neurodevelopmental disorders, acquired cognitive impairment and adjustment disorders.

Outcome measures : Included reviews reported outcomes or data on at least one of the following peer support related outcomes that addressed our research questions: (i) clinical outcomes, (ii) economic or cost-effectiveness, (iii) recovery outcomes, e.g. hope, empowerment, goal-attainment, quality of life, (iv) social outcomes, (v) implementation outcomes and barriers and facilitators to implementation, (vi) experiences of delivering, receiving or working alongside peer support and (vii) theories of what works for whom in peer support.

Information sources and search strategy

We combined terms for peer support, reviews and mental health conditions using Boolean operators (AND, OR). We searched the following databases: MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration and The Cochrane Database of Systematic Reviews (see Additional file 1 : Appendix 2 for full search strategy). Searches were run from January 2012 to November 2022 as these reviews will include primary research published before 2012 [ 31 ]. There was no time limit for the primary papers in the included reviews. We had no language restrictions.

Selection process

Reviewers (KS, RC, JG, RS, RA, KM, PS, SA) screened titles and abstracts, and subsequently full texts. To ensure consistent application of eligibility criteria all reviewers initially independently screened the same ten titles and abstracts and discussed inclusion/exclusion. The remaining titles and abstracts were then screened. Records were double screened blind by two reviewers at both the title and abstract (94% agreement) and full text (86% agreement) stages. All disagreements were resolved through discussion with the study team.

Data extraction

Data extraction was completed in Microsoft Excel by the review team (RC, KS, KM, PS, JG, RS, PB, RA). The data used in the paper were checked by another member of the review team. The extracted data included basic information about reviews (e.g. number of included studies, number of participants, review type, aim/objectives), basic information about primary studies (e.g. references, designs), search strategy (e.g. databases searched, eligibility criteria), population (e.g. gender, age), peer support approach (e.g. peer support type and description), type of comparator, additional information (e.g. quality appraisal methods, review author conclusions), primary and secondary outcomes of systematic review or qualitative results.

Quality appraisal of included reviews

The quality of included reviews was independently assessed by reviewers (RC, KS, KM, PS, JG, RS, PB, RA) using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews), a 16-point tool for assessment of the methodological quality of systematic reviews [ 32 ]. We adapted the AMSTAR 2 to apply for scoping reviews and systematic reviews of qualitative data (described in full in Additional file 1 : Appendix 3). The following questions were adapted: (1) PICO criteria, (2) Protocol requirements, (8) Detail of included studies, (9) Risk of Bias requirement. Two reviewers (KS, AG) 100% double-scored reviews blind with any outstanding disagreements resolved through discussion between AG, KS, and RC. Overall ratings for each study were calculated according to guidance [ 32 ], based on 7 critical domains and 6 non-critical domains within the AMSTAR 2 tool. Studies with no or one non-critical weakness and no critical flaws were rated as high quality. Studies with more than one non-critical weakness and no critical weaknesses were rated as moderate quality. Studies with one critical flaw irrespective of non-critical weaknesses were rated as low quality, and those with more than one critical flaw irrespective of non-critical weaknesses were rated as critically low quality. The AMSTAR 2 guidance [ 32 ] states that reviews of critically low quality should not be relied on for comprehensive and accurate summaries of the literature.

Synthesis methods

Rq 1: what is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health.

Data were tabulated and summarised narratively by two researchers (KS, AG); effectiveness meta-analysis data calculated from two or more studies were tabulated separately from non-meta-analysis effectiveness outcomes. Review outcomes were similar, but not similar enough to combine meaningfully in a meta-analysis. Effect sizes (with 95% CIs and p -values) were reported along with I 2 statistic (with 95% CIs, p -values, χ 2 , and degrees of freedom) where available. We did not tabulate data for subgroup analyses.

RQ 2: What influences the implementation of peer support approaches for mental health?

Outcomes were tabulated according to the main domains in the Consolidated Framework for Implementation Research (CFIR) [ 33 ]. The CFIR provides a comprehensive framework, composed of 5 domains, associated with the effective implementation of interventions [ 33 ]. The 5 domains are as follows: Innovation (the ‘thing’ being implemented); Outer setting (the setting in which the inner setting exists, e.g. hospital system); Inner setting (the setting in which the innovation is implemented, e.g. hospital); Individuals (the roles and characteristics of individuals); Implementation process (the activities and strategies used to implement the innovation) [ 33 ]. Synthesis was conducted using a collaborative process involving one member of the study team (RA) and one lived experience researcher (PS).

RQ 3: What are the experiences of peer support approaches for mental health (e.g. of acceptability) from the perspective of PSWs, healthcare practitioners, service users and carers?

Experiences were synthesised narratively, by three researchers, including two lived experience researchers (TJ, KM, RC) [ 34 ]. Themes from reviews which were identified as addressing research question 3 were extracted and similar themes across the reviews were grouped together. Each group was accounted for using an existing theme from one or more of the reviews or if this was not possible a new theme was developed. Three overarching themes were identified through iterative scrutiny of the data and discussion between TJ, KM, and RC. A summary of the common themes across the reviews, grouped under the three overarching themes, was then developed, including highlighting contrasting findings.

Study selection

The search strategy identified 777 references to be screened (a further 2 papers were identified through other methods); 93 full text articles were assessed for eligibility with 57 excluded (see Additional file 1 : Appendix 4 for reasons for exclusion). Thirty-five reviews (reported in 36 papers) were included (see Fig.  1 ).

PRISMA flow diagram [ 29 ]

Characteristics of included reviews

Review characteristics are detailed in Table  1 . Of the 35 included reviews, 13 were systematic reviews with meta-analyses, 13 were systematic reviews without meta-analyses, 3 were systematic reviews with a qualitative synthesis and 6 were scoping reviews. The individual reviews included between 95 and 40,927 participants; 6 reviews did not report the number of participants. For reviews where the population were service users, almost all were categorised as adults with mental health problems. Thirteen reviews specified that participants had severe mental illness (SMI) diagnoses [ 1 , 21 , 22 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], six reviews explicitly included studies with participants accessing mental health services [ 22 , 37 , 38 , 43 , 45 ] [ 46 ], three reviews were conducted in perinatal populations [ 47 , 48 , 49 ], three reviews included participants with any/common mental health conditions [ 50 , 51 , 52 ], four reviews included participants with substance use disorders [ 1 , 38 , 53 , 54 ], two reviews included participants with eating disorders [ 55 , 56 ], one included people experiencing suicidality [ 57 ] and one included articles on peer support for crisis management [ 58 ]. The samples in the remaining reviews were PSWs and various stakeholders (e.g. non-peer staff, service users) [ 23 , 24 , 34 , 59 , 60 , 61 , 62 , 63 , 64 ]. Most reviews included interventions involving any form of peer support, individual, group or combined, although three reviews looked at group peer support alone [ 35 , 43 , 49 ], and three reviews looked at individual peer support alone [ 1 , 40 , 45 ]. Reviews looked at peer support delivered in-person, online or over the phone, and surveyed a range of approaches including both structured and unstructured peer support (see Table  1 ). The reviews included 426 primary studies. We assessed study overlap; most primary studies ( n  = 300) were only included in one review; however, many primary studies were included twice ( n  = 72), three times ( n  = 18) to a maximum of nine times ( n  = 1) (see Additional file 1 : Appendix 5 for overlapping studies). Only 1 review reported that people with lived experience were involved in the review [ 57 ]. Only 2 reviews assessed certainty of evidence (using GRADE) [ 21 , 22 ].

Most reviews were appraised as low or critically low (97%) quality and one review was appraised as high quality. The most common weaknesses were in critical domains concerning registering protocols before commencement of the review (21 studies), justification of excluding individual studies (28 studies) and considering risk of bias when interpreting results (13 studies). Reviews without meta-analyses were not scored in the critical domains assessing meta-analytical method or publication bias. There were 13 studies with meta-analyses assessed in these two domains: two of these exhibited one critical weakness and two exhibited two critical weaknesses. As scoping reviews are intended to provide overviews of existing literature regardless of risk of bias [ 65 ], scoping reviews were not scored in the critical domain concerning risk of bias assessment techniques (see Additional file 1 : Appendix 3 for adjustments to quality appraisal for scoping and qualitative reviews). Of the 29 reviews that were eligible to be scored in this domain, 10 exhibited a critical weakness. The review eliciting high confidence was a Cochrane review [ 21 ]. No reviews were rated as moderate. AMSTAR 2 ratings are detailed in Table  1 and in full in Additional file 1 : Appendix 3.

Results of synthesis

Rq1: what is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health.

Effectiveness outcomes were reported in 23 reviews (66% of total). A wide variety of clinical, recovery and psychosocial effectiveness outcomes were reported across both meta-analysis [ 21 , 22 , 37 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 48 , 51 , 52 ] and narrative results [ 1 , 21 , 22 , 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 48 , 50 , 51 , 53 , 54 , 56 , 57 , 58 , 60 ]. Comparator groups also varied across the primary studies included in the reviews, including Treatment as Usual (TaU), active controls (e.g. a comparable standard treatment) and waitlist control groups.

All outcomes except for one (family or carer use of formal community support services; [ 44 ]) were service user outcomes, rather than carer, staff or PSW outcomes. Outcomes from systematic reviews with meta-analysis are reported in Tables  2 , 3 and 4 . Effectiveness results from reviews not including meta-analysis are summarised at the end of this section and reported in full in Additional file 1 : Appendix 6. Evidence was heterogenous across all outcomes and reviews, with many analyses reporting no effect. In the meta-analysis results, there was often notable heterogeneity. There was limited data on cost and cost-effectiveness, but the evidence available from three systematic reviews without meta-analyses (See Additional file 1 : Appendix 6) suggested that peer support interventions were low cost and cost-saving [ 38 , 48 , 50 ].

Results from meta-analyses

Clinical outcomes.

For depression outcomes, evidence from two reviews with meta-analyses suggested that peer support is effective in improving perinatal depression [ 47 , 48 ]. Three reviews of peer support for adults and adolescents with mental health problems including those with SMI diagnoses reported no effect on depression post-intervention [ 22 , 35 , 43 ], where two of these reviews looked at group-based peer support alone [ 35 , 43 ]. Two of these reviews reported follow-up results; one review of group peer support for adults with any mental health condition continued to find no effect at 3–6 months follow-up [ 35 ], while the other involving adults with SMI reported improvements in depression and anxiety at 6 months follow-up, despite reporting no effect at post-intervention [ 22 ]. One review [ 52 ] measured clinical recovery in adults with any mental health diagnosis, reporting improvements post-intervention and at 6–9-month follow-up, but no improvement at 12–18-month follow-up.

Most evidence regarding mental health symptom severity among adults and adolescents with mental health diagnoses or who were using mental health services suggested no effect [ 22 , 35 , 41 , 42 , 43 , 44 ], other than for perinatal depression as previously summarised. One review [ 40 ] of individual peer support for adults with primarily SMI diagnoses reported improvements in symptom severity, while another involving adults with SMI [ 44 ] reported symptom improvements following family-led peer support, but no improvement following individual-led peer support. Results for service use varied depending on the measure, for example, peer support was associated with reduced risk of hospitalisation [ 44 ], including after a follow-up period [ 45 ], but no effect was found regarding length of stay [ 41 , 42 ].

All reviews providing meta-analytic evidence relevant to this question were rated low or critically low quality, except from one high-quality review [ 21 ] which found no effect of peer support on patient activation between 1 and 6 months follow-up (a person’s perceived ability to manage their illness and their approach to healthcare) in adults with schizophrenia diagnoses or similar SMI.

Recovery outcomes

Of the seven reviews with meta-analyses reporting data on overall self-reported recovery, five reported improvements in recovery in adults with mental health diagnoses including SMI [ 22 , 35 , 40 , 44 , 45 ]. Two studies found effects for individual peer support interventions alone [ 40 , 45 ], and one reported an effect for group-based peer support alone [ 35 ]. Only two reviews reported no effect [ 21 , 43 ], where one included studies of adults with SMI in both individual and group-based peer support [ 21 ], and the other involved studies with adults and adolescents with any mental health problem in group-based peer support alone [ 43 ].

Three reviews reported follow-up data showing continued improvements for adults with mental health diagnoses including SMI at follow-ups of 6 months [ 22 ], 3–6 months [ 35 ] and 12–18 months [ 45 ], the former and the latter reviewing individual and group peer support, and the second focussing on group peer support alone. One further review reported no improvements at medium-term follow-up (1–6 months) [ 21 ]. One review of adults with any mental health diagnosis identified improvements in personal recovery post-intervention, but not at 6–9 or 12–18 months follow-up, and found no improvements in functional recovery post-intervention or at 12–18 months follow-up, but did report improvements at 6–9 months follow-up [ 52 ].

All reviews providing meta-analytic evidence for these outcomes were rated as critically low or low quality, except for one [ 21 ] which was rated high quality. Based on evidence from three studies, this latter review [ 21 ] found no effect of peer support on recovery in the medium term for adults with schizophrenia diagnoses or similar SMI.

Psychosocial outcomes

Evidence regarding hope or hopefulness was mixed. Four reviews with meta-analyses suggested that peer support resulted in improvements in adults with SMI [ 22 , 37 , 40 , 44 ], where one of these studies looked at individual peer support alone [ 40 ] and the rest included both individual and group peer support. However, three reviews of studies including SMI and mixed mental health diagnoses samples reported no effect [ 21 , 35 , 43 ], where two of these reviews focussed on group-based peer support alone [ 35 , 43 ]. One study [ 22 ] followed up adults with SMI and those using secondary MH services at 3–6 months and found continued improvements in hope. However, another review investigating longer-term outcomes (over 6 months) in adults with SMI found no effect [ 21 ].

Improvements in empowerment were evidenced by two reviews with meta-analyses [ 40 , 51 ] of studies involving adults with any mental health diagnosis including SMI. No effects were reported in four reviews [ 22 , 35 , 43 , 44 ]. One of the meta-analyses finding positive effects of peer support on empowerment looked at individual peer support alone [ 40 ], whereas two of the meta-analyses with no effect solely involved group-based peer support [ 35 , 43 ]. Three studies reported follow-up data. Two showed improvements at 6 months in adults with SMI [ 22 ] and at 6–12 months follow-up among adults using mental health services with any diagnoses [ 45 ]. The other showed no improvements from group-based peer support only in adults with mental health diagnoses including SMI between 3 weeks and 6 months follow-up [ 35 ].

Quality of life reportedly improved in two reviews with meta-analyses [ 37 , 44 ] of studies involving adults with SMI, while there was no evidence of improvement in one other with an SMI sample [ 22 ]. The two studies which reported follow-up data continued to find no effect [ 22 , 45 ].

There were improvements in self-efficacy in adults with any mental health problem in all three reviews with meta-analyses reporting this outcome [ 43 , 44 , 51 ]. Decreases in self-stigma and stigma-related stress in adults and adolescents with any mental health problem were found by one review with meta-analysis of group-based peer support [ 43 ]. There was no evidence for peer support improving satisfaction with care [ 22 , 41 , 42 , 44 , 45 ] or relational outcomes (including social support and network) and building relationships (both personally and with staff) [ 41 , 42 , 44 , 45 ].

All reviews providing meta-analytic evidence for these outcomes were rated as critically low or low quality, except one high-quality review [ 21 ] which found no effect of peer support on hope in adults with schizophrenia diagnoses or similar SMI in the medium or long term.

Summary of results from systematic reviews without meta-analysis

Effectiveness results from systematic reviews without meta-analyses are tabulated in full in Additional file 1 : Appendix 6. These reviews presented mixed results pertaining to clinical outcomes including depression, anxiety, eating disorder pathology, and psychosis. However, two scoping reviews reported evidence of peer support in improving suicidal ideation [ 57 , 58 ]. Evidence was deemed inconclusive regarding the impact of peer support on indicators of service use, where three reviews failed to find evidence for peer support [ 21 , 22 , 41 , 42 ], three reported mixed results [ 1 , 38 , 54 ], and one found evidence for improvements associated with peer support [ 36 ]. More consistent evidence was found indicating peer support improves recovery outcomes [ 1 , 36 , 38 , 40 , 44 , 53 ]. For most psychosocial outcomes, systematic reviews presented mixed evidence, for example different effects were found by one high-quality review for empowerment, hope and self-efficacy, depending on what measures were used [ 21 ]. Despite mixed effects being reported overall for the impact of peer support on satisfaction with care, one review cited some possible associated moderating factors such as the number of conversations had between peer supporter and recipient [ 48 ]. Evidence was marginally less mixed for relational outcomes, such as strength of interpersonal relationships and sense of community, as the majority (three) of relevant reviews found evidence in support of peer support [ 21 , 38 , 58 ], although one review found this did not persist long term [ 21 ].

Implementation was investigated in nine reviews [ 23 , 24 , 36 , 39 , 46 , 50 , 55 , 59 , 62 ]. Table 5 shows an overview of implementation outcomes by CFIR domain [ 33 ]. All reviews relevant to this research question were rated as critically low quality based on the adapted AMSTAR 2 rating scale (see Additional file 1 : Appendix 3).

Studies reported generally high acceptability and feasibility of PSW-led interventions [ 36 , 39 , 46 , 50 ]. When planning a peer-led service, co-producing the design of peer support provision with the community and stakeholders was found to be key [ 59 ].

Outer setting

The existence of national policy and funding provisions for employing and retaining PSWs facilitated PSW-led care [ 39 , 46 , 59 ], as did integration of interventions within existing healthcare systems [ 50 ]. However, barriers included power hierarchies [ 39 ], difficulties incorporating PSWs in medical mental health care models [ 24 , 39 , 46 ], interference of work with welfare benefits [ 62 ] and a lack of recognised PSW certification [ 62 ].

Inner setting

A workplace culture emphasising recovery-orientated practice [ 24 , 59 ], and organisational openness and readiness to employ PSWs [ 39 ], was important. Facilitators included strong leadership and support at the highest level [ 46 ], and flexible and understanding employers, especially in times of crisis [ 59 ]. A key facilitator was a supportive, accepting and trusting workplace culture where PSWs occupy a central position and fit in well with other staff members [ 24 ]. A trusting culture allowed the management of risk in a psychologically safe space [ 59 ]; effective communication and collaboration between PSWs and other workers facilitated this [ 24 ], while stigmatising staff attitudes were a barrier [ 62 ]. It was easier to implement PSWs in a more collaborative and less hierarchical service [ 59 ]. There were practical facilitators and barriers for PSWs also, such as access to desk space or administrative data [ 24 , 46 ], time restraints, high caseloads [ 23 , 24 ] and insufficient funding for PSW role [ 24 , 50 ].

Individuals

The professionalisation and legitimisation of the PSW role was seen as important, with associated performance standards and/or a code of ethics [ 24 ] which was linked to rigorous recruitment practices, ensuring parity in the recruitment of PSWs and other staff [ 46 ]. A further facilitator was high levels of competency among peer-counsellors when delivering interventions and having relevant skills and knowledge, e.g. mental health conditions [ 50 ]. PSWs were often required to have recovered from their mental health difficulties [ 55 ] and be able to use their coping skills and resilience to avoid potential negative impacts on their wellbeing [ 24 ]. PSWs reported a conflicted sense of identity between being a ‘peer’ with experience of mental health problems and a ‘professional’ as a barrier to their work [ 62 ]. The use of champions and implementation leaders to drive the set up and maintenance of PSW interventions was reported as a facilitator [ 46 ], as was staff willingness and ability to work with PSWs and accept them as part of the service [ 24 ].

Implementation process

Studies emphasised the importance of comprehensive training for PSWs delivered both prior to starting work and on an ongoing basis, alongside regular clinical supervision [ 24 , 46 , 50 , 55 ] supporting the management of any problems encountered [ 59 ]. PSW roles should be clearly defined [ 24 , 62 ] and training should also be delivered to other members of staff to help them work effectively with PSWs [ 46 ]. Establishing sustainable models of cost and supervision from the outset was key for the longevity of PSW [ 50 ].

Experiences of both the benefits and challenges of peer support were reported in 11 reviews [ 23 , 34 , 39 , 42 , 46 , 49 , 55 , 60 , 61 , 63 , 64 ] from a range of perspectives: PSWs [ 23 , 34 , 39 , 55 , 61 ], service users [ 39 , 55 , 61 ], non-peer staff [ 61 ], peer support group members [ 49 ], and mixed samples which consisted of combinations of PSWs, service users, non-peer staff, carers, mental health organisations, policy makers and peer programme developers [ 23 , 39 , 42 , 46 , 55 , 60 , 61 , 63 , 64 ]. In one review, it was unclear whose perspective was being presented [ 46 ], although this review only contributed to one theme. All reviews providing evidence for this research question were rated as critically low quality based on the adapted AMSTAR 2 rating scale (see Additional file 1 : Appendix 3). We identified 3 overarching themes: (i) what the PSW role can bring, (ii) confusion over the PSW role and (iii) organisational challenges and impact. Table 6 gives an overview of the overarching themes and subthemes (with more detail in Additional file 1 : Appendix 7). The following provides an overview of each overarching theme from the perspective of the different samples (i.e. PSWs, service users, mixed samples).

What the PSW role can bring

Perspective of psws.

PSWs experienced improved wellness and recovery from working in the role, reporting increased self-esteem, personal growth, and social networks [ 23 , 34 , 55 , 61 ]. They benefited in a variety of ways, e.g. the role provided a route back into employment, improving functioning and social inclusion, and allowed them to learn more about their own mental health [ 23 , 34 ]. PSWs also reported increased self-acceptance as they no longer had to hide their mental health issues [ 34 ]. The role was therefore often reported to be mutually beneficial for PSWs and service users [ 34 , 55 ]. PSWs felt it was important that they were role models for service users, being ‘the evidence of recovery’ [ 34 ]. However, working as a PSW could also have a negative impact on the PSWs’ wellbeing and recovery [ 23 , 34 ]. Reasons for this included the role reminding them of their mental health condition and the ‘sick’ label staying with them [ 23 ].

Perspective of service users

For service users, PSWs could be role models, giving them hope of recovery [ 39 , 55 , 61 ]. PSW support normalised and de-medicalised service user experiences [ 55 ]. Lack of judgement from PSWs reduced feelings of self-stigma for service users [ 55 ]. Service users felt empowered by and valued gaining experiential knowledge from PSWs, perceiving them to be more insightful than non-peer staff, and trusting their services [ 39 ]. Service users also built rapport more easily with PSWs than non-peer staff, feeling they were more approachable and had greater empathy than non-peer staff [ 39 , 61 ]. However, some service users reported that PSWs are not role models and found it challenging to view them as professionals or fully trust their knowledge, due to their lack of training and concerns about their mental health history [ 39 , 61 ].

Perspective of non-peer staff

From working with PSWs, non-peer staff developed increased empathy towards service users and a belief in recovery [ 61 ].

Perspective of peer support group members

Forming relationships in peer support groups and having their experiences validated by others was valuable for recovery [ 49 ]. However, group members could feel isolated when other members’ experiences contrasted with their own [ 49 ].

Perspective of mixed samples

PSWs were perceived to be role models, providing valuable support to service users and giving them hope of recovery [ 60 , 64 ]. Working as a PSW could enable service users to find a role in the community, beyond the identity of being a ‘patient’ [ 61 ]. PSWs could build trust-based pathways to function as a bridge between service users and non-peer staff [ 64 ]. Within teams, working with PSWs could improve recovery-oriented care and PSWs carried out various roles, such as providing psychosocial support, advocating for service users, providing insights based on their lived experiences [ 64 ]. For mental health organisations, PSW roles decreased stigma towards mental health problems and set a positive example [ 61 ]. However, there were fears that the PSWs’ mental health condition could impact the provided support, such as increased PSW absenteeism which could increase non-peer staff caseloads and concerns that service users’ and PSWs’ could experience distress due to exposure to difficult (‘triggering’) content [ 42 , 55 , 60 ]. PSWs experienced pressure due to the perception that they were pioneers, leading to expectations, e.g. failure could reduce future PSW opportunities [ 64 ]. There was also concern that PSWs lacked mental health knowledge, beyond their own experience [ 64 ].

Confusion over the PSW role

A lack of clarity about the PSW job description led PSWs to feel the role was undervalued and tokenistic and meant they felt confused in their role. This impacted their perception of competence which affected their recovery and led to uncertainty in their responsibilities with service users [ 23 , 34 ]. PSWs also found the transition from service user to PSW and knowing where to draw the line between friend and service provider to be challenging [ 23 , 61 ]. Linked to this, their dual identity as a service user and provider could be a source of stress. For example, it meant they could closely connect with service users who had similar difficulties to their own, but this could also be triggering and lead to a recurrence of the PSWs’ own mental health issues [ 34 ]. PSWs expressed varying views on disclosing their recovery story [ 34 , 39 ]. For some, sharing elements of their story was linked to their own personal recovery [ 34 ]. However, other PSWs felt fearful of disclosure, e.g. they were concerned about being labelled ‘mentally ill’ and service users not trusting them [ 39 ].

A lack of clarity on the PSW role could lead service users to view the role as informal, leading to negative perceptions of the PSW services. Perceptions of tokenism of peer support could lead to the content of the PSW intervention ‘feeling irrelevant’ [ 39 ].

PSWs and non-peer staff found the PSW role to be ambiguous, e.g. the role was not clearly defined [ 63 ] and job descriptions were ‘vague’ [ 64 ]. Although this gave flexibility to define the role [ 64 ], it also led to challenges. Some PSWs felt they were expected to develop the role over time and received insufficient training, which hampered service delivery and could result in perceptions that PSWs were tokenistic [ 42 , 63 , 64 ]. Uncertainty about the role also led to a lack of support from non-peer staff [ 63 ]. Relatedly, there was confusion for PSWs over when/with whom to disclose their lived experience [ 63 , 64 ]. Some PSWs felt vulnerable and were reluctant to disclose, but disclosure could build trust with service users, enabled PSWs to be recovery role models, and could educate non-peer staff on alternative views [ 63 , 64 ]. Disclosure was also felt to require discretion when fitting with professional relationships. However, ‘professionalisation’ of PSWs may not challenge the existing boundaries (e.g. traditional hospital-based boundaries which could make it difficult for the sharing of lived experience to be valuable), when challenging these boundaries could change culture [ 63 , 64 ]. The transition for PSWs from patient to staff was challenging, e.g. non-peer staff were concerned about the PSW becoming unwell, making PSWs feel like they are being treated like patients [ 63 , 64 ]. There were issues around boundaries, including whether PSWs should relate to service users as friends or service users [ 63 ].

Organisational challenges and impact

PSWs experienced a lack of support and training for their role, potentially related to unclear job descriptions, and insufficient supervision [ 23 , 34 ]. This meant that PSWs struggled to develop the skills for their roles, including to work with service users with more complex needs than their own experiences [ 23 ]. Although there were some contrasting views, PSWs were concerned that they received low pay which made them feel that they were not valued, and they perceived themselves to be ‘cheap labour’ [ 23 , 34 , 61 ]. Some PSWs felt accepted in their teams however others experienced negative and rejecting non-peer staff attitudes [ 23 , 34 , 61 ]. For example, PSWs reported not being invited to social events and being treated like patients [ 61 ]. Consequently, some PSWs felt excluded, that their roles were tokenistic and experienced self-stigma [ 23 , 34 ]. PSWs as part of the newer recovery model reported challenges around integrating into traditional treatment models, e.g. where doctors spent the least time with service users but held the majority of power and decision making for service users. PSWs were expected to contest the traditional treatment model in support of a recovery focus, e.g. by their presence or in some cases being openly challenging, and this clash between old and new treatment models could lead to friction [ 23 ].

There was a fear that ‘cheap labour’ provided by PSWs may lead to fewer non-peer staff positions [ 61 ].

PSWs often received low pay, which led to role dissatisfaction for PSWs, suggesting the job was tokenistic or the role was unclear [ 63 , 64 ]. One reason for low pay was due to PSWs not requiring certification (i.e. specific qualifications, which e.g. a social worker would require) [ 63 ]. Some PSWs were positive about certification but others felt it could conflict with the grassroots ethos of peer support. However, there was the view that lived experience was not solely sufficient to work in interprofessional teams [ 64 ]. Despite this, supervision and support were often not offered to PSWs leading to risks [ 60 , 64 ].

There were challenges in PSW relationships with non-peer staff which could lead to a lack of support and hostility from non-peer staff. Non-peer staff felt threatened that they may be replaced by PSWs [ 64 ], were uneasy about working with people they previously treated [ 46 ], were concerned about the effectiveness of peer support [ 39 ], and felt expectations to support PSWs, increasing their workload [ 42 ]. This undermined the role of PSWs, e.g. they were subsequently given fewer responsibilities [ 39 ]. For PSWs, they wanted to challenge stigma by taking on more responsibility but high, varying workloads could jeopardise relationships with non-peer staff and team hierarchies hindered their ability to challenge clinically dominant ways of thinking [ 64 ].

A final theme was the perception that service users should be able to choose among PSWs as service providers [ 60 ].

Summary of key findings

An overview and summary of the key findings for each research question is presented in Table  7 .

Key findings

Our umbrella review of 35 reviews explored the effectiveness, implementation and experiences of peer support for mental health.

Effectiveness was reported in 23 reviews. Many reviews reporting effectiveness data reported no effect of peer support on a range of outcomes, mirroring the findings from other reviews [ 9 , 66 ] including those focusing on other types of peer support (e.g. online peer support for young people) [ 67 ]. However, there was consistent evidence from meta-analyses that peer support may improve the clinical outcomes of perinatal depression and risk of hospitalisation of adults with severe mental illness, as well as recovery outcomes, and self-efficacy and stigma-related outcomes. Mixed meta-analytic results were found for the clinical outcomes of overall psychiatric symptoms in adults with SMI, psychosis symptoms, length of hospital stay and patient activation, and for psychosocial outcomes such as hope, empowerment, and quality of life. There was no meta-analytic evidence for improvements in relational support. Evidence from systematic reviews without meta-analysis similarly gave a mixed picture regarding psychosocial and clinical outcomes, but indicated more consistent evidence that peer support has a positive impact on recovery, suicidal ideation, and, to some degree, satisfaction with care.

Many possible sources of heterogeneity across the included reviews could contribute to the mixed findings in this study, such as low-quality methodologies, differences in the populations included, and poor specification of peer support roles or the content of interventions delivered. One important potential contributor to our mixed results is that the primary studies contributing to the included reviews often varied in the type of control groups they considered, for example studies with treatment as usual, active controls and waitlist controls were often reviewed within the same paper. As such, it was not possible to determine whether peer support is effective in comparison to certain types of care provision but not others. In a similar vein, we could not perform subgroup analysis to determine whether specific forms of peer support are more effective on certain populations as most reviews with meta-analyses involved a combination of different formats and a range of participant groups. Nevertheless, there was some indication that differences in the format of peer support may impact its effectiveness on empowerment, as the two meta-analyses involving individual peer support alone found a positive effect on empowerment, but the two looking at group-based peer support alone did not. However, further research is needed to adequately address such questions.

Although this overview of quantitative evidence does not give unequivocal support for peer support on a variety of outcomes, the mixed results must be understood not only in the context of heterogeneity of the quantitative research conducted thus far, but with regard to the qualitative evidence documenting strong support for this intervention (as discussed in more detail below). Given that the implementation of peer support in mental health services is still relatively rare and highly variable, many of the trials conducted thus far may have tested peer support in environments where it is not fully embedded in the organisation and culture. Indeed, peer support may have positive impacts on the operation of mental health services that have not been measured as quantitative outcomes in existing trials—such as a stronger culture of person-centred care. More consistent quantitative results demonstrating the benefit of peer support may increasingly emerge as it becomes better integrated in the mental health care system.

We identified several factors reported to be important for the successful implementation of peer support, which were summarised and structured using the CFIR. These factors included adequate training and supervision for PSWs, a recovery-oriented workplace structure, strong leadership and a supportive and trusting workplace culture with effective collaboration between PSWs and non-peer staff. Barriers to peer support being implemented effectively included a lack of time, resources, and appropriate funding, and a lack of recognised PSW certification. Policy, research and campaign groups have advocated implementation approaches in line with these findings, for example, ImROC (implementing Recovery through Organisational Change) [ 14 , 68 ], who support peer support implementation globally and international competence frameworks from New Zealand [ 69 , 70 ], outline recovery focus as a core principle of peer support and emphasise the importance of training and ongoing professional development; peer support practice guidelines in the USA outline the importance of and give guidelines for supervision [ 71 ]. Formalised career pathways for PSWs [ 72 ] may help to address some of the identified barriers to effective implementation of peer support work, although these are still early in their development [ 68 ].

Experiences of peer support were from a range of perspectives (e.g. PSWs, service users, non-peer staff) and were organised under three main themes. The benefits of peer support for PSWs, service users and non-peer staff were expressed in many reviews; however, there were also conflicting and challenging experiences of the role. The mental health experience of PSWs was viewed as valuable, but also subject to some stigmatising views. For PSWs, the role could improve their personal wellness and recovery, providing a route back into employment and improving functioning, and provide service users with role models of recovery. The reciprocal benefits of peer support have also been highlighted as an advantage of peer support in resources developed by NHS England [ 19 ]. However, PSWs reported the ‘sick’ label stayed with them in the role, with non-peer staff at times concerned that PSWs mental health would impact their work, and some service users reported that they found it challenging to trust PSWs knowledge due to their lack of training and mental health history. A key experience, which became the core of our second theme, was the ambiguity of the PSW job description, including lack of clarity over boundaries with service users and when to disclose PSWs’ personal experiences. This ambiguity meant that the role was flexible, but also led to the perception that it was tokenistic and left PSWs feeling confused which impacted their own recovery. IMROC recommend the prioritisation of clear roles when implementing peer support [ 68 ]. Professional accreditation can counter the view of peer support as tokenistic, e.g. the UK Peer Support Competence Framework outlined by the Royal College of Psychiatrists [ 73 ] and the Canadian Peer support Accreditation and Certification, a national standard endorsing peer support work as a valuable career, developed in 2017 by PSWs themselves [ 74 ]. The final theme ‘organisational challenges and impact’ included experiences such as PSWs receiving inadequate support, training and supervision, and receiving low pay, leaving them feeling undervalued. Some non-peer staff attitudes were also a reported issue; while some PSWs felt accepted within teams, others experienced negative and rejecting non-peer staff attitudes, such as being treated as patients and not being invited to staff social events. Organisations should prepare, structurally and culturally, for the introduction of PSWs in order to ensure PSW wellbeing and reduce the risk of absences due to sickness [ 68 , 75 ].

Strengths and limitations

We conducted a comprehensive search of several relevant databases and identified a large number of reviews for inclusion, providing the first detailed summary of review findings relating to effectiveness, implementation and experiences of peer support. We also had consistent involvement of researchers with lived experience of mental health and peer support delivery and receipt throughout the design, data screening and extraction, analysis and synthesis, and manuscript drafting for this paper, which allowed lived experience priorities and experiences to guide our approaches to data and our decision making throughout.

We aimed to focus our review on paid peer support; however, this information was underreported in the reviews, and even when reported, interventions were often grouped with peer support interventions that did not fully meet our eligibility criteria (e.g. were unpaid). We also synthesised data from studies where payment status of PSWs was ambiguous, i.e. not reported. This limits our ability to draw firm conclusions around paid peer support specifically, as a significant portion of the data synthesised was from studies investigating unpaid or voluntary peer support. Another limitation was the lack of involvement of people with lived experience in the included reviews, with involvement reported in only one review [ 57 ]. Given the service user-led origins of peer support, future reviews should ensure involvement of people with lived experience. This is addressed in more detail later in this paper. Most included reviews were appraised by the AMSTAR 2 as low or critically low (97%) quality with only one review appraised as high quality. Although the low quality of reviews is a limitation, we aimed to report an overview of all current evidence for peer support to inform policy makers and healthcare practitioners, therefore to maximise the evidence base, we synthesised the reviews scored as ‘critically low quality’. Our ratings are also in line with a prior umbrella review of peer support which rated 87% of reviews as critically low quality and the remainder as low quality, but reported outcomes from all reviews [ 66 ].

Beyond the aforementioned limitations regarding variation in studies within each review, there is also a loss of granular detail through the umbrella review process of summarising data across reviews, which themselves contain many studies which have been summarised. The person-centred nature of peer support may mean that there are meaningful outcomes for the service user which are not easily captured in standard outcome measurement tools or recognised as clinically significant. Variation in peer support roles across studies may have contributed to the contradictions in our findings for RQ3, e.g. the challenges around PSW roles being ambiguous, but also the reported benefits of a flexible role.

A strength of our review was our broad inclusion criteria, for example, for qualitative data on experiences of peer support we reported data from the perspectives of service users, non-peer staff and PSWs. Though some data was reported separately by role, there were studies where experiences were reported together, and these perspectives were difficult to disentangle. Finally, we did not conduct a formal meta-synthesis of the qualitative experiences data; therefore, some detail may have been missed.

Implications for practice

Peer support may be effective at improving some clinical outcomes, self-efficacy and recovery outcomes for some people and could augment the standard service range. Certain groups may benefit from peer support more than others; evidence was strongest for depression outcomes within perinatal populations, but extremely variable for other populations. Peer support may differ in effectiveness depending on population needs and characteristics. PSWs need adequate pay, clear role descriptions and guidelines (e.g. about boundaries and disclosure), ongoing training and supervision, and opportunities for progression. Attitudes about peer support held by non-peer staff may significantly support or impede the implementation and experience of PSWs, and non-peer staff may require training about PSW roles and how to work collaboratively with PSWs. Culture, hierarchical structure and staff acceptability of peer support impact implementation and experience of peer support—structural and cultural change may be required for peer support to succeed, e.g. ensuring a recovery-oriented care model is operating in the service.

Implications for policy

Successful implementation of PSWs in healthcare settings is likely to require a coproduction approach with clearly defined PSW roles, a receptive hierarchical structure and staff, strong leadership and appropriate training (for PSWs and staff) with clinical and/or peer supervision alongside safeguarding. Issues relating to cost, lack of time and lack of resources are key considerations for service providers aiming to implement PSW that is sustained and effective within services. Additionally, Services could benefit from clear, coproduced guidelines, outlining the steps that are most likely to lead to successful PSW implementation.

Implications for research

Future primary and secondary research could usefully explore the differences in efficacy, implementation and experiences in paid PSW over time as it becomes more established; an important distinction as there are likely to be differences in these outcomes as the role of PSW develops. Such studies could consider using more personalised outcome measures such as goal-based outcome measurement [ 76 ]. Current PSW roles are still poorly defined and PSW content, including PSW variations (such as whether PSWs should deliver structured or more loosely structured, informal interventions, or whether interventions should vary according to need and context), need further exploration. Realist investigations around what works for whom, how and in which contexts would uncover more fine-grained detail on the specific contexts and mechanisms that explain these differences. Very few reviews included in this umbrella review reported lived experience researcher leadership or involvement in the undertaking of the study. It is imperative for future research in this area to appropriately reflect the priorities of those who are directly involved in PSW, either as providers or as service users. As the number of PSWs increases and more formalised roles are created, positive impact may not be restricted to outcomes of those supported by PSWs, but also to the functioning of services at an organisational level [ 68 ]. Further research is needed to evaluate how teams function with and without PSWs in order to understand how they may impact experiences through changes at a system level [ 68 ].

Our umbrella review has summarised data from 35 reviews on the effectiveness, implementation, and experiences of peer support for mental health. Although we attempted to focus solely on paid peer support, this detail was often not reported in the reviews. While data on effectiveness was mixed, there was some evidence of improvements on outcomes including depression, particularly perinatal depression, self-efficacy, and recovery, illustrating the potential benefits of wider PSW implementation across mental health services. Good implementation of peer support depends on co-design with people with lived experience, clear job descriptions, a recovery-oriented workplace culture, strong leadership, appropriate training for PSWs and staff , and supervision for PSWs. However due to limited information on cost or cost-effectiveness, we are unable to draw conclusions around resources required to implement PSWs. Experiences of peer support were from a range of perspectives. Peer support was mutually beneficial for PSWs’ and service users’ wellbeing and recovery and PSWs became role models. However, at times PSW roles were ambiguous, this meant that the role was flexible but could also lead to confusion which could impact PSWs own recovery. Potential strategies to successfully implement peer support include that the PSW roles should be clear, PSWs should be appropriately trained and paid, as well as supported and supervised within a trusting and accepting workplace structure and culture that advocates for a recovery-oriented model of care.

Lived experience commentary, written by LM and KM

This study provides a useful summary of the available research on peer support. By providing an overarching review of 35 reviews including 426 available studies, the paper brings together the knowledge on a topic of growing importance and understanding of the experiences, effectiveness, and implementation of peer support. However, this evidence is limited to ‘paid peer support workers’ included in data from academic literature of systematic reviews.

The nature of an umbrella review means that the systematic reviews themselves are synthesised, limiting our ability to look at specific details in the primary studies, for example to look for evidence of lived experience involvement or co-authorship or demographics of participants. The papers within the review are likely to have originated from traditionally funded research enquiries, and an umbrella review potentially magnifies academic or clinical perspectives over user voices and interests. While this is a frustration in any mental-health-related topic, this is particularly concerning in relation to peer support, with its origins in our user-led history.

The roots in user-led peer support are also overlooked when limiting the studies to paid peer support work. Although they might use the same language of mutuality and reciprocity, the two feel different. We are hesitant to suggest that we would prefer the skills and expertise of our supporters to be voluntary and unpaid; we strongly believe their expertise should be valued and funded. But there is something magical about informal peer support which can be lost when it is over-policed in bureaucratic cultures. Additionally, with studies included in the review dating back to 1979, we question how relevant these studies are in informing England’s evolving peer support landscape.

A crucial area of future research is exploring what type of peer support works best for whom and in what circumstances, and how we can deliver this. Furthermore, we need to better understand how NHS cultures can be supported to value the expertise that originates in our lived experience, including the marginalised experiences which have been disproportionately represented in mental health services.

Availability of data and materials

The data used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

A MeaSurement Tool to Assess systematic Reviews

Consolidated Framework for Implementation Research

Implementing Recovery through Organisational Change

Lived Experience Working Group

Population, Intervention, Comparator group, Outcome

Peer support worker

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Acknowledgements

This work is supported by the NIHR UCLH BRC.

This study is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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Ruth E. Cooper and Katherine R. K. Saunders are joint first-authors.

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NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Ruth E. Cooper, Katherine R. K. Saunders, Jessica Griffiths, Ruth Stuart & Alan Simpson

NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK

Anna Greenburgh, Rebecca Appleton, Phoebe Barnett, Sophie M. Allan, Brynmor Lloyd-Evans & Sonia Johnson

Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK

Phoebe Barnett

National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK

University of East Anglia, Norwich, UK

Sophie M. Allan

MHPRU Lived Experience Working Group, London, UK

Prisha Shah, Karen Machin, Tamar Jeynes, Lizzie Mitchell, Beverley Chipp & Stephen Jeffreys

Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, UK

Alan Simpson

Camden and Islington NHS Foundation Trust, London, UK

Sonia Johnson

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All authors (RC, KS, AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ) substantially contributed to the conception or design of this study. Data acquisition was undertaken by: KS, RC, JG, RS, RA, KM, PS, SA, PB. The data were synthesised and interpreted by: KS, AG, RA, PS, KM, TJ, and RC. KS and RC led on drafting the manuscript with input and/or editing by all other authors (AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ). All authors (RC, KS, AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ) read and approved the final manuscript.

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Additional file 1: appendix 1..

Prisma checklist [ 29 ]. Appendix 2. Full search strategy. Appendix 3. AMSTAR2 ratings. Appendix 4. Excluded studies following full text screening, with reasons. Appendix 5. Study overlap. Appendix 6. Effectiveness of peer support outcomes: results for non-meta-analysis results. Appendix 7. Experiences of peer support (detailed themes).

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Cooper, R.E., Saunders, K.R.K., Greenburgh, A. et al. The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review. BMC Med 22 , 72 (2024). https://doi.org/10.1186/s12916-024-03260-y

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Musculoskeletal patients’ preferences for care from physiotherapists or support workers: a discrete choice experiment

• Panos Sarigiovannis   ORCID: orcid.org/0000-0001-7960-1500 1 , 2 ,
• Luis Enrique Loría-Rebolledo 3 ,
• Nadine E. Foster 1 , 4 ,
• Sue Jowett 5 &
• Benjamin Saunders 1  

BMC Health Services Research volume  24 , Article number:  1095 ( 2024 ) Cite this article

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Delegation of clinical tasks from physiotherapists to physiotherapy support workers is common yet varies considerably in musculoskeletal outpatient physiotherapy services, leading to variation in patient care. This study aimed to explore patients’ preferences and estimate specific trade-offs patients are willing to make in treatment choices when treated in musculoskeletal outpatient physiotherapy services.

A discrete choice experiment was conducted using an efficient design with 16 choice scenarios, divided into two blocks. Adult patients with musculoskeletal conditions recruited from a physiotherapy service completed a cross-sectional, online questionnaire. Choice data analyses were conducted using a multinomial logit model. The marginal rate of substitution for waiting time to first follow-up physiotherapy appointment and distance from the physiotherapy clinic was calculated and a probability model was built to estimate the probability of choosing between two distinct physiotherapy service options under different scenarios.

382 patient questionnaires were completed; 302 participants were treated by physiotherapists and 80 by physiotherapists and support workers. There was a significant preference to be seen by a physiotherapist, have more follow-up treatments, to wait less time for the first follow-up appointment, to be seen one-to-one, to see the same clinician, to travel a shorter distance to get to the clinic and to go to clinics with ample parking. Participants treated by support workers did not have a significant preference to be seen by a physiotherapist and it was more likely that they would choose to be seen by a support worker for clinic scenarios where the characteristics of the physiotherapy service were as good or better.

Conclusions

Findings highlight that patients treated by support workers are likely to choose to be treated by support workers again if the other service characteristics are as good or better compared to a service where treatment is provided only by physiotherapists. Findings have implications for the design of physiotherapy services to enhance patient experience when patients are treated by support workers. The findings will contribute to the development of “best practice” recommendations to guide physiotherapists in delegating clinical work to physiotherapy support workers for patients with musculoskeletal conditions.

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Musculoskeletal (MSK) conditions such as arthritis and low back pain are the leading cause of years lived with disability worldwide; they affect an estimated 20.2 million people across the UK, where they are the second leading cause of sickness absence from work [ 41 ]. Most MSK conditions can be managed in primary care or outpatient services in hospitals; evaluation and treatment by physiotherapists are frequently part of the treatment pathway [ 4 ]. Patients are assessed by physiotherapists and if they need follow-up treatments, these are provided by either a physiotherapist or a physiotherapy support worker.

The physiotherapy support worker role was developed to address some of the challenges affecting healthcare service delivery and the physiotherapy workforce worldwide. This includes an increasingly ageing population and an associated burden of healthcare; spiralling costs; increased patient expectations and a shortage of registered physiotherapists [ 3 , 11 ] (Lizarondo et al., 2010; Munn et al., 2013). Physiotherapy support workers, who may also be known as physiotherapy assistants, rehabilitation assistants, technical instructors or physiotherapy technicians, are non-registered staff who work alongside physiotherapists to provide delegated interventions and responsibilities [ 33 ]. They do not hold a qualification accredited by a professional association and are not formally regulated by a statutory body.

In the UK, physiotherapy support workers form approximately 15% of the total physiotherapy workforce [ 37 ] and a significant proportion of them work in MSK physiotherapy services within the National Health Service (NHS). They may undertake any activity that is in pursuit of physiotherapy goals provided that the activity is delegated to them by a registered healthcare professional with appropriate supervision in place and, where necessary or indicated, access to support and advice from a registered physiotherapist [ 38 ]. However, physiotherapy support workers’ roles are relatively undefined and as such, there is considerable variation in the duties and tasks they undertake [ 31 ]. National guidance from the Chartered Society of Physiotherapy (CSP Footnote 1 ) about delegation of tasks to support workers largely leave decision-making to the individual physiotherapist, their judgement of the task and their assessment of the competence of the support worker [ 39 ]. Consequently, in some physiotherapy services, physiotherapy support workers have a predominantly clinical role whereas in others they fulfil primarily an administrative role such as inputting data and booking appointments which leads to variation in clinical care [ 31 ].

A recent survey that explored current practice of UK MSK physiotherapists in relation to delegating clinical tasks to physiotherapy support workers, demonstrated that there is considerable variation in practice and delegation appears very patient-dependent [ 33 ]. This evidence suggests the need for a best practice framework to guide physiotherapists when delegating clinical tasks to support workers and standardise delegation. This need is being addressed through the Musculoskeletal Outpatient Physiotherapy Delegation (MOPeD) mixed methods study [ 34 ]. The first stage of the MOPeD study was a focused ethnographic study which explored how the culture in physiotherapy services may influence how tasks are delegated to physiotherapy support workers. It included detailed observations in two NHS musculoskeletal outpatient physiotherapy services and interviews with patients and clinicians. Stage 2a was a consensus study to reach agreement about what ‘best practice’ delegation recommendations should include.

A crucial step in the process of developing the ‘best practice’ recommendations is to understand musculoskeletal patients’ preferences about whether they are treated by physiotherapists or by physiotherapy support workers. The aim of the current study, which forms stage 2b of the MOPeD study, was to explore patients’ preferences about their care in MSK outpatient physiotherapy services and estimate specific trade-offs patients are willing to make in treatment choices when they are treated by physiotherapy support workers in MSK outpatient physiotherapy services.

• Discrete choice experiment

A discrete choice experiment (DCE) was carried out. The DCE was conducted to elicit patients’ preferences when treated by physiotherapists and physiotherapy support workers in NHS MSK physiotherapy services. DCEs are an attribute-based survey method for measuring benefits (utility). Within healthcare, DCEs have been applied to address a wide range of issues in the delivery of healthcare including measuring and valuing attributes of a healthcare service and identifying the factors that influence choices and decisions of patients, the public and healthcare professionals [ 28 , 35 ]. DCEs are based on the assumption that a service can be described by its characteristics or attributes, and the extent to which an individual values the service depends on the levels of these characteristics [ 36 ]. In a DCE, respondents are asked to choose between two or more alternatives, implicitly trading between the characteristics’ levels.

Ethical approval for the study was granted by the South West – Frenchay NHS Research Ethics Committee (REC) and the UK Health Research Authority (REC reference 21/SW/0158, IRAS project 297095).

Attributes and levels

Development of the attributes and levels was guided by the qualitative findings from the first stage of the MOPeD study, which included semi-structured interviews of 19 patients who were treated by physiotherapists and support workers for a MSK condition (Sarigiovannis et al., in preparation), and further input from the study’s patient and public involvement and engagement (PPIE) and clinical advisory groups [ 34 ]. From the thematic analysis of the interviews, we identified factors that influenced patient preference. In addition, we explicitly asked participants of the PPIE group to identify the most important physiotherapy service characteristics that would influence their choice if they had to choose between two different physiotherapy services. The qualitative findings and the feedback from the PPIE and clinical advisory group were reviewed and combined to inform the selection of attributes and levels for the DCE [ 7 ]. The findings were reviewed by the PPIE group again and finally, seven attributes were included in the DCE. Table  1 shows the attributes and levels used in the MOPeD DCE.

For each choice task, participants were asked to select one of the two physiotherapy services (for further details refer to DCE instrument  section). An opt out option was considered but it was decided not to include one as the choice frame reflects the real choice a patient would face. Additionally, it has been shown that inclusion of an opt out option results in small differences between the forced and unforced choice model while at the same time it compromises statistical significance [ 5 , 40 ]. Given the attributes and levels, there were 1536 possible combinations of choice tasks (2 3  × 3 × 4 3 ). A D-efficient design, for a multinomial logit model (MNL) Footnote 2 was used to select 16 choice tasks using the NGENE software. The design included an alternative specific constant (ASC) for the second alternative, which captures the likelihood of choice with respect to the first alternative when all attributes are held equal. The design was blocked into two versions of eight choice tasks [ 15 , 21 ]. The final design was selected based on the lowest D-error, maximum level balance and utility balance, and minimal within-alternative correlation, minimal overlap [ 26 , 29 , 36 ].

DCE instrument

The DCE was administered as a cross-sectional questionnaire online survey with different sections which included questions about the participants’ health as well as sociodemographic data such as ethnicity, education and employment. The questionnaire was available online on the Qualtrics platform and participants completed it using tablet devices which were available at the participating clinics. However, a paper version of the questionnaire was produced to facilitate the ethical approval process (additional file 1). Participants were randomised to complete one of the two versions of the choice-set questions. An example of a choice-set question is shown in Fig.  1 together with the text that introduced the choice tasks.

Explanation of scenarios and example of a choice task (question 1, block 1)

The order of the choice tasks was randomised in each version. The questionnaire was piloted three times prior to the final version, to ensure ease of comprehension and test completion times. Following the first pilot, the order and wording of questions changed and after the second pilot an additional section about participants’ current treatment was added to facilitate comprehension. No changes were made after the third and final pilot. Depending on their answers, each participant was required to answer 22 to 25 questions in total. For example, only participants who answered that they used the car park at their physiotherapy clinic were asked to answer if the car park was ample or limited.

Patient and public involvement and engagement

Meetings were held throughout the study with a group of seven patients to develop the DCE: three male and four female. All patients in the group had experience of treatment by a physiotherapist and/or physiotherapy support worker for a MSK condition. This support and feedback were essential in selecting the DCE attributes, designing and piloting the questionnaire, producing the participant.

information leaflets and interpreting the results. For example, based on the feedback from the PPIE group, it was decided to only offer the questionnaire in an online format which participants would complete using tablet devices in the participating physiotherapy clinics.

Clinical advisory group

The design and methods of the DCE were also informed by discussion with a group of clinicians consisting of four physiotherapists, three physiotherapy support workers, one physiotherapy operational lead and one clinical lead. Based on the feedback received from the study’s clinical advisory group, it was decided that patient recruitment would be completed by the lead author, who was employed by the participating Trust, and three research facilitators. The group supported the delivery of the study, interpretation of results and dissemination.

DCE sample size

The minimum sample size needed for DCEs depends on the specific hypotheses to be tested [ 10 ]. The sample size calculation was based on Orme’s formula which takes into account the number of choice tasks, the number of alternatives and the maximum number of levels for all attributes [ 24 ]. The absolute minimum number of participants required for the DCE would be 125 participants per block or 250 participants in total. However, as the need to conduct subgroup analysis was taken into consideration, it was decided to recruit between 180 and 200 per block or 360–400 participants in total [ 25 ].

Participant eligibility criteria and recruitment

Adult patients (18 years old or older) who were treated for a MSK condition in one of the eight participating physiotherapy clinics in Midlands Partnership University NHS Foundation Trust (MPFT) were eligible to participate. The clinics were part of a primary care musculoskeletal physiotherapy service which served urban and rural areas covering the geographical area of North and South Staffordshire. Patients were referred to the physiotherapy service predominantly by general practitioners (GPs), first contact practitioners (FCPs) or advanced physiotherapy practitioners (APPs).

Physiotherapists within participating site(s), invited patients to self-complete the questionnaire when patients were either attending for their follow-up physiotherapy appointment or were discharged from treatment during pre-arranged recruitment days during the 4-month-recruitment period. Patients were directed to the researcher (PS) or the research facilitator when they expressed their interest to participate or to find out more information about the study. Patients who agreed to participate were asked to provide informed, written consent prior to completing the DCE questionnaire. Patients were provided with a tablet to complete the survey in a quiet office where the researcher (PS) or a research facilitator were available to help them if they encountered any difficulties with the equipment.

Data analyses

Data analyses were conducted in STATA (Stata Corporation 2023, Stata Statistical Software: Release 18. College Station, Texas: Stata Corporation LLC). Data were analysed using an MNL model with robust standard errors. Additionally, subgroup analyses were conducted to identify the potential effect of observed patient characteristics [ 8 ]. For example, the sample was split into various subgroups including patients who were referred for physiotherapy because of a spinal condition or conditions other than spinal, patients with reduced or not reduced activities of daily living (ADL) due to their musculoskeletal condition(s), patients with or without at least a degree qualification, patients aged either under 65 years old or 65 years old and older, patients who were female or not and patients being treated by physiotherapists or by support workers. Marginal rates of substitution (MRS) (e.g., the ratio of two parameters) were calculated in terms of waiting times and travelling distance to allow direct comparison across subgroups which facilitated interpretation of data and account for observed heterogeneity [ 9 , 12 , 42 ]. Waiting times and travelling distance were selected since they have been reported to be important for patients [ 17 ] (Pitkänen and Linnosmaa, 2021). Finally, mean estimates were used to estimate the probability of choosing one of the two physiotherapy services based on scenarios of interest (e.g., between services provided by physiotherapist and support worker).

Study participants

382 patients were recruited, with 232 (60.73%) attending their physiotherapy appointments within North Staffordshire and 150 (39.27%) in South Staffordshire. Mean completion time of the online survey was 11.16 min. 251 participants (65.71%) were female and 190 patients (49.74%) were 65 years old or older. 371 participating patients (97.12%) described their ethnic group as “white”. 155 participants (40.57%) reported having no qualifications, whereas 142 (37.17%) held at least a degree qualification. 192 participants (50.26%) were retired and 117 (30.63%) preferred not to reveal their household income. 176 (46.07%) participants stated that they suffered from long-term conditions which affected their activities of daily living. Characteristics of the study participants are shown in Table  2 .

MNL model analysis

There was no evidence the position of the alternative scenario impacted the likelihood of choosing a service (e.g., no left to right bias). The results (Table  3 ) showed patients prefer being seen by a physiotherapist as opposed to a support worker; waiting less time to be seen for the first follow up appointment and receiving continuity of care. Furthermore, the results indicated that patients prefer to have more follow-up treatments; travel less distance to get to the physiotherapy clinic and have appointments in clinics with ample parking. Finally, being treated in an exercise class with other patients was preferred less than when being treated one-to-one without equipment. However, when the treatment was delivered one-to-one, they were indifferent to having access to equipment. Appendix shows the MNL model analysis for the relevant subgroups.

Marginal rates of substitution for waiting time and distance

Figure  2 shows the MRS in terms of waiting time for the two subgroups: patients currently treated by support workers and those treated by physiotherapists. Patients treated by physiotherapists were willing to wait an additional period of 8.76 weeks to be seen by a physiotherapist, 13.57 weeks to be treated by the same clinician for their follow-up treatments, 0.35 weeks for each additional follow-up appointment, 8.82 weeks to be treated one-to-one without equipment instead for being treated in a class with other patients, 0.34 weeks to be seen one-to-one with equipment instead of one-to-one without equipment, 1.16 weeks per mile being closer to the physiotherapy clinic and 3.53 weeks to go to a clinic with an ample parking. Patients who were treated by physiotherapy support workers were willing to wait an additional period of 0.23 weeks to be seen by a physiotherapist, 7.71 weeks to be treated by the same clinician for their follow-up treatments, 0.95 weeks for each additional follow-up appointment, 1.07 weeks to be treated one-to-one without equipment, 0.49 weeks to be seen one-to-one with equipment, 1.40 weeks per mile being closer to the physiotherapy clinic and 4.10 weeks to go to a clinic with an ample parking.

Willingness to wait values to get a marginal change per attribute for patients treated by support workers and physiotherapists

Figure  3 shows the MRS for travelling distance for the same subgroups. Patients treated by physiotherapists were willing to travel an additional distance of 7.57 miles to be seen by a physiotherapist, 0.86 miles for each week that they have to wait less to be seen for their first follow-up appointment, 11.72 miles to be treated by the same clinician for their follow-up treatments, 0.30 miles for each additional follow-up appointment, 7.61 weeks to be treated one-to-one without equipment instead for being treated in a class with other patients, 0.29 miles to be seen one-to-one with equipment instead of being treated one-to-one without equipment, and 3.53 miles to go to a clinic with an ample parking. Patients treated by physiotherapy support workers were willing to travel an additional distance of 0.17 miles to be seen by a physiotherapist, 0.72 miles for each week that they have to wait less to be seen for their first follow-up appointment, 5.52 miles to be treated by the same clinician, 0.68 miles for each additional follow-up appointment, 0.76 miles to be treated one-to-one without equipment instead for being treated in a class, 0.35 miles to be seen one-to-one with equipment, and 2.94 miles to go to a clinic with an ample parking.

Willingness to travel values to get a marginal change per attribute for patients treated by support workers and physiotherapists

Probability of choosing services

Table  4 shows the probability of participants selecting one of the two physiotherapy service options listed in three different scenarios with two services each. Scenario 1 describes a choice between a service ( Service 1 ) where patients are treated by physiotherapists and one ( Service 2 ) where patients are treated by physiotherapy support workers in which other service characteristics are seemingly less favourable (e.g., farther away and more waiting time). Scenario 2 is similar to Scenario 1 with the only difference being the distance to the physiotherapy clinic has been reversed between the two services (i.e. 16 miles distance for Service 1 and 2 miles distance for Service 2 ). Scenario 3 also describes a Service 1 where the treatment is provided by physiotherapists and a Service 2 where treatment is provided by support workers, but with other service characteristics that seemingly favour the latter.

Results showed that in Scenario 1, on average most patients (96.72%) would choose the service with the physiotherapist ( Service 1 ). Furthermore, who the patient’s current clinician is does not seem to impact the likelihood of choice: 97.80% patients being treated by physiotherapists and 90.74% patients being treated by support workers would choose the service with the physiotherapist ( Service 1 ). Similarly, in Scenario 2, on average most patients (77.88%) would choose the service with the physiotherapist ( Service 1) . However, given the change in travel distances to each clinic, there was a bigger difference between the two subgroups: 83.81% of patients treated by physiotherapists would choose Service 1 compared to 50.10% of patients treated by support workers.

In Scenario 3, given the least favourable service characteristics of the service where the treatment is provided by physiotherapists ( Service 1 ), on average the choice proportions between the two services were more equally split with 46.66% of patients would choose a service with a support worker. At the same time, there was also evidence that current treating clinician had an effect on probabilities: 69.56% of patients treated by support workers were likely to choose the service which included a support worker versus 40.18% of those treated by physiotherapists. Conversely, 59.82% of participants who have been seen by a physiotherapist versus 30.44% of those seen by a support worker would choose a service where treatment is provided exclusively by physiotherapists even when the other characteristics are less favourable.

Main findings

This paper reports the findings of a study which used DCE methodology to elicit patients’ preferences when they are treated by physiotherapists and physiotherapy support workers in MSK outpatient physiotherapy services. Patients elicited expected preferences. Nevertheless, the results of this DCE showed that patients’ experience of being treated by a physiotherapist or support worker previously is a significant factor when making a choice about the future. Patients who had been seen by support workers were likely to choose to be seen by a support worker again provided the other service characteristics such as travelling distance, parking facilities or number of follow-up treatments, are similar or marginally better when compared to those of a physiotherapy service where follow up treatments are provided by physiotherapists.

Comparison with previous research literature

Charles et al. [ 6 ] conducted a DCE to explore older patients’ preferences for hip fracture rehabilitation services. The DCE attributes included whether the treating clinician was a qualified physiotherapist/occupational therapist or a support worker. The authors reported that there was a significant preference for the healthcare professional delivering the rehabilitation sessions to be a qualified physiotherapist or occupational therapist. Nevertheless, their results should be viewed with caution as the study sample used in their DCE was small (41 patients). Additionally, Charles et al. [ 6 ] described support workers in their DCE as “supervised unqualified assistants” which may have been confusing and misleading for participants. Physiotherapy support workers are non-registered clinicians but not unqualified as the vast majority of them have qualifications that enable them to work safely and effectively in their role [ 31 ].

Uncertainty and lack of clarity in relation to support workers’ role as well as lack of previous experience of being treated by a physiotherapy support worker, may have been among the factors which influenced patients, who were not treated by support workers in our study, to choose to be treated by a physiotherapist instead of a support worker. Historically, there has been a lack of regulation and registration for physiotherapy support workers, and as a result, many of these positions have evolved with variations in the title, and an inconsistent understanding of the role as well as the educational and supervision requirements [ 14 , 32 ].

Convenience is a well-known factor for treatment choice. It has been reported that patients tend to choose their preferred location taking into account parking availability, duration of trip and transport services’ availability and costs (Perry et al., 2015, Pitkänen and Linnosmaa 2021). Pitkänen and Linnosmaa (2021) reported that, in general, all patients prefer high-quality providers within short distances. This is supported by the findings of this study as patients preferred to travel the shortest possible travelling distance to get to the physiotherapy clinic. Nevertheless, patients in our study were prepared to travel longer distances to be seen by the same clinician. Continuity of care of care is known to have important benefits for patients, healthcare professionals and healthcare systems [ 13 , 16 , 22 ].

Mason [ 23 ] reported that between 70 and 90% of patients who accessed hospitals used cars to attend for outpatient appointments and that and the parking experience could be an additional source of financial pressure, worry and stress, which appeared to affect patient satisfaction principally when it was either very good or very bad. Participants in our sample clearly demonstrated their significant preference for physiotherapy clinics with ample parking.

Physiotherapy treatments for MSK conditions are usually delivered on a one-to-one basis or in group settings. There is evidence that physiotherapy treatments provided in groups are similarly effective to one to one care and cost-effective [ 1 , 30 ]. While group-based treatments may be appropriate for some patients, they will not suit all patients [ 19 ]. Participants in our study preferred to be seen one to one instead of in a group; however, patients treated by support workers did not have a strong preference to be seen one to one. It is reported that healthcare providers increasingly seek to improve quality of patient care by focusing on patients’ needs and preferences, with ‘patient-centredness’ recognised as a domain of quality in its own right [ 27 ]. To implement patient-centred care, it is essential that clinicians take into consideration patient preferences when they formulate their treatment plan [ 18 ].

Strengths and limitations

A robust process was followed in designing the DCE, involving incorporation of findings of the previous stages of the MOPeD study and input from different stakeholders, including patients. This process was reflected in the face validity of the analysis results. Additionally, a face-to-face data collection approach in this DCE resulted in high response rate and in receiving no incomplete questionnaires. Finally, we recruited 382 patients which allowed us to conduct various subgroup analyses. However, this study comes with limitations. First, the data analysis used a conditional or multinomial logit model (MNL) which has restrictive assumptions. For example, independence or irrelevant alternatives, independent and identically distributed errors and identical preferences across respondent e.g., no preference homogeneity [ 20 , 29 ]. An MNL was used, instead of a more flexible model that explores unobserved heterogeneity (but also contains requires other assumptions), to focus on more policy actionable observed heterogeneity as shown in the subgroup analysis and calculation of MRS and probabilities.

Second, linearity of the continuous variables was not tested because these were designed as continuous variables and not as categorical. The reason for this design specification was to minimise the degrees of freedom needed to estimate the model given the expected sample size [ 2 ]. Furthermore, the decision to treat them as continuous variables was supported by the guidance from the literature and the clinical advisory group of the study given the focus and ease of interpretation of the results if presented as marginal rates of substitution.

Third, participation of the study was limited to patients attending appointments in the eight participating physiotherapy MSK clinics within MPFT in North and South Staffordshire. Although the participants sample was not a representative sample of the UK population of MSK patients for ethnicity as most participants described their ethnic group as “white”, it was representative of the population of MSK patients that attend physiotherapy appointments in North and South Staffordshire. Partial postcode data were collected (the first part of the participants’ postcode) to ensure anonymity and comply with ethical approval but it was not possible to link the collected postcode data to full postcode data from other studies and such comparisons could not be made. We thus acknowledge that our findings may not be generalisable to all UK MSK patients including those who attend physiotherapy appointments for a MSK condition in the private sector. Nevertheless, the findings of this study highlight issues which are not pertinent exclusively to the NHS or the MSK clinical setting in relation to patients’ preferences when they are treated by support workers. Therefore, the findings may have wider applicability beyond the MSK setting or the NHS context and as such may be useful for informing research and practice in other settings both in the UK and internationally.

Conclusions and implications

The findings reported in this paper provide evidence about patients’ preferences as well as what service characteristics patients consider important when they are treated by physiotherapy support workers in MSK outpatient physiotherapy services. The findings demonstrated that patient experience of being treated by a physiotherapist or support worker is a significant factor when making a choice about the future. Unless patients have the experience of being treated by a physiotherapy support worker, they prefer to be treated by a physiotherapist regardless of any other less favourable characteristics of the physiotherapy service such as longer waits, distance and limited parking. Even when patients are treated by support workers, they seem to choose to be seen by a support worker again only when the other service characteristics are as good or favourable when compared to a service where treatment is provided only by physiotherapists.

The findings of this study indicate that there is a lack of understanding of the support workers’ role. They also suggest that it would be useful for patients to be given a clear explanation about the support worker role, their capabilities and why they are the most suitable and competent person for particular aspects of their treatment, in order to increase patients’ confidence and acceptability in being seen by a support worker. Finally, our findings highlight that continuity of care is important for patients. Within the study’s limitations, these findings can inform design of a physiotherapy service delivery to enhance patient experience when patients are treated by physiotherapists and support workers.

The findings of this study will be triangulated together with the results from the other stages of the MOPeD study to directly inform the development of “best practice” recommendations which incorporate the preference of patients, to guide physiotherapists to delegate clinical tasks to physiotherapy support workers in the MSK setting.

Availability of data and materials

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK’s chartered physiotherapists, physiotherapy students and support workers.

The MNL model is described as the ‘workhorse of choice modelling’ and it has been recommended as a natural first model to estimate [ 20 ].

Abbreviations

Activities of Daily Living

Advanced Physiotherapy Practitioners

Alternative Specific Constant

Chartered Society of Physiotherapy

Discrete Choice Experiment

First Contact Practitioners

General Practitioners

Integrated Research Application System

Multinomial Logit

Musculoskeletal Outpatient Physiotherapy Delegation

Midlands Partnership University NHS Foundation Trust

Marginal Rates of Substitution

Musculoskeletal

National Health Service

Patient and Public Involvement and Engagement

Research Ethics Committee

United Kingdom

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Acknowledgements

The authors would like to thank the study participants, members of the study’s Patient and Public Involvement and Engagement (PPIE) group and members of the study’s Clinical Advisory group for their valuable input and advice.

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Panos Sarigiovannis was funded by National Institute for Health and Care Research award (Clinical Doctoral Research Fellowship NIHR301550) for this research project. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.

NE Foster is funded through an Australian National Health and Medical Research Council Investigator grant (ID: 2018182).

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Panos Sarigiovannis

Health Economics Research Unit, University of Aberdeen, Aberdeen, AB25 2ZD, UK

Luis Enrique Loría-Rebolledo

STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, , Herston, Brisbane, Australia

Nadine E. Foster

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PS conceptualised and developed the idea for the study, designed the study, led the analysis of the data, wrote the first draft of the manuscript and critically edited the manuscript. LLR provided guidance in designing the study as well as conducting the data analysis and critically edited the manuscript.  NF, SJ and BS conceptualised and developed the idea for the study, were involved in designing the study, analysing the data and critically edited the manuscript. All authors read and approved the final manuscript.

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Ethical approval was granted by the South West – Frenchay NHS Research Ethics Committee and the UK Health Research Authority (REC reference 21/SW/0158, IRAS project 297095).

All participants were approached within the recruiting physiotherapy departments and provided informed written consent prior to completion of the DCE.  All methods were carried out in accordance with the Declaration of Helsinki.

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Supplementary material 1, mnl model analysis - coefficient values for all participants and various subgroups a.

• Note: Due to scaling issues, the magnitude of the coefficient cannot be directly used to compare preference estimates. However, the significance provides insight as to how preferences change across subgroups
• a Coefficient values in bold indicate that the p value ≤ 0.05

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Sarigiovannis, P., Loría-Rebolledo, L.E., Foster, N.E. et al. Musculoskeletal patients’ preferences for care from physiotherapists or support workers: a discrete choice experiment. BMC Health Serv Res 24 , 1095 (2024). https://doi.org/10.1186/s12913-024-11585-w

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How to Become a High School History Teacher in Minnesota: Requirements & Certification in 2024

by Imed Bouchrika, Phd

Co-Founder and Chief Data Scientist

Minnesota offers strong career prospects for educators across all levels, with a projected job growth rate of 4.1% for secondary school teachers between 2022 and 2032. Each year, the state expects to see about 1,290 new job openings for secondary teachers. High school history teachers in Minnesota earn an average annual salary of $70,170 as of 2023. With over 19,000 secondary school teachers employed statewide, the demand for qualified educators remains steady.

In this article, we explore the requirements and certifications needed to become a high school history teacher in Minnesota.

Key Things You Should Know About Becoming a HS History Teacher in Minnesota

• Licensing Administrative Body: In Minnesota, the Professional Educator Licensing and Standards Board (PELSB) oversees the licensing process for educators. This body is responsible for setting standards, issuing licenses, and ensuring compliance with state regulations.
• Licensing Requirements: To obtain a high school teaching license in Minnesota, candidates must hold at least a bachelor's degree from an accredited institution, complete a state-approved teacher preparation program, and demonstrate proficiency in the subject area they wish to teach. Additionally, candidates must pass a background check.
• Licensing Exam: Prospective teachers must pass the Minnesota Teacher Licensure Examinations (MTLE), which includes a basic skills test and a subject-specific test relevant to the teaching area. The MTLE is designed to assess the knowledge and skills necessary for effective teaching.
• Application Process: After meeting educational and testing requirements, candidates can apply for their teaching license through the PELSB online portal. The application requires submission of transcripts, test scores, and proof of completed teacher preparation programs. Processing times can vary, so applicants should plan accordingly.
• Continuing Education: Once licensed, teachers in Minnesota must complete continuing education requirements to maintain their licenses. This includes completing a minimum of 125 clock hours of professional development every five years, ensuring that educators stay current with teaching practices and educational standards.

Table of Contents

What are the educational requirements for becoming a history teacher in minnesota, what is the certification and licensing process for history teachers in minnesota, how important is teaching experience and what are the internship opportunities for history teachers in minnesota, what are the minnesota state standards and curriculum requirements for teaching high school history, what is the job market like and what are the salary expectations for history teachers in minnesota, what professional development and continuing education opportunities are available for history teachers in minnesota, what are effective classroom management strategies and teaching methods for history teachers in minnesota, what are the career advancement opportunities and specializations for history teachers in minnesota, what legal and ethical considerations must history teachers follow in minnesota, what resources and support are available for new history teachers in minnesota, other things you should know about becoming a high school history teacher in minnesota.

Those who wish to become a high school history teacher in Minnesota, educators must meet specific educational criteria. Here’s a practical breakdown of the requirements:

• Degree Levels: A minimum of a Bachelor’s degree is essential. This degree should ideally be in history or a closely related field. While a Master’s degree is not mandatory for initial licensure, it can enhance career prospects and earning potential.
• At least 30 semester credits in history, covering various periods and themes.
• Education courses that focus on pedagogy, classroom management, and instructional strategies.
• Teacher Preparation Programs: Enrollment in an accredited teacher preparation program is crucial. These programs provide the necessary training and practical experience through student teaching opportunities, which are vital for developing effective teaching skills.
• Accreditation: It’s important to ensure that the educational institution you choose is accredited by a recognized body. In Minnesota, programs accredited by the Council for the Accreditation of Educator Preparation (CAEP) are preferred, as they meet state standards for teacher education.
• Subject Matter Competency: To demonstrate proficiency in history, candidates must pass the Minnesota Teacher Licensure Examinations (MTLE) in social studies. This assessment evaluates knowledge in history, geography, economics, and government, ensuring that teachers are well-prepared to educate their students.

By following these steps and fulfilling the educational requirements, aspiring history teachers can successfully navigate the path to licensure in Minnesota, paving the way for a rewarding career in education.

In 2023, there were around 19,180 high school teachers in the state. See the chart below for more information on the employment levels of K12 teachers in Minnesota. 

To become a high school history teacher in Minnesota, you must navigate a structured certification and licensing process. Here’s a practical guide to help you through it:

• Complete a Bachelor’s Degree: Start by earning a degree in education or a related field, with a focus on history. This foundational step is crucial as it prepares you for the teaching profession.
• Teacher Preparation Program: Enroll in a state-approved teacher preparation program. This program will provide you with the necessary pedagogical skills and classroom experience.
• Apply for a Single Subject Teaching Credential: Once you have completed your degree and teacher preparation program, you can apply for a Single Subject Teaching Credential in History. This credential allows you to teach history at the high school level.
• The Basic Skills Test, which assesses your reading, writing, and math abilities.
• The Content Knowledge Test for Social Studies, which covers history and related subjects.
• Submit Your Application: After passing the exams, submit your application for licensure through the Minnesota Department of Education. Be prepared to provide transcripts, exam scores, and proof of your teacher preparation program.
• Background Check: Complete a criminal background check, as this is a standard requirement for all teaching candidates in Minnesota.
• Receive Your License: Once your application is approved, you will receive your teaching license, allowing you to begin your career as a history teacher.

A Minnesota teacher reflects on her journey, saying, “Navigating the licensing process felt overwhelming at times. I remember the anxiety of waiting for my exam results, but the moment I received my license was incredibly rewarding. It was a testament to my hard work and dedication.”

Teaching experience is crucial for aspiring history teachers in Minnesota, as it not only enhances your skills but also fulfills certification requirements. Here’s a breakdown of what you need to know:

• Student Teaching Experience: Minnesota mandates that all teacher candidates complete a student teaching internship, typically lasting 12-14 weeks. This hands-on experience is vital for developing classroom management skills and understanding curriculum implementation.
• Finding Internships: Aspiring history teachers can seek internships through local school districts, universities, or educational organizations. Websites like the Minnesota Department of Education and the Minnesota Association of Colleges for Teacher Education provide resources and listings for available positions.
• Certification Requirements: To obtain a teaching license in Minnesota, candidates must complete a state-approved teacher preparation program, which includes student teaching. Additionally, passing the Minnesota Teacher Licensure Examinations (MTLE) is necessary. They can ensure that they fulfill this requirement with accredited online teaching certification .
• Build relationships with mentor teachers and peers.
• Seek feedback regularly to improve your teaching methods.
• Engage in reflective practices to assess your teaching effectiveness.
• Alternative Pathways: If traditional student teaching isn’t feasible, consider options like volunteering in educational settings, tutoring, or participating in educational workshops. These experiences can provide valuable insights and enhance your resume.

By strategically pursuing teaching experience and internships, you can effectively prepare for a rewarding career as a high school history teacher in Minnesota.

To become a high school history teacher in Minnesota, it is essential to understand the state's specific standards and curriculum requirements. Minnesota mandates that students complete 3.5 credits in social studies, which must include U.S. history, world history, geography, government, citizenship, and economics. These standards are designed to ensure that students acquire a comprehensive understanding of historical and social concepts, aligning with the state's high school history curriculum requirements.

Here are key components to consider:

• Curriculum Standards: Minnesota's social studies standards are structured to be integrated across disciplines, allowing for a more holistic approach to teaching history. This differs from some states that may have more rigid subject separations, emphasizing the importance of understanding the state's standards for history teachers.
• Implementation Timeline: The latest standards were adopted in 2024 and will be fully implemented by the 2026-27 school year, providing a clear timeline for educators to align their lesson plans accordingly.
• Resources for Educators: The Minnesota Department of Education offers various resources, including professional development sessions and collaboration opportunities through organizations focused on social studies education. These resources help teachers effectively incorporate state standards into their curricula, ensuring they are well-prepared to meet the evolving educational landscape.
• Lesson Planning: History teachers should integrate the state standards into their lesson plans by focusing on the required content areas and utilizing available resources to enhance student engagement and understanding. By adhering to these guidelines, aspiring history teachers can effectively prepare their students for graduation while fostering a deep appreciation for history.

For those looking to further their education and career in this field, exploring options such as an EdDin curriculum and instruction jobs can provide valuable insights and opportunities.

By understanding and implementing Minnesota's social studies standards, history teachers can create a rich learning environment that prepares students for both academic success and informed citizenship.

The job market for high school history teachers in Minnesota is generally favorable, with a steady demand for qualified educators. According to the latest data, the average salary for a high school history teacher is approximately $70,170 per year , though this can vary significantly based on location and experience.

• Teachers in urban areas, such as Minneapolis and St. Paul, often earn higher salaries, sometimes exceeding $70,000 annually.
• In contrast, rural districts may offer salaries closer to $55,000, reflecting the cost of living and funding differences.
• Compensation packages typically include health insurance, retirement plans, and paid time off, which can enhance overall earnings.

The job outlook remains positive, with ongoing retirements and a push for more diverse teaching staff creating opportunities.

A Minnesota teacher reflects on her experience, saying, “When I first started, I was surprised by the pay differences across the state.” She notes, “It took time to navigate the hiring process, but the support from my colleagues made it worthwhile.” Ultimately, she emphasizes, “The job market is competitive, but the rewards of teaching history are immeasurable.”

The projected job growth for high school teachers in general stands at  4.1% from 2022 to 2032 . This translates to 1,290 job openings per year during the same period.

To become a high school history teacher in Minnesota, it's essential to engage in ongoing professional development and continuing education. Here are some key opportunities and resources available:

• Workshops and Seminars: The Minnesota Historical Society offers various workshops tailored for history educators, such as History Day 101 and Northern Lights Academy. These sessions cover essential teaching strategies, curriculum planning, and project implementation, making them a vital part of professional development for history teachers in Minnesota.
• Webinars: Virtual sessions, like the Northern Lights eBook Introduction Webinar, provide teachers with updated resources and interactive tools to enhance their teaching methods. These online opportunities are particularly beneficial for educators looking to incorporate new technologies into their classrooms.
• Continuing Education Credits: Many workshops offer Continuing Education Units (CEUs), which are crucial for maintaining licensure in Minnesota. Teachers should ensure they accumulate the required credits through these professional development activities, as continuing education for Minnesota history educators is essential for career advancement.
• Networking and Collaboration: Participating in workshops allows educators to connect with peers, share best practices, and collaborate on curriculum development. This networking can lead to innovative teaching strategies and a more enriched educational experience for students.

By actively participating in these opportunities, history teachers can stay informed about new teaching methodologies and state standards, ensuring they provide the best education possible. For those interested in furthering their qualifications, pursuing a teaching bachelor's degree online can also be a valuable step in their professional journey.

In summary, engaging in these professional development activities not only enhances teaching skills but also fosters a community of dedicated educators committed to excellence in history education.

To thrive as a high school history teacher in Minnesota, mastering classroom management and teaching methods is essential. Here are practical strategies to consider:

• Establish Clear Expectations: Set rules and procedures from day one. Consistency helps students understand boundaries and fosters a respectful environment.
• Engaging Lesson Plans: Incorporate diverse materials such as primary sources, multimedia presentations, and interactive activities. This approach not only captures students' interest but also enhances their understanding of historical contexts.
• Active Learning Techniques: Utilize methods like group discussions, debates, and role-playing to encourage participation. Research shows that active learning can improve retention rates by up to 50%.
• Differentiated Instruction: Recognize the diverse learning needs in your classroom. Tailor your lessons to accommodate various learning styles, ensuring all students can engage with the material effectively.

In Minnesota, obtaining a teaching license requires passing the Minnesota Teacher Licensure Examinations (MTLE) and completing a state-approved educator preparation program. By implementing these strategies, you can create a dynamic and inclusive history classroom that meets the needs of all students.

Becoming a high school history teacher in Minnesota opens up various avenues for career advancement and specialization. Here are some key opportunities and pathways for history educators in the state:

• Specialization Areas: History teachers can focus on specific fields such as civil rights, environmental history, or historical preservation. This allows educators to tailor their teaching to their interests and the needs of their students. These specializations can significantly enhance career advancement for history teachers in Minnesota, providing unique opportunities to engage with specific topics in depth.
• Administrative Roles: Transitioning into administrative positions, such as department head or school administrator, is a viable option for experienced teachers. This often requires additional qualifications, such as a master's degree in educational leadership or administration. Many teachers find that pursuing these roles not only increases their influence within the school but also opens doors to further career advancement.
• Certifications and Endorsements: Obtaining additional certifications, such as a license in special education or an endorsement in social studies, can enhance a teacher's qualifications and marketability. Minnesota offers various pathways for teachers to pursue these endorsements, making it easier for educators to diversify their skill sets. For those interested in special education, an online bachelor's in special education can be a great starting point.
• Educational Policy and Curriculum Development: History teachers can also engage in educational policy or curriculum development roles. This may involve working with school districts or educational organizations to design history curricula that meet state standards and address contemporary issues. Many educators find this path rewarding, as it allows them to influence how history is taught across various educational settings. They can even focus solely on education policy doctorate careers .

In reflecting on her journey, a teacher from Minnesota shares, “I started as a history teacher, but I always wanted to influence curriculum decisions.” She recalls the challenges of balancing classroom responsibilities while pursuing a master's degree. “It was tough, but now I lead a team that shapes how history is taught across our district,” she notes, highlighting the rewarding nature of her career progression. This experience underscores the importance of exploring various specializations for high school history educators in Minnesota, as they can lead to fulfilling roles that impact the educational landscape.

In 2023, high school teachers in the state earn around $70,170 per year. See the chart below for more salary information. 

To become a high school history teacher in Minnesota, it is essential to understand the legal and ethical responsibilities that govern the profession. Here are key considerations:

• Licensing Requirements: Teachers must hold a valid license issued by the Professional Educator Licensing and Standards Board. This includes meeting educational prerequisites and passing relevant examinations. Understanding these licensing requirements is crucial for anyone looking to navigate the legal and ethical responsibilities of teachers in Minnesota.
• Ethical Standards: Minnesota has established a code of ethics that mandates teachers to conduct themselves professionally. This includes providing education without discrimination, safeguarding student welfare, and maintaining confidentiality. History teachers must also avoid distorting historical facts and ensure that their teaching is based on accurate information. Upholding these ethical standards is vital for fostering trust and integrity in the classroom.
• Handling Controversial Topics: When addressing sensitive historical issues, teachers should strive for a balanced approach. They are encouraged to present multiple perspectives and foster an environment where students can engage in respectful discussions. This is crucial for promoting critical thinking and understanding diverse viewpoints, especially when discussing complex historical events.
• Reporting Obligations: Teachers are legally required to report any suspected abuse or unsafe conditions affecting students. This includes being vigilant about the physical and emotional safety of their students, and ensuring a conducive learning environment. Adhering to these reporting obligations is a fundamental aspect of the legal and ethical responsibilities of teachers in Minnesota.
• Classroom Environment: Minnesota laws emphasize creating a safe and inclusive classroom. Teachers must be aware of their responsibilities to maintain a respectful atmosphere, free from harassment or discrimination, which is vital for effective learning. A positive classroom environment not only enhances student engagement but also aligns with the ethical standards expected of educators.

By adhering to these guidelines, history teachers in Minnesota can create a positive educational experience while fulfilling their legal and ethical obligations. For those interested in furthering their education and meeting these requirements, pursuing an online master's in teaching low tuition can be a valuable step.

New history teachers in Minnesota have access to a variety of resources and support systems designed to facilitate their transition into the classroom. Here are some key avenues for finding assistance and materials:

• Professional Development: The Minnesota Historical Society offers a range of classroom-ready resources, including lesson plans and activity books that focus on Minnesota's history, culture, and significant events. These materials are tailored for both elementary and secondary education levels, providing essential resources for new history teachers in Minnesota.
• Mentorship Programs: New teachers can benefit from mentorship opportunities through local school districts and educational organizations. Connecting with experienced educators can provide guidance on curriculum development and classroom management, ensuring that new teachers receive the support they need.
• Networking Organizations: Joining professional organizations, such as the Minnesota Council for the Social Studies, can help new teachers network with peers, share resources, and participate in workshops focused on history education. This networking can be invaluable for those seeking support for history teachers in Minnesota.
• Online Resources: Many educational websites provide downloadable activities, primary source analysis tools, and instructional videos that can enhance lesson planning. These resources often include engaging activities that connect historical events to contemporary issues, making them a great addition to any history curriculum.
• Community Engagement: Encouraging students to explore their local neighborhoods and historical sites can foster a deeper understanding of history. New teachers can utilize community resources to create meaningful connections between students and their surroundings, enriching their teaching experience.

By leveraging these resources, new history teachers in Minnesota can build a strong foundation for their teaching careers. For those interested in furthering their education, exploring careers in library science can also provide additional pathways and resources. You can find more information by reading about  careers in library science .

Here's What Graduates Have to Say About Becoming a High School History Teacher in Minnesota

• Teaching history in Minnesota has allowed me to connect students with our rich local heritage. I love seeing their eyes light up when they learn about the Iron Range and its impact on our state. It’s rewarding to inspire future generations. I feel like I’m making a difference. Brianna
• Growing up in a small town, I never realized how much history shaped our community. Now, as a high school history teacher, I share those stories with my students. It’s fulfilling to see them appreciate our past and understand its relevance today. I’m proud to be part of their journey. Clint
• The licensing process was clear, but it was the MTLE exam that really tested my understanding of history. PELSB’s support and resources helped me navigate the steps, and now I’m proud to be teaching in a vibrant school district. I see opportunities growing in education, especially with job openings increasing every year. It’s a rewarding career that keeps you engaged and constantly learning. Moira

Key Findings

• The Professional Educator Licensing and Standards Board (PELSB) is the key authority overseeing teacher licensure in Minnesota, managing the licensing standards, issuance, and compliance for educators statewide.
• To become a high school history teacher in Minnesota, candidates need at least a bachelor's degree, completion of a state-approved teacher preparation program, and a successful background check. Additionally, with a projected 4.1% job growth for secondary school teachers from 2022 to 2032, there will be 1,290 job openings annually across the state.
• Candidates must pass the Minnesota Teacher Licensure Examinations (MTLE), which includes both a basic skills assessment and a subject-specific test. Given the growing demand for teachers, high school teachers can expect competitive salaries, with secondary school teachers earning an average of $70,170 annually in 2023.
• After fulfilling educational and exam requirements, candidates submit their licensure application through the PELSB online portal. Employment data shows 19,180 secondary school teachers were employed in Minnesota in 2023, reflecting a steady demand for educators.
• Teachers must complete 125 clock hours of professional development every five years to maintain their license. This ensures educators remain up-to-date with teaching practices while contributing to a robust educational environment where elementary, middle, and secondary school teachers collectively serve more than 52,000 students annually.

What are the requirements to teach history in Minnesota?

To teach history in Minnesota, you must obtain a teaching license from the Minnesota Department of Education. This typically requires completing a bachelor’s degree in education with a focus on history or social studies, passing the required licensure exams, and completing a student teaching experience. Additionally, you may need to fulfill continuing education requirements to maintain your license.

How much do high school history teachers make in Minnesota?

High school history teachers in Minnesota earn an average salary ranging from $50,000 to $70,000 annually, depending on factors such as experience, education level, and the school district. Teachers in urban areas or those with advanced degrees may earn higher salaries. Benefits such as health insurance and retirement plans are also commonly provided, contributing to overall compensation.

What skills are essential for a high school history teacher?

Essential skills for a high school history teacher include strong communication abilities, critical thinking, and organizational skills. Teachers should be adept at engaging students with diverse learning styles and fostering a positive classroom environment. Additionally, a passion for history and the ability to connect historical events to contemporary issues can enhance student interest and understanding.

Are there opportunities for professional development for history teachers in Minnesota?

Yes, there are numerous opportunities for professional development for history teachers in Minnesota. Many school districts offer workshops, conferences, and training sessions focused on innovative teaching strategies, curriculum development, and technology integration. Additionally, teachers can pursue advanced degrees or certifications in history education, which can further enhance their skills and career prospects.

References:

• education.mn.gov (11 Mar 2024). Social studies . education.mn.gov
• mnhs.org (n.d.). Classroom-Ready Resources. mnhs.org https://www.mnhs.org/classroomready
• cla.umn.edu (n.d.). Career Exploration . cla.umn.edu
• revisor.mn.gov (21 Aug 2017). Part 8710.2100 . revisor.mn.gov

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• v.8(5); 2021 May

Initial Training for Mental Health Peer Support Workers: Systematized Review and International Delphi Consultation

Ashleigh charles.

1 School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom

Rebecca Nixdorf

2 Department of Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Nashwa Ibrahim

3 Psychiatric and Mental Health Nursing Department, Faculty of Nursing, Mansoura University, Masoura, Egypt

Lion Gai Meir

4 Department of Social Work, Ben Gurion University of the Negev, Beer Sheva, Israel

Richard S Mpango

5 Butabika National Referral Hospital, Butabika, Uganda

6 School of Health Sciences, Soroti University, Soroti, Uganda

7 MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda

Fileuka Ngakongwa

8 Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania

9 Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania

Hannah Nudds

Soumitra pathare.

10 Centre for Mental Health Law and Policy, Indian Law Society, Pune, India

11 Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

Julie Repper

12 ImROC, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, United Kingdom

Heather Wharrad

13 Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom

Philip Wolf

14 Department of Psychiatry II, Ulm University II, Ulm, Germany

Candelaria Mahlke

Associated data.

Search strategy for the systematized review.

Coding framework developed from the thematic synthesis of peer support worker initial training manuals (n=32).

Changes suggested in round 1 of the Delphi consultation (N=110).

Round 2 Delphi consultation rating of importance (n=89).

Round 2 Delphi consultation rating of web-based delivery (n=89).

Initial training is essential for the mental health peer support worker (PSW) role. Training needs to incorporate recent advances in digital peer support and the increase of peer support work roles internationally. There is a lack of evidence on training topics that are important for initial peer support work training and on which training topics can be provided on the internet.

The objective of this study is to establish consensus levels about the content of initial training for mental health PSWs and the extent to which each identified topic can be delivered over the internet.

A systematized review was conducted to identify a preliminary list of training topics from existing training manuals. Three rounds of Delphi consultation were then conducted to establish the importance and web-based deliverability of each topic. In round 1, participants were asked to rate the training topics for importance, and the topic list was refined. In rounds 2 and 3, participants were asked to rate each topic for importance and the extent to which they could be delivered over the internet.

The systematized review identified 32 training manuals from 14 countries: Argentina, Australia, Brazil, Canada, Chile, Germany, Ireland, the Netherlands, Norway, Scotland, Sweden, Uganda, the United Kingdom, and the United States. These were synthesized to develop a preliminary list of 18 topics. The Delphi consultation involved 110 participants (49 PSWs, 36 managers, and 25 researchers) from 21 countries (14 high-income, 5 middle-income, and 2 low-income countries). After the Delphi consultation (round 1: n=110; round 2: n=89; and round 3: n=82), 20 training topics (18 universal and 2 context-specific) were identified. There was a strong consensus about the importance of five topics: lived experience as an asset , ethics , PSW well-being , and PSW role focus on recovery and communication , with a moderate consensus for all other topics apart from the knowledge of mental health . There was no clear pattern of differences among PSW, manager, and researcher ratings of importance or between responses from participants in countries with different resource levels. All training topics were identified with a strong consensus as being deliverable through blended web-based and face-to-face training (rating 1) or fully deliverable on the internet with moderation (rating 2), with none identified as only deliverable through face-to-face teaching (rating 0) or deliverable fully on the web as a stand-alone course without moderation (rating 3).

Conclusions

The 20 training topics identified can be recommended for inclusion in the curriculum of initial training programs for PSWs. Further research on web-based delivery of initial training is needed to understand the role of web-based moderation and whether web-based training better prepares recipients to deliver web-based peer support.

Introduction

Peer support is rapidly developing into a central approach to support mental health recovery [ 1 ]. It has been defined as “a system of giving and receiving help founded on the key principles of respect, shared responsibility, and a mutual agreement of what is helpful” [ 2 ]. Formal peer support involves individuals with lived experience of mental health conditions and/or mental health services—variously called peer providers, peer specialists, peer support volunteers, or as peer support workers (PSWs)—who are engaged in a peer support capacity to support others’ recovery from mental health conditions [ 3 ].

There is strong empirical evidence for the positive benefits of implementing PSW roles. PSWs contribute to an increase in service user engagement, a sense of empowerment [ 4 ], improved social relationships [ 5 ], self-efficacy [ 6 ], hope [ 7 ], self-management [ 8 ], and positive clinical outcomes [ 9 , 10 ]. PSW roles are being implemented internationally, increasingly in lower middle-income countries such as India [ 11 ] and Uganda [ 12 ], where PSWs are engaged to address the mental health care gap [ 13 ].

Numerous PSW training programs exist [ 14 , 15 ]. These programs are designed to prepare individuals for the PSW role and sometimes also to meet the required competencies for accreditation. However, PSW roles and activities vary depending on their particular setting and context. For example, PSWs may work one-on-one or in a group setting with people who use mental health services, they may support individuals through service transitions, from hospital to the community, into employment, and/or to access local opportunities or resources. Training programs vary depending on the setting, local context, and resources.

Peer support has traditionally been provided as a face-to-face intervention. However, with the growth of digital mental health interventions changing the ways in which mental health care is delivered, peer support is increasingly being offered via digital technologies known as digital peer support. Digital peer support is defined as automated or live peer support services that can be delivered through multiple modalities [ 16 ], such as web-based peer support [ 17 ], smartphone-supported interventions [ 18 , 19 ], and web-based peer-to-peer networks [ 20 ]. A recent systematic review concluded that digital peer support appears to be both acceptable and feasible, with a strong potential for clinical effectiveness [ 16 ]. The use of web-based PSW approaches such as digital peer support is likely to increase in response to the COVID-19 global pandemic [ 21 ]. This new development means that PSW training may also be offered on the web, and some initial training topics may need to be updated or reviewed.

Initial training is essential for a formal PSW role. Several studies have reported the need to identify core peer support competencies in mental health [ 22 , 23 ]. However, there is no consensus on the core training topics required for PSW roles and accreditation [ 24 ]. Given the advances in digital peer support and lack of evidence about what topics are important in initial PSW training, there is a need to establish the level of consensus about the content of initial PSW training. A specific knowledge gap relates to the extent to which initial PSW training topics can be delivered on the web. Web-based training may offer benefits, including opportunities to access more prospective PSWs on a larger scale and the reduction of costs as compared with face-to-face training but may not be feasible for training in the relational aspects of the PSW role.

Aims and Objectives

The aim of this study is to conduct a Delphi consultation technique to establish the level of consensus regarding initial PSW training topics. The objectives were (1) to identify training topics; (2) to identify the extent to which each identified training topic can be delivered on the web; and (3) to assess the degree of consensus that exists with respect to findings from objectives (1) and (2) overall, between PSWs and PSW managers versus PSW researchers and between countries with different resource levels.

This study was conducted as a part of UPSIDES (Using Peer Support in Developing Empowering Mental Health Services), a 5-year (2018-2022) European Union–funded multinational study that aims to replicate and scale up peer support interventions for people with severe mental illness. Ethics approval was obtained from the University of Nottingham, Faculty of Medicine and Health Sciences Research Ethics Committee (FMHS 377-1908). All participants provided web-based informed consent after reading the participant information sheet available on the web.

A systematized review was conducted to develop a preliminary list of training topics, followed by a three-round Delphi consultation. Round 1 refined the preliminary list, and rounds 2 and 3 established a consensus.

Participants

Inclusion criteria were age 18 years or above, able to provide informed consent electronically, and one of the following: publication record relating to peer support work (researcher group) or experience of working as a PSW group or clinical or practical experience in training and/or supervision of peer support (manager group). Participants were not screened for inclusion but self-identified as belonging to one or more of the above groups.

Systematized Review

First, we conducted a systematized review of initial PSW training manuals to identify a preliminary list of topics for use in initial PSW training. A systematized review includes elements of a systematic review process while stopping short of being a full systematic review [ 25 ]. The inclusion criteria were as follows:

• Training manuals designed specifically for mental health PSWs, that is, designed for people with lived experience of mental health conditions, to prepare them to work in a PSW role with other people with mental health conditions.
• Involved face-to-face training, web-based training, or a combination of both.
• Training with and without accreditation or certification was included, as countries vary in their progress toward an accreditation process.
• Training for both a generic PSW role or for work with a specific mental health subpopulation, for example, dual diagnosis with substance misuse, dementia, and young people.
• Published in the English or Arabic language.

Exclusion criteria were as follows:

• Training manuals not specifically for mental health PSWs.
• Does not include initial PSW training, for example, focus is on stigma related to mental health, human rights, peer leadership, consumer-run organizations, gender identity, and childhood trauma.
• Train the trainer manuals.

Training programs were identified from seven sources:

• The MEDLINE database was searched using the search strategy shown in Multimedia Appendix 1 .
• Gray literature databases (OpenGrey, New York Academy of Medicine’s Grey Literature Report, TRIP, and Health Quality Ontario) were searched using the phrases: “mental health peer support work training manuals,” “mental health consumer provider training manuals,” “certification training for mental health peer support workers,” and “mental health peer support workers’ core competencies.”
• Google and Google Scholar were searched using the same phrases mentioned above. The first 100 hits were then screened.
• Massive open online course platforms (Coursera, edX, FutureLearn, Canvas Network, and Independent) were searched using the massive open online course list website [ 26 ], using the same phrases mentioned above.
• The preliminary findings from a related ongoing systematic review [ 27 ].
• The websites of mental health organizations include the Substance Abuse and Mental Health Services Administration [ 28 ], National Mental Health Commission [ 29 ], Scottish Recovery Network [ 30 ], Mental Health America [ 31 ], Mental Health Innovation Network [ 32 ], Depression and Bipolar Support Alliance [ 33 ], and REdeAmericas [ 34 ].
• The websites of PSW certification, accreditation, and professional bodies include the Missouri Peer Specialist [ 35 ], Nevada Certification Board [ 36 ], National Association of Peer Supporters [ 37 ], and Global Mental Health Peer Network [ 38 ].

Searches were conducted in April 2019, and no date restrictions were applied. Endnote software was used to collate the identified manuals. Screening and data extraction were equally divided between AC and NI. Both researchers independently analyzed their allocated manuals and discussed any discrepancies with MS (eg, inclusion and exclusion of manuals). The data abstraction table was populated by extracting data relating to country (specific country and country income level), service setting (eg, community or inpatient), target population (eg, general mental health or dementia), training modality (face-to-face, internet-based, or both), training topics (using terms from source documents), definitions or training goals or learning objectives (where specified), and examples of the training exercises.

Both AC and NI independently conducted thematic analysis [ 39 ]. Vote counting for each theme was conducted, and the 2 analysts discussed the discrepancies. AC, NI, and MS then conducted a process of data reduction, which involved comparing the training topics within and across themes and merging and integrating subthemes to generate one coherent coding framework or codebook comprising the training topic name and definition.

Delphi Consultation

A three-round Delphi consultation was then conducted. Delphi consultation is a systematic method of determining how much agreement exists on a particular topic based on experts’ opinions [ 40 ]. The method involves an iterative and multistage process, comprising multiple rounds of questions designed to combine opinions and assess group consensus.

Compared with the traditional Delphi method, which is delivered via questionnaires through face-to-face meetings, a web-based Delphi offers participants the time to deliberate their responses, thus increasing the validity of results, and requires less resources, for example, time and costs [ 41 ]. In addition, given the growth of PSW roles internationally and the wide range of peer support programs that exist, the web-based Delphi was chosen as an appropriate method to answer the research question, as it has the potential to access a diverse and large group of experts engaged in peer support from around the world [ 42 ]. Compared with other research designs, the Delphi method can produce rigorous and rich data because of multiple rounds and refinement based on response feedback [ 43 ]. Limitations include a low level of reliability of judgment among experts, lack of clear methodological guidelines, and difficulty in assessing the degree of expertise included [ 44 ].

Participants for the Delphi consultation were recruited through advertising (1) across networks including the Recovery Research Network [ 45 ], UPSIDES consortium, Recovery College Network, and Being Network (Australia); (2) by partner organizations including Nottinghamshire Healthcare National Health Service Foundation Trust, Institute of Mental Health; (3) social media, including Twitter; and (4) snowball sampling. Purposive sampling was used to obtain a balance in role (researcher, PSW, and manager) and income level (high, middle, and low).

In each round, prospective participants were invited via email to complete an anonymous web-based survey using the Jisc survey platform (round 1 and 2) or Google Forms (round 3). Participants were sent 2 reminder emails to complete each round of the survey. All correspondence with the participants occurred via email. An initial pilot test of each round was conducted with 5 nonparticipants, which resulted in minor amendments. Round 1 was distributed over eight screen pages, and rounds 2 and 3 were distributed over four pages. The personal information collected was stored separately from the results’ data on a secure webserver, and participants were allocated identification numbers, for example, P001, which were used to track responses and duplicates. Only the research team had access to personal and research data. No incentive was offered for participation. Participants were able to change their responses using a back button but could not complete the survey without answering all questions. Round 1 began in November 2019, and round 3 was completed in July 2020.

In round 1, after reading the participant information sheet outlining the length of time of the survey, how data are stored, where, and for how long, and the purpose of the study, participants gave informed consent and provided sociodemographic details including if they had any experience of web-based training (about anything). Participants then rated each training topic and associated definition for importance using a 4-point Likert scale (“0=Not important at all,” “1=A bit important,” “2=Quite important,” and “3=Very important”). A free-text response was available to participants, providing the opportunity to suggest additional training topics or changes to the topic name or definition. Qualitative data were analyzed thematically. Two analysts (AC and NI) independently reviewed and synthesized responses using the following framework: proposed topic name, change to language or definition, and additional topics to be covered. Agreement on the topics and definitions arising from the first round was determined by further discussion, refinement, and synthesis with a third analyst (MS). The finalized list of training topics was created based on these responses, including the deletion of topics quantitatively rated as not important, refinement of name or definition, and addition of new topics where relevant.

In round 2, participants rated each topic and associated definition for importance using the same rating scale as in round 1, and also rated the extent to which the topic could be delivered on the web using a 4-point Likert scale (“0=No, it can only be delivered through face-to-face training,” “1=Partially, eg, as blended learning with some aspects delivered online and some face-to-face,” “2=Fully online as a moderated online course, ie, with a peer support worker trainer providing online support and moderation,” and “3=It can be fully delivered online as a standalone course without moderation”).

In round 3, participants were shown their own round 2 ratings and the mean round 2 ratings from other participants in (1) their group (researcher, PSW, and manager or supervisor), (2) the income level of their country setting (high, middle, and low), and (3) overall. Participants were asked to rerate each component for importance and web-based delivery using the same rating scales as in round 2.

For the Delphi consultation, strong consensus was defined as at least 80% of participants in the group with the same rating, and moderate consensus was defined as at least 50% of participants in the group with the same rating. An arbitrary threshold for a high- and moderate-level consensus was implemented.

The systematized review identified 32 training manuals in English, comprising face-to-face and web-based PSW training from 14 different countries (Argentina, Australia, Brazil, Canada, Chile, Germany, Ireland, the Netherlands, Norway, Scotland, Sweden, Uganda, the United Kingdom, and the United States). Training varied in length from 54 hours to 1 year, and the manuals covered a range of PSW training from working with adults, older adults, adolescents, and young people. A total of 502 topics and 348 learning objectives or definitions were extracted. The coding framework synthesized from the training manuals comprised 18 themes and is shown in Multimedia Appendix 2 . The coding framework was used as the basis for developing 18 topics and associated definitions, as shown in the first column of Multimedia Appendix 3 .

The characteristics of the Delphi consultation participants, including the number of responses for each round, are shown in Table 1 .

Characteristics of the Delphi consultation participants (N=110).

a PSW: peer support worker.

Participant Characteristics

The participants came from 21 countries, including higher-income (Australia: n=33; the United Kingdom: n=22; Canada: n=7; Poland: n=7; Germany: n=4; Ireland: n=4; Switzerland: n=4; Israel: n=3; Norway: n=3; Italy: n=2; the United States: n=2; New Zealand: n=1; Belgium: n=1; Singapore: n=1), middle-income (India: n=4; Tunisia: n=2; Brazil: n=1; Egypt: n=1; Argentina: n=1), and lower-income (Uganda: n=6; Tanzania: n=1) countries.

All participants completed round 1 and rated each of the 18 topics for importance. Round 1 ratings and all proposed changes are shown in Multimedia Appendix 3 . Analysis of the round 1 free-text responses (n=68) and mean rating scores resulted in multiple refinements to the round 1 topic names and definitions. Although the mean score for knowledge of mental health was ranked low compared with other topics, the free-text responses suggested that the definition should be amended to reflect PSW training needs, and this was changed markedly for round 2. Two topics— role-specific PSW skills and competencies and work skills —were identified as being relevant in some contexts but not others. These context-specific topics were presented separately in a different format for round 2, along with an explanation for the participants. Three additional topics and definitions were created— PSW supervision , developing a career as a PSW , and role-specific PSW skills and competencies —that were adapted from the subpopulation and specialized modules topic.

The revised list of 20 topics and associated definitions were used for round 2, which are shown in the fifth column of Multimedia Appendix 3 . Of 110 participants, a total of 89 (80.9%) participants completed round 2. The round 2 ratings of importance are shown in Multimedia Appendix 4 and of web-based delivery are shown in Multimedia Appendix 5 . Additional comments were received from round 2 participants about the role-specific PSW skills and competencies topic, resulting in minor refinements to the definition of knowledge of mental health topic. The final list of topics and definitions, which were used in round 3, is shown in Textbox 1 .

Final list of topics and definitions for initial peer support worker training.

Topics always needing coverage

• Presenting the local and international history of peer support, survivor or activist grassroots knowledge, and key information on the context of peer support, PSW, principles, and concept of expertise by experience is essential to formal PSWs
• Teaching about the meaning, stages, and culture of recovery, allowing integration into the PSW’s own experiences and practice. Additionally, teaching leadership, supporting informed choice, and working with service users in difficult times
• Familiarizing prospective PSWs with approaches and frameworks underlying which peer support could be practiced. For example, the tree of life, coaching frameworks, strengths-based approach, Intentional Peer Support, and Wellness Recovery Action Planning
• Introducing prospective PSWs to different frames of understanding of mental health, including nonmedical models of understanding mental distress (eg, Hearing Voices, Alternatives to Suicide, or Mad Studies) and medical models (eg, diagnosis or interventions), the different types of service setting (eg, inpatient units), and the mental health needs of different populations (eg, age groups, dual diagnosis, or marginalized and minority groups)
• Providing training about the meaning and implications of human rights legislation, including regional or national mental health laws and international legislation such as Convention on the Rights of Persons with Disabilities, to inform values-based PSW practice and skills in working within systems to uphold and protect the rights and social justice for people they work with, for example, through advocacy
• Teaching about PSW values, beliefs, and actions, supporting self-reflection and an understanding about mental health practice and accountability including the importance of boundaries, levels of disclosure, and confidentiality
• Practicing PSWs in a way compatible with the cultural needs, values, background, and context of people using services
• Providing prospective PSWs with essential competencies needed for formal PSWs through an overview of different PSWs’ job descriptions; teaching the importance of maintaining role integrity and reflecting on the essential qualities and values of PSWs
• Highlighting how the experience of mental health problems, alongside other peer experiences such as service use, is a central resource for the PSW role; exploring methods and strategies for using lived experience with service users, including the safe, purposeful, and appropriate use of one’s story to benefit others
• Supporting self-reflection and offering strategies for PSWs to promote wellness, recovery, and resilience (eg, teaching PSWs about their workplace rights, self-advocacy, stress management techniques, vicarious trauma, self-care, and how to use reflective practice)
• Ensuring prospective PSWs have the fundamental connecting skills (eg, listening skills, use of language, and awareness of verbal and nonverbal cues), which facilitate effective communication with service users in different settings and situations, and helping them develop these skills if necessary
• Offering peer support to understand and respond to the trauma of people using services to help them regain or achieve wellness and healing
• Helping PSWs to understand how to respond collaboratively, supportively, respectfully, and empathically to someone in a crisis
• Training prospective PSWs on the skills needed to start, facilitate, or cofacilitate a peer support group, in addition to understanding the group processes, dynamics, and coproduction practices and addressing any arising issues
• Ensuring PSWs have the skills needed to deal with workplace challenges, including knowledge of support options and training in dealing with work-related pressures, such as working with other professionals with conflicting values, workplace culture, organizational structures, exposure to violence, discrimination, bullying, and managing power dynamics and conflict
• Ensuring prospective PSWs know about local services and community resources and about formal communication or referral processes to other services; ensuring PSWs are sensitive to the balance between helpful referrals and supporting self-management or being heard
• Introducing PSWs to the purpose, types of, and importance of supervision
• Involves teaching prospective peers about the professionalization of the PSW role, including motivational drivers, career development, training opportunities, and financial management

Context-specific topics

• Equipping PSWs with role-specific skills (eg, motivational interviewing, solution-focused thinking, family therapy approach, intentional sharing, and understanding cognitive behavioral therapy and mindfulness), understanding of service settings (eg, inpatient units and community teams) and the mental health needs of different populations (eg, age groups, dual diagnosis, homelessness, and marginalized and minority groups)
• Teaching the administrative skills of recording and documenting direct mental health care and incidents and other work-related skills, such as time management

Of 110 participants, a total of 82 (74.5%) completed round 3. Of these 82 participants, 76 (93%) had completed round 2. The round 3 ratings of importance, ordered by median rating, are shown in Table 2 .

Delphi Consultation round 3 rating of importance (n=82).

b Scale 0 (low) to 3 (high).

c Strong consensus.

d Moderate consensus.

The median rating of importance was “Quite Important” or “Very Important” for all topics. Across all participants, the first five topics in Table 2 reached a strong consensus on importance.

The round 3 ratings for web-based deliverability, ordered by median rating, are shown in Table 3 .

Delphi Consultation round 3 rating of web-based delivery (n=82).

b Scale 0 (face-to-face) to 3 (fully via the internet).

d Moderate consensus .

The round 3 median ratings for web-based delivery indicated that all topics can be delivered partly or fully on the web with moderation but none without moderation. No topics reached a strong consensus for the mode of training delivery. The range of median responses relating to web-based delivery was smaller for PSWs (1-1.5) than for managers (0-2) and researchers (1-2), indicating that PSWs were more consistent in placing importance on some face-to-face training contact.

Principal Findings

In this 21-country study, 20 topics were identified that can be recommended for inclusion in the curriculum of a PSW initial training program. There was a strong consensus about the high importance of five topics: lived experience as an asset , ethics , PSW well-being , PSW role focus on recovery , and communication . There were no substantial differences between role perspectives (PSW, managers, and researchers) and countries with different resource levels relating to importance. All training topics were identified as being partly or fully deliverable on the web, but none could be provided on the web without moderation. There was no consensus about the right balance between face-to-face and web-based training with moderation, even though PSWs were more consistent in identifying the need for a face-to-face training component.

Strengths and Limitations

A strength of this study is the number of participants (N=110) from different countries (n=21) and the low attrition (round 1-2: 19%; round 1-3: 25%) compared with other Delphi studies [ 46 ]. Another strength is that the Delphi was reported in line with the Checklist for Reporting Results of Internet e-Surveys checklist [ 47 ]. This study has several limitations. First, there is a need for more representation from middle- and lower-income countries, which might have allowed between-setting differences to emerge, which was not achieved despite purposive sampling efforts. Second, participation in a web-based consultation may be more difficult for people in environments with poorer internet access and intermittent electricity, which may disproportionately affect PSWs. Third, participants were asked if they had completed web-based training earlier but not specifically web-based PSW training, which could then have been further explored in the analysis. In addition, web-based deliverability was not defined and was based on participant judgment rather than evidence from experience. Fourth, the use of two web-based platforms that may have confused participants and were not specifically designed for Delphi consultations. Alternative Delphi-specific platforms exist, including ExpertLens [ 48 ], Mesydel [ 49 ], and Delphi2 [ 50 ]. Fifth, PSW training manuals available in languages other than English or Arabic might have identified a wider range of training topics.

Finally, a full systematic review was not conducted, and the limitations associated with implementing a systematic review include the following: (1) lack of patient, population, intervention, comparison, and outcomes criteria; (2) included and excluded manuals were not listed; (3) methodological quality assessment and reliability of manuals were not explored; and (4) discrepancies between reviewers were not reported.

Comparison With Other Work

Achieving an international consensus on topics that are of high importance in PSW training is important for three reasons. First, it offers prospective PSWs a description of the tasks and skills involved in the PSW role, which may inform their decision making about whether to train as a PSW. Second, it provides training providers and organizations with a list of core topics that should be covered in the content of initial PSW training programs in all settings and two additional context-specific topics that may be relevant. Third, it provides an evidence base for developing training curricula and a framework for PSW accreditation. The standardization of PSW training across settings and countries is contentious. On the one hand, an international consortium of peer leaders from 6 continents developed an international charter, which defined peer support and identified key principles and guiding values [ 51 ]. In conjunction with this Delphi consultation, a framework is emerging that could underpin the international PSW accreditation process. On the contrary, unintended consequences of institutionalizing the PSW role are emerging, with one qualitative study in the United States concluding that it “has the potential to reduce the very centrality of experiential expertise, reproduce social inequalities, and paradoxically impact stigma” [ 52 ].

The identification of training topics relevant to specific contexts reflects cultural and organizational influences on implementation [ 53 ]. Identified barriers that may lead to context-specific modifications include the lack of credibility of peer worker roles, professionals’ negative attitudes, tensions with service users, struggles with identity construction, cultural impediments, poor organizational arrangements, and inadequate overarching social and mental health policies [ 54 ]. These influences can lead to preplanned modifications implemented during initial PSW training, as well as unplanned extensions to the PSW role [ 55 ]. Several studies have found that this role extension can reduce role clarity and integrity, such as by incorporating medical ways of working [ 56 ] and creating identity conflict [ 57 ]. For example, a 10-site comparative case study across England found that different understandings of professionalism and practice boundaries can erode the distinctiveness of the PSW role [ 58 ].

PSW training has evolved in response to organizational needs and more recently the COVID-19 global pandemic. In a recent commentary, barriers to implementing web-based peer support in low- and middle-income countries in the context of COVID-19 were identified [ 59 ]. The low-to-moderate consensus about web-based delivery of training found in our study indicates that further work is needed to explore the relative costs and benefits of web-based versus face-to-face training.

All topics were rated as candidates for at least partial web-based delivery, which raises two questions. First, what is the role of web-based moderation? In addition to knowledge and skills development, an important component of PSW training is ensuring that participants have the ability to maintain role integrity in a context where many will have to deal with microaggressions [ 60 ]. Similarly, a recent editorial identified specific contested areas relating to the role of PSW in restraint, administration of medication, and lone working in the community [ 61 ]. These may all be sensitive issues for PSWs to explore in training, for example, due to personal experiences, which may be more difficult to explore in moderated web-based discussions. Furthermore, individuals considering PSW training may struggle with motivation [ 62 ] and the pressure to succeed [ 63 ], and role challenges can include overwork and symptom recurrence [ 64 ]. There is some evidence that a therapeutic alliance in digital interventions is possible [ 65 ], but the extent to which the requisite resilience and motivation for the PSW role can be fostered through web-based training delivery is an important future focus.

Second, does web-based training prepare recipients better to deliver web-based peer support? Relationships are central to PSWs [ 66 ], and one impact of COVID-19 is to increase the use of web-based approaches by trained PSWs as an alternative relationship medium. Combining web-based and offline peer support has been shown to be a promising concept, with one qualitative Norwegian study of peer support recipients finding it enabled connectedness and allowed individuals to balance anonymity and openness [ 67 ]. Web-based training may help future PSWs to have both technological skills and the confidence to engage with PSW recipients on the web. In middle- and low-income countries, this blend of training delivery could also provide an accessible, wide-reaching, and cost-effective approach to increase the availability of PSW training places. A systematic review identified that the role content of PSWs is often underreported [ 68 ]. The topics identified in our study can inform the reporting of both the training program and PSW role components in future PSW evaluations.

This study developed a list of training topics for the initial PSW training. One use is to inform PSW training manuals, such as the UPSIDES PSW training program [ 69 ], which is being evaluated in Germany, India, Israel, Tanzania, and Uganda [ 70 ]. The use of an evidence-based training curriculum will increase the effectiveness of programs to prepare individuals for working as PSWs.

Acknowledgments

The study UPSIDES is a multicenter collaboration between the Department for Psychiatry and Psychotherapy II at Ulm University, Germany (Bernd Puschner, coordinator); the Institute of Mental Health at University of Nottingham, United Kingdom (MS); the Department of Psychiatry at University Hospital Hamburg-Eppendorf, Germany (CM); Butabika National Referral Hospital, Uganda (Juliet Nakku); the Centre for Global Mental Health at London School of Hygiene and Tropical Medicine, United Kingdom (GR); Ifakara Health Institute, Dar es Salaam, Tanzania (Donat Shamba); the Department of Social Work at Ben Gurion University of the Negev, Be’er Sheva, Israel (Galia Moran); and the Centre for Mental Health Law and Policy, Pune, India (Jasmine Kalha). UPSIDES received funding from the European Union’s Horizon 2020 Research and Innovation Programme under grant 779263. MS acknowledges the support of the Center for Mental Health and Substance Abuse, University of South-Eastern Norway, the National Institute for Health Research Nottingham Biomedical Research Centre, and research group work support from the Economic and Social Research Council (grant ES/J500100/1 and ES/P000711/1). This publication only reflects the authors’ views. The Commission is not responsible for any use that may be made of the information it contains. The funding bodies had no role in the design of the study, writing of the manuscript, or decision to submit the paper for publication.

Abbreviations

Multimedia Appendix 1

Multimedia appendix 2, multimedia appendix 3, multimedia appendix 4, multimedia appendix 5.

Authors' Contributions: AC, MS, NI, RN, and CM conceptualized the study. AC, MS, and NI conducted a systematized review, analyzed, and interpreted the data. AC had full access to all the data in the study and had final responsibility for the decision to submit for publication. RN and CM contributed to the design of the Delphi consultation, analysis, and interpretation of data for the work. HN contributed to the design of the Delphi consultation, quality review, and data acquisition. LGM contributed to ethical processes. AC, NI, and MS drafted the manuscript. All authors contributed to the interpretation of the data, critically revised the manuscript, and approved the final submitted draft.

Conflicts of Interest: None declared.