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Peer support to assist in transition to adult services

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A mental health service trialled the use of peer support workers to help improve the experience of clients moving from the children and young people’s to adult services

Abstract

A peer support worker employment initiative was developed to help young service users with the transition from child and adolescent to adult mental health services, an area that needs improving nationally. This article describes how the initiative was set up and its effectiveness.

Citation: Oldknow H et al (2014) Peer support to assist in transition to adult services. Nursing Times; 110: 6, 20-21.

Author: Helen Oldknow is project manager for children and young people’s mental health services; Kevin Williamson is a nutritionist at early intervention in psychosis adult division; Karen Etheridge is assistant director for children and young people’s mental health services business division; all at Rotherham, Doncaster and South Humber Foundation Trust

Introduction

Moving from child to adult services can be a difficult and frustrating time for patients and service users (Royal College of Nursing, 2007).

This is a particular concern in mental health, where assessment and treatment can vary greatly between the two settings; this can cause problems for service users and their care network, such as unmet expectations and gaps in service provision (Health and Social Care Advisory Service, 2006). This transition has been the focus of numerous recent studies. Singh (2009) identified specific difficulties around:

  • Patient experience;
  • Disengagement;
  • Thresholds for acceptance;
  • Long delays in completing transitions.

Joint working between the services was also identified as an obstacle.

Mowbray et al (1998) found peer support to be effective in supporting adults using mental health services. The concept of peer support workers (PSWs) is recent and is being adopted in some adult mental health services throughout the country.

We believe Rotherham, Doncaster and South Humber Foundation Trust is the first to implement this in children’s and young people’s services.

The project

The rationale came from emerging evidence about the benefits of using PSWs in adult services, and the suggestion that the transition between child and adult services could be improved (RCN, 2007). Peer support can facilitate recovery by promoting hope and providing support based on common experiences. Box 1 lists the aims of the project.

Box 1. Peer support worker project aims

  • Improve service users’ experience of transition
  • Provide meaningful paid work to people with experience of mental distress
  • Reduce the stigma of mental health problems and the perceived boundaries between professionals and service users
  • Provide positive role models
  • Inspire hope of recovery for children and young people and their families 

Project preparation

On preparing for the project, the assistant director of children’s and young people’s services (CYPMHS) explained:

“I knew we were the first [in the] organisation. It was about making it work and not to have any major problems associated with it, so it was about ensuring the governance arrangements for the new workers [and] establishing how they would be supported. Because our services can be quite stressful to work in, we didn’t want to make these people unwell through working with us.”

The project fits in with the direction in which the trust aims to develop services, while recent national directives have encouraged it to look at ways of working better with service users. As a result, we gained support from the chief executive and board of directors, which was crucial to implementation.

Method

We agreed to trial the use of PSWs for three months. The post required education to GCSE level, a lived experience of mental health problems, an ability to share personal stories of recovery in a professional manner, and a sense of humour.

We received more than 100 applications, out of which 25 people were shortlisted and six appointed. Another PSW was appointed later in the learning disability service but not included in this evaluation.

Nurses, occupational therapists and social workers were identified to mentor the PSWs during the project. Training was provided by these mentors, as well as bespoke training by the Institute of Mental Health. The training is to prepare people with experience of mental distress to work alongside others with similar experiences. A key element of it is co-facilitation; it is given by two trainers who between them have clinical expertise, experience of distress, and an academic understanding of recovery and peer support. This provides an opportunity to role model joint working in people from different backgrounds.

Additional training was commissioned to prepare CYPMHS and adult mental health service staff to work alongside PSWs. Both teams had to be prepared as the PSW role is intended to act as a “bridge” between the two. The IMH delivered three sets of training before PSWs were introduced as per Implementing Recovery through Organisational Change. Training covered the following:

  • The role of PSWs in teams and organisations;
  • Effective, collaborative teamworking;
  • Realising hopes and addressing concerns;
  • Team reflective practice;
  • Opportunities for PSWs to harness lived experience in teams.

Evaluation

An evaluation with the service user and carer research group involved consulting PSWs, their mentors and CYPMHS staff about their experiences. This assessed:

  • How the PSW model is implemented;
  • If changes are needed to the model;
  • How the preceptorship model is experienced by stakeholders.

The evaluation involved several methods, including face-to-face interviews, a focus group, an email survey and documentary analysis.

The interviews of the trust’s chief executive and the assistant director of the CYPMHS business division were conducted by members of the trust’s service user and carer research group. They were audiotaped and transcripts were sent to the interviewees to ensure a true reflection of their views was recorded.

All six PSWs took part in the focus group. A schedule of themes was agreed by the project team for the focus group and mentor group. Notes were taken by an experienced researcher and a member of the trust’s service user and carer-led research group.

We gained consent through invitations to participate and confirmed this before starting the interview/focus group. All participants were advised they could opt out at any time, without giving any reasons.

An email survey was sent to all peer support mentors.

Discussion

The mentors were all clear on the aims of the PSW model and its benefits.

However, the PSWs themselves had some difficulty in understanding the structure of the model, although they were clear that their role was supporting young people with mental health issues. It became evident that the PSW role was subject to local variations. In one area, only a limited number of young people needed support with the transition, so the PSW instead worked with young people who needed a supportive mentor.

The model has been successful in two ways. First, feedback from service users has shown it has improved transition; this is also evident in a longer-term implementation of the model.

An in-depth review of service user feedback would be a logical next step to consider whether the PSW work meets their needs. This could be achieved by reviewing the routine feedback data already collected or by creating a specific questionnaire.

One of the greatest challenges to implementing the service, which must work in both CYPMH and adult services, was the attitude of staff. Some reported suspicion or lack of clarity of the role and its benefits, while others voiced concerns over the limitations of sharing experiences, some of which may be traumatic, and may risk making the service user feel worse or decreasing the mental wellbeing of the PSW. This was a common finding in a recent review of PSW employment initiatives (Gillard et al, 2013). While a minority of staff were initially resistant, this has changed and staff now seek out PSWs to be involved in cases. This beneficial shift has been attributed to the attitudes and personalities of the people employed.

The other way in which the initiative has succeeded is in its effect on the PSWs, who say the work has benefited their mental state. One element of protection for the PSWs is mentor supervision, given at regular intervals. Some stakeholders voiced concerns that while this helps safeguard the wellbeing of PSWs, it does create extra work for mentors.

Conclusion

Successfully introducing PSWs into existing teams relies on team members’ understanding of the role and the processes for training, management and support. Nurses need to develop skills in mentoring, guiding and monitoring the work of their PSW colleagues.

There is potential for PSWs to work in nurse education to embed “expert patient” and the “no decision about us, without us” principles and help reduce perceived barriers, prompting recovery-focused care. We plan to continue using PSWs and to work with the IMH to evaluate this project.

Key points

  • Moving from child to adult mental health services can be a difficult and frustrating time for service users
  • Peer support can facilitate recovery by promoting hope and providing support based on common experiences
  • Many adult mental health services are introducing peer support workers
  • Training can prepare people with experience of mental distress to work alongside others with similar experiences
  • Staff attitudes can be one of the biggest challenges to implementing change
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