key: cord-0798198-wgflhtec
authors: Mirbahaeddin, Elmira; Chreim, Samia
title: A Narrative Review of Factors Influencing Peer Support Role Implementation in Mental Health Systems: Implications for Research, Policy and Practice
date: 2022-01-11
journal: Adm Policy Ment Health
DOI: 10.1007/s10488-021-01186-8
sha: 18294f603e4d66c0251b29a0dbfc492917fb1cda
doc_id: 798198
cord_uid: wgflhtec

With increasing calls to incorporate recovery principles into conventional mental health care, the importance of peer support worker (PSW) services has gained attention. However, studies consistently show that PSWs remain underutilized. Although research addresses several factors that influence formal implementation of their role, there is lack of a comprehensive framework that synthesizes the factors and addresses their interlevel interactions. This paper provides a narrative review and synthesis of literature on multilevel factors that influence formal PSW role implementation in mental health systems. We conducted a search of literature and reviewed 38 articles that met inclusion criteria. Our thematic analysis involved identifying first and second order categories that applied across studies, and developing third order interpretations through iterations. We synthesized the findings in a multilevel framework consisting of macro, meso and micro level influences. Influencing factors at the macro level include broader socio-cultural factors (medical model, recovery values, professional power dynamics, training and certification), regulatory and political factors (policy mandates, political commitment), and economic and financial factors (funding, affordability of services). Factors at the meso level include organizational culture, organizational leadership, change management, and human resource management policies. Micro level influences pertain to relationships between PSWs and team members, and PSW wellbeing. Interlevel interactions are also outlined. Limitations and implications for research, policy and practice are addressed.

Research has increasingly shown that peer support plays an important role in mental health systems (Byrne et al., 2016; Gillard et al., 2015; McCarthy et al., 2019; Otte et al., 2020b) . Health systems in various countries such as the US, Canada, UK and Australia are increasingly recognizing the role of peer support workers (PSWs) in mental health services (Commonwealth of Australia, 2013; Cyr et al., 2016; Department of Health (DH), 2012; SAMHSA, 2021) . However, studies consistently show that PSWs remain underutilized in formal mental health systems because of various barriers and influences on implementation of their role (Otte et al., 2020a) . This paper provides a narrative review of the literature on the multilevel influences on peer support role implementation.

A peer supporter in mental health is a person who has lived experience of mental health issues and offers support or services to others with mental health issues. Peer support is "a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful" (Mead et al., 2001, p. 135) . Solomon (2004) categorizes peer support into four groups ranging from voluntary to formal, specifically: self-help groups, peer-run services, peer partnerships, and peer employees. The focus of this paper is on peer employees or paid peer support workers (PSWs), who-unlike those who engage in voluntary peer support-hold formal roles in mental health/social services organizations. PSWs provide services in a variety of settings that include hospitals, community health centres, and transitional programs (Gillard et al., 2020; Repper & Carter, 2011; Vigod et al., 2013) .

PSWs can be role models for recovery for other individuals experiencing mental health issues (Cyr et al., 2016; Rebeiro Gruhl et al., 2016) . PSWs' engagement with peers tends to differ from professionals' engagement; for example, PSWs are able to establish stigma-free relationships with hard-to-reach populations (Ibrahim et al., 2020; MacLellan et al., 2017) . PSWs may be called certified peer specialists (Grant et al., 2012) , peer support providers (Asad & Chreim, 2016; Moll et al., 2009) , advisors (Agrawal et al., 2016) , or other terms.

The literature points to several potential contributions of peer support including fostering recovery and hope for people suffering from mental health issues, connecting with hard-to-reach populations, supporting a smooth transition from hospital to community, and changing perceptions of stigma (Asad & Chreim, 2016; Ibrahim et al., 2020; MacLellan et al., 2017; Mulvale et al., 2019) . It has been pointed out that peer support lowers symptom distress and improves quality of life (Cyr et al., 2016) and that supplementing mental health services with peer support significantly reduces re-hospitalization (Sledge et al., 2011) , hence reducing the overall cost of service. Although some authors have indicated that there is paucity of quality evidence on the effectiveness of peer support (Chinman et al., 2014; LaFrance et al., 2017; Lloyd-Evans et al., 2014) , a few studies have attempted to provide some evidence. For example, a randomized clinical trial that integrated peer support in a transitional discharge model of care with clients who have a chronic mental illness found that the intervention participants with peer support had been discharged an average of 116 days earlier per person (Forchuk et al., 2005) . Overall, despite its benefits to mental health care, peer support is not well integrated within mainstream mental health services (Rebeiro Gruhl et al., 2016) . This paper addresses the influences on (lack of) integration of the PSW role.

These influences manifest at the health systems and policy level, organizational level, and team/individual level. Although research addresses several of these factors, there is lack of a comprehensive framework that synthesizes them and addresses their interlevel interactions. Gillard finds the current PSW evidence base "frustratingly messy" (Gillard, 2019, p. 343) . Further, in the absence of a multilevel review, it is difficult to understand how factors at various levels interact to compound the obstacles or enablers to implementation of the role. This paper draws on a multilevel perspective to provide a narrative review of the literature on macro, meso and micro level factors that influence the implementation of the PSW role in mental health care. The research question is: what are the multilevel factors that influence formal implementation of the PSW role in mental health care and how do factors interact across levels?

Application of a multilevel perspective has enabled better understanding of factors that influence the implementation of changes in roles, practices, groups, and organizations in health systems (Chreim et al., 2007; Kooij et al., 2018; Nelson et al., 2014; Smith et al., 2019) . With respect to influences on implementation of the PSW role specifically, some studies have adopted the Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., 2009 ). This framework offers five levels of investigation including technology-related factors; outer setting (e.g. policy); inner setting (e.g. resources in an organization); process (e.g. engagement of stakeholders); and individual health professionals (e.g. individuals' knowledge). Siantz et al. (2016) applied CFIR in an empirical investigation and Ibrahim et al. (2020) used it in a systematic review to identify barriers and facilitators to PSW role implementation. These are highly informative studies, but the influences they consider are mostly at the individual, group and organizational levels. Less attention has been directed to the system level influences (e.g. the policy environment, societal norms) and to the interactions between factors operating at different levels.

Yet "organizational phenomena unfold within complex and dynamic systems" that are influenced by the broader environment (Hitt et al., 2007 (Hitt et al., , p.1385 . Multilevel thinking is essential in understanding these "nested arrangements" (Hitt et al., 2007 (Hitt et al., , p.1387 . A multilevel perspective also facilitates understanding of interlevel dynamics (i.e. how factors on one level interact with factors at another level). Interlevel analysis allows researchers to build theoretical and empirical bridges across levels and tackle "real-world problems" (Hitt et al., 2007 (Hitt et al., , p.1395 . Since the focus on one level might prevent adequate attention to other levels and also overlook their interactions, researchers have examined not only multilevel influences, but also interlevel interactions. For example, Chreim et al. (2007) tracked the reconstruction of the professional role identity of physicians by focusing on influences in the environment external to the organization (macro level), organizational influences (meso level), and individual influences (micro level), and by considering their interactions. In this paper, we adopt a multilevel perspective in our review of the literature on factors that influence the implementation of the PSW role in mental health services. We also address interlevel interactions.

In this review, we adopted a narrative approach and conducted an interpretive synthesis of the literature (Greenhalgh et al., 2018) on influences on PSW role implementation. This type of review is particularly useful for this study because it not only involves identification of themes (the influencing factors) in the literature, but also allows achievement of synthesis through subsuming concepts in published studies into a more abstract or higher-order structure (Dixon-Woods et al., 2005) . A narrative review allows reflexive description and critique of the findings from extant literature (Greenhalgh et al., 2018) . A narrative review-similar to an integrative review (Whittemore and Knafl, 2005 )-can examine a phenomenon by using diverse empirical, theoretical, and methodological literature; it need not be limited to primary empirical studies. Our review included quantitative and qualitative research as well as reviews, which allowed us to rely on and synthesize different evidence types (Dixon-Woods et al., 2005) . Since a narrative synthesis often includes a systematic way of searching the literature (Dixon-Woods et al., 2005; Greenhalgh et al., 2018; Major & Savin-Baden, 2010) , we followed the procedures outlined below.

Database search: Two researchers conducted a search of the literature and performed iterative screening for the inclusion of papers. Online search was from academic databases, including CINAHL (Ebsco), Scopus, MEDLINE (Ovid), PsycINFO (Ovid), and Web of Science. The online database search was guided by a librarian to retrieve the most relevant published articles from each database. The search was filtered for only English language papers and those from 2000 to 2020. The search strategy included three components: (1) peer support, (2) role implementation/integration, and 3) mental health. The search string included synonyms or subject terms related to these phrases and used Boolean operators. The string was edited based on the specifications of each database in order to capture the papers in the same way. For example, ("peer support" or "peer support worker" or "peer provider" or "peer specialist") AND (role and integration or implement or integrate or implementation) AND ("mental health" or "mental illness" or "mental disorder" or "psychiatric illness"). The search resulted in 689 papers (including duplicates). An additional 8 papers were identified through hand search, reading references, or other sources. Overall, 380 records remained after duplicates were removed.

After removing the duplicates, a pilot screening of all the article titles and abstracts was performed by two reviewers using primary inclusion criteria. The reviewers used Covidence, a web-based software platform for teams coordinating their work on reviews (Veritas Health Innovation, Melbourne, Australia; www. covid ence. org). Conflicts were carefully discussed, and a final list of inclusion and exclusion criteria was reached (Table. 1). Using the refined criteria, the reviewers conducted a second abstract screening that yielded a smaller number of conflicts (16 papers), all of which were resolved through a second conflict resolution session. Papers relating to the context of forensic mental health services were removed because of the specificities of this context (regulations, funding, organizational factors) that do not apply to mental health services more broadly. The process of reviewing papers was then followed by eligibility screening of the full texts and quality assessment described below (55 papers). Finally, 38 papers were included in the review.

Search flow diagram: A PRISMA Flow Diagram (2009) illustrates the steps taken during the literature search and the number of articles included at each step based on the inclusion criteria below.

Inclusion and exclusion criteria: The criteria we usedoutlined in Table 1 -determined the selection of papers at each stage (Fig. 1 ).

There is disagreement in the literature on whether quality of articles should be evaluated, and on the approach that needs to be used should one decide to evaluate quality (Dixon-Woods et al., 2005; Greenhalgh et al., 2018) . Our approach was to include only articles that were published in peerreviewed indexed journals with an impact factor or a Scopus CiteScore. We also conducted a quality appraisal that was informed by the McMaster University critical appraisal forms (Law et al., 1998; Letts et al., 2007) . The forms determined quality, considering such criteria as identification of study purpose, review of relevant literature, details on methods (such as study design, sampling, data collection, analyses and overall rigour), results, implications for research and practice. We evaluated each paper using the assessment criteria and ranked it using a scale of strong, moderate, and weak. Papers evaluated as weak were removed. Figure 2 , based on the included papers, shows increasing attention to and growing importance of research on PSW role implementation.

Our reading of extant research on factors that influence implementation of PSW role was similar to other researchers who have found the literature dispersed and fragmented (e.g. Gillard, 2019) . Hence our goals were to organize and integrate. We adopted a multi-level perspective to achieve both these goals. Other researchers have used multilevel mentation (2000-2020) frameworks to study influences on role and change implementation (e.g. Chreim et al., 2007; Kooij et al., 2018; Nelson et al., 2014; Smith et al., 2019) and we were inspired by their work. Using a mixture of deductive approach (based on the frameworks proposed by multilevel authors) and inductive approach (based on our reading of the data we were working with), we developed a framework that distinguishes between macro, meso and micro level factors. We designated influences that operate in the external environment of organizations and that tend to be outside of the control of organizations as macro level influences. These were influences operating at the health system, societal or national economic levels, for example. Influences at the meso level are within a certain level of control by the organization. These influences are relevant across departments and go beyond a small team or single individual. At a lower level of analysis, we find influences of a micro nature that involve team and individual behaviors and dynamics that influence the role implementation. We would like to point out that our review and the framework we adopted involves interpretation, as do all types of syntheses (Dixon-Woods et al., 2005) . A narrative synthesis is a flexible and effective way to develop themes that bring coherence to separate data from a body of evidence (Briner & Denyer, 2012; Popay et al., 2006) .

Our analysis involved reviewing each paper and deriving themes that we allocated to the various levels. For example, we considered influences related to health policy to operate at the system level and we designated them as macro level influences. We followed the recommendations of Miles, Huberman and Saldana (2020) in our analysis. As they advised, themes were amended and recategorized as the analysis progressed. The process was not linear and included iterative loops in thematic analysis (Major & Savin-Baden, 2010; Miles et al., 2020) . For example, in the early steps, we had identified change management as a meso level theme that included the topic of organizational leadership. After further analysis, the notion of organizational leadership emerged as a central factor that influences PSW role implementation, and it became evident to us that organizational leadership could be separated from change management and discussed as a theme on its own. Similar iterative processes allowed us to refine the various themes and subthemes (Miles et al., 2020) .

According to Major and Savin-Baden (2010), synthesis means "taking parts and developing them into a new whole" (p.64). It involves combining themes across the studies, identifying second order categories across studies, and developing third order interpretations (Major & Savin-Baden, 2010) . Using constant comparisons, we synthesized and clustered themes into larger categories. For example, we reflectively clustered dominance of the medical model in mental health care and professional power dynamics into a second order category that we called macro socio-cultural context. Our analysis also involved considering how factors at one level could influence factors at the same or another level. Throughout the synthesis, we discussed interpretations to establish the plausibility of the findings (Major & Savin-Baden, 2010; Greenhalgh et al., 2018) . The final product of our analysis-a multi-level framework that summarizes the influences and the interlevel interactions-is provided in Table 2 .

In this section, the literature on factors influencing PSW role implementation is reviewed. Table 2 shows the factors at each level and reflects the interlevel influences. It is important to note that the themes we report are not mutually exclusive. Separating themes is necessary for presentation purposes, but as our analysis will show, a factor can operate at various levels, as well as intralevel.

Factors at the macro level pertaining to PSW role implementation relate to the macro socio-cultural context, the regulatory and political context, and the economic and financial context.

Literature shows that dominance of the medical model in mental health care and professional power dynamics influence PSW role implementation. The medical model culture that prevails in mental health services is a major barrier to recovery-focused approaches and to PSW role implementation (Byrne et al., 2016) . This culture privileges a hierarchical structure whereby power lies in having a medical or clinical background (Ehrlich et al., 2020) . Tensions exist between the view of those in favor of peer support and the traditional view based on the medical approach. These tend to be opposing discourses, and Byrne et al. (2016) refer to such opposition as two worlds colliding (p. 217). While advocates of peer support rely on the principles of recovery, experiential knowledge, and the philosophy of self-determination and empowerment (Gillard et al., 2017) , the medical model has an emphasis on the "expert knows best" attitude, medication treatment, therapy, and other highly regulated services (Byrne et al., 2016, p. 220 ).

The medical model and the "expert knows best" approach encourage power imbalances in favor of organized professions (Byrne et al., 2016) . Peer support is based on personal relationships and caring, and PSWs' effectiveness depends on quality of relationship and mutual trust that they establish rather than use of knowledge obtained by academic qualifications (Repper & Carter, 2011) . However, established professions show resistance to PSWs' practice through prejudice, stigma, and discrimination (Walker & Bryant, 2013) , hindering the implementation of PSW role. Byrne et al. (2019) refer to the "institutionalized discrimination" towards people with a history of mental illness in Australia and "prejudicial attitudes" from the mental health professions that inhibit the PSW role development. Such discrimination has been observed in other jurisdictions as well such as Canada (Mulvale et al., 2019) . Despite enduring dominance of the medical model, there has been increasing attention to recovery-oriented approaches and acceptance for the role of PSWs (as we show in the next section). This has accompanied attention in several jurisdictions to developing training programs to enhance the competencies of PSWs and to provide certification (Rebeiro Gruhl et al., 2016) . Hence, PSWs can be formally certified allowing their qualifications to be recognized in the mental health system as has been the case in many states in the US (Grant et al., 2012) . Certification is also available in other countries, such as Australia (Fan et al., 2018) and training programs have become more common (e.g. several European countries, Japan) (Berry et al., 2011; Burr et al., 2020; Matsui & Meeuwisse, 2013) . Training and certification help enhance the legitimacy of PSWs in an otherwise professionalized domain and can facilitate their integration into the mental health system.

System-level policies have influenced the implementation of PSW role in mental health care through downward directives. In the US, there have been state and federal health care policies that mandate mental health centers hire PSWs called "certified peer specialists" (Grant et al., 2012) . Grant et al. (2012) showed successful integration of the PSW role in these settings. In Canada, the Mental Health Commission of Canada has recommended the development of peer support in mental health care, however, the integration of PSW role in clinical settings has remained a challenge (Mulvale et al., 2019) , showing that recommendations by high level bodies are helpful but likely not sufficient. This is in contrast to stipulations that the inclusion of peer specialists is a requirement in Assertive Community Treatment (ACT) teams in some Canadian provinces such as Ontario (White et al., 2003) .

In the UK, the policy decision to include recovery in frontline services resulted in the creation of a peer support worker role by the NHS that has been distinct in terms of offering mutuality, empowerment, modeling hope, and the sharing of lived experience with peers (Gillard et al., 2015) . PSW role implementation in the NHS has also led to enactment of occupational health practices, staff training, and other measures such as developing referral processes (Berry et al., 2011; Creamer et al., 2012) .

High level regulation can target various areas of PSW employment, including, for example, recruitment, working hours and pension. Burr et al. (2020) found that PSWs in Switzerland work 35% of a full-time equivalent (13 h per week) because mental health organizations had no legal obligation to employ PSWs. In Ontario, Canada, the Ministry of Health requires 0.5 full-time-equivalent paid staff in a PSW position in Assertive Community Treatment Teams and PSWs have been consistently recruited throughout the province (White et al., 2003) . Directives from higher levels of authority on recruitment and remuneration policies enable the integration of PSWs in mental health organizations.

In Australia, policy mandates to include people with lived experience started in the 1990s, and ever since, government plans and standards have recognized the employment of PSWs (Byrne et al., 2019) and have advocated for the employment of lived experience roles as essential to the implementation and development of recovery-orientated service delivery (Byrne et al., 2019; Franke et al., 2010) . Despite this policy environment, challenges persist in Australia because of prevalence of the medical model and tokenism of lived experience (Byrne et al., 2016; Ehrlich et al., 2020) , indicating that policies that are not accompanied by changes in the dominant views in the social/cultural environment may lead to compliance but not genuine change in terms of embedding peer support in the mental health system (Siantz et al., 2016) . The importance of increasing political commitment has been highlighted as a means to develop legal requirements and stipulations that are favourable to PSW role integration in the mental health system (Burr et al., 2020) . These legal requirements in turn help legitimize the PSW role as an integral part of the system. However, the literature also calls for caution so as not to tightly regulate or prescribe the PSW role, pointing to potential disadvantages and explaining that peer support involves inherent creativity and flexibility in the role, which enables PSWs to provide individualized support (Asad & Chreim, 2016; Berry et al., 2011; McCarthy et al., 2019) .

Providing financing for PSWs' services has been an influencing factor, and countries that have accounted for peer support services in the financial structure of the health system have been able to integrate the PSW role in mental health care (Grant et al., 2012) . For example, several states in the US have provided Medicaid reimbursement for services of certified peer specialists and paved the way for PSWs to be formally employed (Grant et al., 2012) . Literature shows that system-level funding support enables financial arrangements for PSWs within mental health organizations, e.g., through funding for embedded peer support programs in mental health care or the development of training opportunities (Davis et al., 2010; Ibrahim et al., 2020) . Research also indicates that PSW services create a social return on investment and emerging evidence supports the economic justification of investing in the recovery-focused services that they provide (Ibrahim et al., 2020) .

Despite the relative affordability of services of PSWs, obstacles remain to formal integration of their role in mental health systems, due in part to enduring patterns and established views. Peer support comes from a history of consumer-run movement (eighteenth century in Europe and during the 1970s and 1980s in North America) which is founded on naturally occurring, voluntary peer support (Ibrahim et al., 2020; Mulvale et al., 2019) . Therefore, PSWs have a long history of not being paid for the services they offer. The interlevel impact of a history of voluntary work is reflected at the level of organizations, where there tends to be absence of pay scale and other HR policies related to PSW remuneration (Hebert et al., 2008; Ibrahim et al., 2020; Wall et al., 2020) . This reflects a relative devaluation of the PSWs' skills within the hierarchy of occupations in mental health care (Asad & Chreim, 2016) .

Other high level economic factors such as national economic uncertainty can pose barriers to funding that can secure PSWs' employment. For example, in the US, the 2008 economic crisis budget cuts could jeopardize PSWs' position mainly because Medicaid funding could be eliminated for services of the certified peer specialists (Grant et al., 2012) . Economic uncertainty as an influencing factor is a topic that has not received sufficient attention in the literature.

In sum, impediments to implementation of the PSW role in mental health care systems include dominant and enduring structures and discourses on mental heath care that favor the medical approach and professional designation in service delivery, discrimination against and lack of understanding of the value of recovery for mental health, and economic uncertainty that leads to cuts in mental health services. However, in various jurisdictions, there appears to be a shift in views and increasing recognition of the value of peer support, the provision of training and certification that enhance the legitimacy of the role, changes in policies and regulations, and increased financing that enable integration of the PSW role in the mental health care system.

Factors at the meso level include organizational culture, organizational leadership, change management and workplace strategy, and human resource management policies.

Peer support services are offered within organizations that have different organizational cultures. Literature often refers to common challenges relating to PSWs' integration into more hierarchical organizations-challenges that include lack of appropriate supervision (Creamer et al., 2012; Gopalan et al., 2017) and unclear role definitions, accountability, and boundaries (Byrne et al., 2019) . These organizations tend to show apprehension relating to PSWs' access to peers' medical records (Chinman et al., 2010) .

Comparative studies including organizations with more or less hierarchical cultures have been conducted to identify how contextual factors influence PSW role implementation. In a study in the US, Moran et al. (2013) found that contextual factors that create challenges to the PSW role differ between "conventional" mental health settings (e.g., ACT teams) and consumer-run agencies. They showed that challenges for the employed PSWs in conventional mental health services that are run by non-peers include direct and indirect expressions of prejudice, lack of recovery focus, and being the only PSW in the organization. A comparative case study in the UK showed that expectations related to the role of PSWs vary across organizations (Gillard et al., 2015) . This study showed that in organizations with a structured and hierarchical culture, the distinctiveness of the PSW role in bringing a "meaningfully different practice" was undermined as the expectations from the PSWs were that they demonstrate roles similar to existing health care roles that have "clinical-like boundaries" (p.690). Hence the role became constrained, and when its implementation was an early decision with lack of understanding of the role in the team, staff resistance occurred. In contrast, the PSW role maintained its distinctiveness in organizations with a solid collective understanding of the role and a culture supportive of peer work (Gillard et al., 2015) .

Commitment of organizational leadership has been found to be an important factor in preparing the organization for implementation of PSW role and supporting PSWs in integrating into mental health teams (Franke et al., 2010) . As indicated above, at the macro level, policy leaders can offer opportunities for training, certification, and funding for PSW positions at a health systems level, and can create systems for evaluation of peer support programs (Mulvale et al., 2019) ; in turn, organizational leaders can build upon the macro system-level foundation and implement strategies that include recovery-oriented principles to facilitate integration of PSWs in mental health teams. Support from senior organizational leaders enables changes in services when a PSW role is introduced, especially where a clinical setting is new to the role and needs orientation on importance of and practices associated with lived experience (Hopkins et al., 2021) . Leaders can provide a vision for integration of PSWs as part of person-centred care teams and offer education about the PSW role and its benefits "while recognizing that adoption of peer support requires a culture change that takes time" (Mulvale et al., 2019, p.72) . Organizational leaders can alter organizational policies and set goals to move beyond medically focused services and to include recovery-oriented services that enable employment of PSWs (Byrne et al., 2016) . They can also facilitate hiring and training of PSWs (Chinman et al., 2012; Gates et al., 2010; Shepardson et al., 2019) .

Educating immediate supervisors of PSWs about the role can also facilitate integration since supervisors "broker" the relationship between the organization and PSWs and between the PSWs and co-workers (Kuhn et al., 2015) . The importance of supervision is strongly highlighted in the literature and has been associated with "success" and sustainability of peer support programs (Creamer et al., 2012; Gopalan et al., 2017; Kemp & Henderson, 2012; Siantz et al., 2016; Walker & Bryant, 2013) .

Implementing the PSW role often requires that the mental health organization demonstrate openness to change, especially when the culture and dominant views at the organization are not supportive of recovery practices or incorporating lived experience as part of mental health care services (Berry et al., 2011) . Research shows that mental health organizations can benefit from a change management model. Such model would consider system level policies, strategies and changes and translate them at the organization, practice, and individual levels (Mulvale et al., 2019) . Alignment with supportive national and regional level government policy directives can help mental health organizations better implement the PSW role (Hopkins et al., 2021) . Chinman et al. (2010) describe a multi-step approach used successfully in the VA (Veterans Affairs) mental health system. It entailed consultation and solicitation of those involved in the peer role implementation and consisted of several steps, namely exposure (providing information and discussion on the role), adoption (leadership decision and subsequent support for the role implementation), implementation (trial use of PSWs and refinement of the role based on discussions and decisions). Franke et al. (2010) provide another example of a change model. Spearheaded by South Australian Department of Health, the Peer Work Project was launched for training and sustainable employment of PSWs. This project suggested a model (prepare, train, support) as a tool for the introduction of formal PSWs at the employing organization. The model included a segment on organizational preparation (including role definition, training staff, developing policies, procedures, and induction processes) and followed with organizational support (including supervision, staff meetings, and workplace mentoring) to achieve sustainable employment for trained PSWs (Franke et al., 2010) . This program shows how directives and programs enacted at the system level can be taken up by organizations intent on change that supports the implementation of the PSW role.

Consultation of various parties involved in the change, such as supervisors, clinicians and PSWs paves the way to achieve better integration (Gates & Akbas, 2007; Gillard et al., 2017; Otte et al., 2020a; Shepardson et al., 2019) . It has also been pointed out that PSW role development and integration can be an ongoing process involving proactively monitoring and removing challenges (Chinman et al., 2012) . Evidence points to a workplace strategy alongside change management to effectively promote the PSW role integration (Gates et al., 2010; Gillard et al., 2017) . A workplace strategy that develops a comprehensive peer support program structure and appropriate human resource policies enables the sustainability of PSWs' role (Gillard et al., 2017; Kuhn et al., 2015) .

The literature refers to organizational policies on hiring, remunerating, training and socializing, and retaining PSWs as enabling or hindering PSW role integration.

With respect to hiring, the literature shows the importance of establishing criteria for the recruitment of PSWs. A research project in the VA in the US called Peers Enhancing Recovery demonstrated potential for integration of PSWs in case management teams (Chinman et al., 2012) . The findings showed that the Human Resources department, based on past experience with hiring professionals, often did not know how to utilize lived experience as a hiring criterion, causing confusion and preference to hire individuals with credentials other than lived experience. Organizational guidance on how to utilize PSWs is identified as a factor that supports placing PSWs in work roles that are centered around lived experience and helping others in recovery (Mancini, 2018) . Development of a program structure for the integration of PSWs' role rather than siloed recruitment of PSWs on an adhoc basis (Hebert et al., 2008; Frank et al., 2010; McCarthy et al., 2019) also enables role implementation.

(Mis)understanding of the importance of lived experience impacts the remuneration of PSWs. Remuneration is a gauge for the level of education, expertise, and hierarchy of positions in mental health organizations (Asad & Chreim, 2016; Ibrahim et al., 2020) . Inadequate remuneration and limited workplace resources give the impression that the skills of a PSW are not valued (Asad & Chreim, 2016; Vandewalle et al., 2016) . Literature shows that interprofessional power dynamics that manifest at the system level also appear at the organizational level when considering remuneration disparity (Burr et al., 2020; Repper & Carter, 2011) . Findings show that an appropriate "pay scale classification" for PSWs (Otte et al., 2020a) that fairly values their contribution to the wellbeing of the service users (Gates & Akabas, 2007) is essential for the formal integration of PSW roles in mental health organizations.

Training offered by organizations also enables PSWs' integration into mental health services. Asad and Chreim (2016) found that there are different types of training that enhance PSW role integration, including training that is offered to all staff as a socialization process, workshops specific to peer support services, and ongoing learning opportunities during the job. In addition, training may be delivered through several contributors who all agree to provide a holistic and continuous training experience to the PSWs (Chinman et al., 2010) . For example, in the VA in the US, training is provided by other employed PSWs, other staff from mental health intensive case management through shadowing, and/or contractors who train for specific mental health programs (Chinman et al., 2010) .

Training for PSWs and mental health teams holds several benefits. First, PSWs tend to develop their sense of professional identity and a more distinct role as they differentiate their strengths from other mental health workers (e.g. their unique relationship with peers, having authentic empathy and a normalizing function, and a "different sort of creativity" in working with the peers [Berry et al., 2011] ). Wall et al. (2020) identified that PSWs showed high intrinsic motivation and high self-efficacy after training. Second, training alleviates potential conflicts in mental health teams by improving teams' tolerance and acceptance for PSWs' work practices (Berry et al., 2011; Matsui & Meeuwisse, 2013; Rebeiro Gruhl et al., 2016) . Training PSWs and teams lessens potential discrepancies (experienced by both the PSWs and the teams) between the job description presented at the recruiting interview, and the reality of the PSWs' role (Berry et al., 2011; Davis et al., 2010; Gates et al., 2010) . Mancini (2018) found that it was essential and important for PSWs to seek ongoing professional development opportunities and continuing education similarly to other "helping professions" that are mandated to keep skills up to date. The author pointed to the need for career advancement with incremental pay and ranks that reflect skill level and experience and that these various methods "would allow them greater legitimacy and bargaining power within traditional mental health organizations" (p.132).

In addition to training, organizations can facilitate PSWs' self-education and access to resources. One such resource is access to material or workshops that help PSWs understand the technical terminology typically used in mental health settings (Asad & Chreim, 2016; Ibrahim et al., 2020) . Other resources become available when organizations hire simultaneously or employ multiple PSWs as this can offer a network of peers; this empowers PSWs to discover their strengths and to support each other through collegial consultation (Berry et al., 2011; Burr et al., 2020; Gillard et al., 2017; Wall et al., 2020) . The Peer-to-Peer Resource Center in VA is an example of a PSW network for continuous training and support on general peer support skills (Chinman et al., 2010) .

Another organizational human resource policy that enables integration of PSW role refers to sick leave as part of PSW employment. In the VA in the US, for example, a sick leave policy is applied for the employed PSWs in the same way that it applies to other staff (Chinman et al., 2010) . Human resources policies that enable integration of PSWs would also benefit from looking ahead at retention. Retention of PSWs relates to providing not only proper remuneration (fairly balanced between workload and compensation (Wall et al., 2020) , training, and job development opportunities, but also physical resources such as a computer and an office to meet with peers (Burr et al., 2020; Ibrahim et al., 2020; Moran et al., 2013) . Comprehensive human resources policies that acknowledge the value of the skills and work of PSWs enable integration and sustainability of the role.

In sum, the following facilitate the implementation and the sustainability of the PSW role: a supportive organizational culture, leadership commitment at all levels of the organization that signals the importance of lived experience and recovery in mental health services and supports the implementation of the PSW role, adoption of change management and workplace strategies, and finally, enacting comprehensive human resources policies.

Micro level influences on PSW role implementation include the relationships with team members and (in)ability to achieve wellbeing.

Tensions in relationships with other mental health staff have limited PSWs' integration into mental health teams (Otte et al., 2020a) . These tensions are partly because of a lack of trust in and understanding of the experiential knowledge of the PSWs (Ibrahim et al., 2020) . Literature highlights that PSWs find stigma prevalent and a "normal" part of their job in mental health care, which is ironic given their vital contribution to stigma reduction (Byrne et al., 2019; Mancini, 2018) .

PSWs may experience various forms of stigma. They experience structural stigma that emanates from lack of HR policies (as mentioned above) related to PSWs. There are cases where PSWs do not have the same privileges at work as their non-peer colleagues e.g., career development and other employment benefits (Mancini, 2018; Siantz et al, 2016) . PSWs also experience stigma relating to stereotypes about mental illness that negatively affect health professionals' attitude and lead to discrimination towards the PSWs (Byrne et al., 2019; Otte et al., 2020a) . The reflection of such attitude is evidenced as "direct and indirect expressions of prejudice" (Moran et al., 2013, p.284) . PSWs may experience prejudice from the staff in general, and especially in cases when the PSW transitions from a "patient" to a PSW (Moll et al., 2009 ). In the case of colleagues who had previously treated the PSW, negative attitudes can manifest in absence of courteous collaboration (Ibrahim et al., 2020; Walker & Bryant, 2013) . As such, PSWs can experience exclusion from meetings or lack of reciprocal communication with the other staff that hinder PSW integration within teams (Byrne et al., 2016; Shepardson et al., 2019) .

Research findings show that a low "readiness" level of the PSWs and the non-peer staff for the integration of the PSW role in the team play a significant part in the PSWs' experiences of stigmatization (Mancini, 2018) . PSW integration within teams may happen gradually as attitudes shift and team members develop an understanding of the role (Asad & Chreim, 2016; Ehrlich et al., 2020; Mulvale et al., 2019; Tse et al., 2017) . Findings of a peer support project in Hong Kong (Mindset project) showed that despite the uncertainty about the PSW role at the beginning of the implementation, staff progressively developed trust and awareness about the role and changed their perception of peer support services to a point that they viewed PSWs as an "asset" both for the staff and the peers (Tse et al., 2017) .

Another aspect of relationships with other staff that may influence integration is PSW disclosure of details about their own mental illness to the teams, which can be experienced as a challenge by the PSW (Chinman et al., 2010; Gates et al., 2010; Kemp & Henderson, 2012) . Literature points to cases when mental health teams (e.g. Mental Health Intensive Case Management for the veterans in the US) strongly agreed on hiring PSWs who are comfortable disclosing about their mental illness and sharing their recovery experience (Chinman et al., 2010) . This can enable integration of PSWs by helping them build trust with team members, although-as we have argued above-for this approach to be effective, there needs to be acceptance of the value of lived experience and belief in recovery on the part of team members.

There are other disclosure issues that can create challenges for the integration of PSWs within teams and which concern PSWs' sharing of information on the peers (or service users) with the other staff (Asad & Chreim, 2016; Kemp & Henderson, 2012; Moll et al., 2009; Repper & Carter, 2011) . PSWs' effort of maintaining a balance between their commitment to providing support for their peers and the expectations of the mental health professionals to obtain information on clients is an enduring challenge (Ehrlich et al., 2020; Otte et al., 2020a) . Sharing insights and achieving agreement on peer information disclosure within the team enables PSW role integration (Gillard et al., 2017; Repper & Cater, 2011) . Overall, issues related to defining the role boundaries of PSWs can impact whether role integration is hindered or enabled (Asad & Chreim, 2016) .

Maintaining PSWs' wellbeing is another micro factor that enables role implementation. This is an important issue for PSWs because of potential for being burdened when engaging in peer support (Otte et al., 2020a (Otte et al., , 2020b Vandewalle et al., 2016) . There are also issues of managing the boundaries with the peers that include for example, after-hours involvement, friendship vs. friendly behavior, and setting a distance (Chinman et al., 2010; Otte et al., 2020a; Rebeiro Gruhl et al., 2016) . Interactions with the peers may lead to emotional involvement or attachment and PSWs need to manage their feelings at the end of their professional relationship (Moran et al., 2013; Vandewalle et al., 2016) . Evidence suggests that access to self-care, training, and supportive supervision can help address some of these concerns (Chinman et al., 2010; Davis et al., 2010; Ibrahim et al., 2020; Otte et al., 2020a; Walker & Bryant, 2013) .

The importance of self-care (e.g. psychotherapy, meditation, relaxation techniques) (Burr et al., 2020) and access to sick leave (Shepardson et al., 2019) have been reported in the literature. Moreover, findings from a systematic review show that PSWs' access to a peer support network or a community of practice helps them better address the potential challenges concerning their wellbeing (Ibrahim et al., 2020) . Gates and Akabas (2007) have identified a lack of networking opportunities and social support as one of the stressful hindrances to PSW integration in mental health organizations. Berry et al. (2011) report on a PSW's experience: "I seem to be the only one that's working in this pure peer role and that has, on occasions, felt a bit lonely" (p.244). Isolation can take a toll on PSWs. The theme of isolation is prevalent in the literature, and the phenomenon of isolation is particularly evident in health systems and organizations that do not have depth and breadth in policies and practices that enhance peer support. We have outlined various areas where policy makers and leaders in organizations can intervene to help create system and organizational change that values peer support work and enriches the work life of PSWs.

In sum, the focus at the micro level is on the PSWs' relationships and experiences. The literature indicates that cultivating professional, positive and trusting relationships with team members facilitates integration of PSWs in mental health teams. As our discussion indicates, however, the onus is not only on the PSW to cultivate positive relationships, as this is difficult to undertake when one faces stigmatization, discrimination, and prejudice from other staff. This points to the importance of change management and training approaches at the organizational level to educate those in the PSWs' role set about the importance and practice of peer support (as we discussed in the meso factors section). Ensuring wellbeing and setting role boundaries with both peers and team members enables implementation of the PSW role.

This review of the literature suggests that peer support role implementation in mental health care is facilitated by enablers at three levels-macro, meso and micro. In what follows, we outline our contribution, address limitations, reflect on important themes related to PSW role implementation that were addressed or omitted from the literature, and point to implications for future research, as well as for policy and practice.

Our review contributes to the literature in various ways. The review includes empirical research using a variety of data collection/analysis methods, as well as scoping and systematic review papers on specific topics, and hence offers diverse angles from which to understand PSW role implementation. Further, while the number of studies and the approaches used in research have increased over the last few years, indicating a growing interest in an important topic, the information available is not structured or organized to provide a comprehensive view. Our review provides a comprehensive, holistic view that-to our knowledge-has not been attempted in the literature, and yet is much needed to provide integration. In this review, we have organized the findings from the literature into three levels of analysis, showing the multilevel factors that influence PSW role implementation in mental health care. In addition, we have provided a multilevel framework outlining the interlevel influences in Table 2 . Another contribution is to offer a multilevel framework that may be adopted and/or adapted in other research or reviews that focus on implementation of roles, programs or changes in health care.

This review, like other reviews, also has limitations. Despite our consultation and close work with a Librarian and our best efforts to be thorough, it is possible that a researcher using different terminology for the literature search might identify other articles that were not captured by our search criteria. Further, any review relies on interpretation and determination-made by the researchers-of the key themes to include in the literature synthesis (Greenhalgh et al., 2018) . Other researchers may employ other themes in their review.

Research has consistently showed that the challenges outweigh the enablers of PSW role implementation. While there is extensive evidence and research on influences at the meso and micro levels, factors at the macro level have received less attention, and are on occasion vaguely implied. We outline areas of future research that need to be pursued-most (but not all) at the system level-and consider how such research can also attend to dynamics at the meso and/or micro level.

The review showed the importance of attending to professional power dynamics at the macro level in understanding PSW role implementation. Literature on the sociology of professions indicates that professions claim professional legitimacy and autonomy to provide services due to education, credentials and licensure (Abbott, 1988; Freidson, 2001) . Power dynamics have been a recognized issue at the system level as the creation of new roles threatens power and status of members of established professions (Currie et al., 2012) , and policy-driven workforce developments in highly professionalized health systems create tension by confronting the more privileged professions with newer occupations (Bourgeault & Mulvale, 2006) . Research is needed to identify how the introduction of the PSW role at the system level is met by associations representing established professions, and the dynamics that lead to either collaboration or competition. In a similar vein, it is important to understand how knowledge and expertise based on lived experience can become legitimized and accepted by a system focused on knowledge based on formal education and extensive socialization. Future research can also address whether and how collaboration enacted at the system level has a trickle-down effect to the organizational level (for example, in terms of providing PSWs with similar work conditions and recognition as other professionals) and at the micro level of interactions.

In addition, in our review, we found that research from high-income countries (HICs) e.g., the US, Australia, Canada and the UK constitutes the majority of publications. A number of authors state that peer support has been applied and studied primarily in Western contexts and little is known about peer support in non-Western contexts (Fan et al., 2018; Gillard, 2019; Hall et al., 2019; Tse et al., 2017) . The limited research on low-mid income countries (LMICs) and non-Western countries such as Kenya, Timor-Leste and Hong Kong (Hall et al., 2019; Tse et al., 2017; Wall et al., 2020) showed that PSW role implementation can provide culturally acceptable/consistent and affordable services (Fan et al., 2018; Puschner et al., 2019) , and can be a means to engage "families and communities as active participants in health system development" (Hall et al., 2019) . Often lack of resources and shortage of health professionals drive the employment of PSWs in some countries, especially in rural or remote areas. Further research is needed on LMICs and non-Western countries that uncovers existing and promising practices of peer support and helps build an evidence base (Wall et al., 2020) . This review has showed that a number of jurisdictions have regulations (e.g. requirements for embedding peer support in mental health teams) or programs (e.g. for certification) in place to enable implementation of PSW role, yet evidence is mixed regarding the effectiveness of these approaches. Research is needed on how regulations are effectively translated to practices at the meso and micro levels in such a way that helps avoid tokenism of peer support. Comparative research across jurisdictions that have had more and less success with implementation, focusing on the system level dynamics that enable and hinder role implementation would help provide more clarity.

Moreover, this review has showed that economic uncertainty at a national or jurisdictional level has not received sufficient attention in the literature, yet is likely to play an important role in influencing PSW role implementation. This is a topic that is ripe for further research. The review has also showed that system level funding for PSW employment is not strongly institutionalized in most jurisdictions. More research could elucidate the financial return on investment related to employment of PSWs-an area that has not received sufficient attention. Collaborations with researchers in the field of health economics can help identify approaches and measures that could be used. This should be in addition to considering the social return in terms of achieving recovery and wellness for people experiencing mental health problems, reduction of various forms of stigmatization and integration in the community. These and other topics we have proposed as directions for future research would benefit from data collection through interviews with policy makers to obtain their views, as one source of data among others.

In this review, there was a lack of studies on how micro level factors can influence the system level, and more specifically, for example, how individual PSWs may exert any influence on the system. It is possible that such influence requires activism by individuals, as well as the creation of groups or social movements (e.g. the consumer movement). We did not find studies that focus on system level implementation of formal peer support originating with micro-level actors. Case studies of these events-if and where available-would be illuminating. The literature on institutional work (for example, Hampel et al., 2017; Lawrence, 2017) may provide inspiration for research that would address this issue.

The papers included in this review did not address how gender may influence implementation of the PSW role. Although demographic data were reported in some survey studies, there was no indication as to whether the gender of PSWs was a factor in their role implementation. Future research might examine if and how gender stereotypes impact PSW role implementation. Literature on community health workers, for example, has identified relative lower wages for female workers (Ved et al., 2019) . How gender might influence hiring, remuneration and other practices related to integration of PSWs in health care is an important topic for future research.

The majority of the empirical papers in this review involved qualitative research and the few studies that incorporated quantitative data tended to provide descriptive statistics (e.g., Burr et al., 2020; Chinman et al., 2012; Hopkins et al., 2021; White et al., 2003) . Research on implementation of PSW role in organizations would benefit from quantitative approaches that address such topics as network of relationships that develop within the organization upon implementation of the role and how this may help explain enablers or obstacles to the implementation.

A number of studies in this review reported on pilot projects for the expansion of PSW employment in mental health organizations (Franke et al., 2010; Gates et al., 2010; Gillard et al., 2017; Shepardson et al., 2019) . Future reports on pilot studies may track the progress of these projects and the lessons learned in the different stages of implementation and institutionalization. Longitudinal research would be valuable to understand what influences the sustainability of the role.

This review has implications for policy. Policies and regulations, through their trickle-down effect on meso and micro levels, can play a central role in the recognition and acceptance of the PSW role. Policies for which there are societal readiness and acceptance are easier to enact, and because the cultural values underpinning such policies are widely accepted, there is stronger likelihood that implementation of the PSW role will go beyond tokenism. Hence, policy makers can engage in discourse and education that highlight the social and economic value of peer support based on research, thus creating legitimacy for the role in an otherwise highly professionalized and hierarchical system. This also paves the way for the allocation of more resources to peer services in mental health and provides necessary funds for organizations to plan recruiting and retaining PSWs with formal contracts. Attending to more successful cases or jurisdictions would suggest opportunities for policymakers to learn about the various ways of incorporating PSWs in mental health systems.

From a practice standpoint at the organizational level, this research provides insights for informed managerial decision-making regarding the need to adopt a change management strategy that targets and consults various stakeholders. There is also the need for adoption of a comprehensive human resources management approach. This research showed that micro level factors pertaining to improving PSWs' workplace relationships, experiences and wellbeing are essential factors in the role implementation. Organizational leaders and immediate supervisors of PSWs can apply this knowledge by modeling stigma free approaches and behaviors.

In conclusion, peer support has been underutilized in mental health systems despite evidence of its benefits and of increasing need for mental health support and care. We hope that our paper provides a solid base for future multilevel research, policy and practice related to an increasingly important topic in health care.

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The authors would like to thank Peyman Varshoei