Organisational culture and communication: The introduction of Peer Workers to Psychiatric Wards

Organisational Culture and Communication:

The introduction of Peer Workers to Psychiatric Wards

Terminology: The term Peer Workers in this paper refers to mental health consumers

who are employed in the role Peer Worker. Consumers currently admitted to the ward

will be referred to as patients. The term consumers will refer more generically to any

mental health consumer.

Introduction

Since the 1960's there has increasingly been a consumer-rights movement in mental

health evidenced in a number of ways. Most recently the client-centred service, chronic

disease management and recovery-oriented frameworks have emphasised amongst

other aspects, the use of Peer Workers in the care of consumers.

Peer Workers are mental health consumers who have recovered or are stable, have

experience in the mental health system, and are trained to provide support and

advocacy for other consumers during their illness and within the health system. A recent

incident highlighted some of the issues about the role of the Peer Workers and their

relationships with other members of the clinical team.

Peer Workers have been employed in an acute psychiatric ward in a major teaching

hospital in Adelaide for over a year. Recently, a detained patient from the acute

psychiatric ward asked a Peer Worker to accompany her when she went to the

Guardianship Board for a review of her detention. At the hearing, after the treating

psychiatrist made his submission and recommendations, the judge asked the Peer

Worker her opinions. The Peer Worker told the consumer's story, which explained some

of the behaviour the psychiatrist had raised as being of concern. As a result the

Identification of the wards and persons involved has been masked.1

detention was renewed for one month instead of the six months that the psychiatrist had

requested. Upon returning to the ward, the clinical team reportedly ostracised the Peer

Worker.

This incident (which will be referred to as ‘the incident’ in this document) is the basis of

the examination of the role of the Peer Worker in an inpatient psychiatric facility.

This incident highlights a number of issues about the role of the Peer Worker, their

relationship with other clinical team members, whether they are considered part of the

clinical team, and their role. It has significant relevance as other organisations are

currently being funded to train Peer Workers for employment primarily as part of culture

change in the health system but perhaps also in other areas such as the legal system.

Theoretical Framework

This incident and its wider implications will be considered primarily through a critical-

interpretative analysis, with particular emphasis on health system subcultures as

evidenced in a high-dependency psychiatric ward.

Organisational culture is “shared key values and beliefs” that conveys a sense of identity

to participants, facilitates the commitment to the shared goals, enhances social stability

and directs sense-making. (Smircich, 1983, p345-346) It is a deep phenomenon of basic

assumptions developed from the process of learning to cope together with problems of

“external adaptation and internal integration”, “sharing emotionally involving problems”,

assumptions that have seemed to work in these situations and hence been adjudged

‘correct’. (Schein, 1986, p30-31) In the health system these assumptions are taught at

university and developed on the job, in daily procedures and intense, sometimes crisis

situations. In the hospital setting the shared culture binds disparate professions together

into a team, validating their roles and self-images while uniting them to achieve the

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organisation goals of delivering healthcare as it is defined within the culture. The

introduction of a new role, Peer Workers, with ambiguous status to the established

culture not only threatens the shared beliefs and values, but also threatens social

stability. Established sense-making fails as this role directly challenges the assigned role

the person would normally take – patient. The Peer Worker also challenges the defined

goals of the organisation because they represent that recovery is a journey the

consumer takes, not something that is ‘done’ to them by the clinical team.

From a systems framework perspective, organisational culture is seen as an internal

variable which encompasses goals, administration, socio-cultural system, production

system and technology / structure, and provides a normative and symbolic framework for

participants and onlookers. A strong culture in this context can be used to “rationalize

and legitimate activity” (Smircich, 1983, 344-345) such as the way the clinical team could

rationalise ostracising the Peer Worker who had defied the established norms.

Organisation culture will form around any relatively stable work unit where there are

shared stresses and experiences. (Schein, 1993, p47-49) The medical culture is strongly

and historically based on an hierarchical structure. From a socio-cultural perspective an

examination of decision making, power and conflict resolution within this hierarchical

culture gives perspective to the incident described. In particular French and Raven's

notions about expert power as the basis for imposing power over decision making as

ineffective and Mintzberg's notion of coalition of power (Mintzberg, 1983, pp22-30) is

evidenced in the joint action of the multi-disciplinary clinical team.

The hierarchical structure and the notions implicit in the status of members is based on

the concept of meritocracy, the valuing of having earned a position in the hierarchy

through university education and experience. (Conrad, 1994, p289-292) The imposition

of Peer Workers who are 'qualified' by virtue of their experience of illness – usually

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considered negatively as a defining feature of the "patient / consumer / client" to whom

healthcare is ‘done’ – threatens the basis of status, prestige and power invested in

clinical team members.

Psychiatric wards have their own culture within the context of the broader hospital

culture. Within the ward culture there are a number of subcultures including

occupational cultures, speciality subcultures as well as other externally influenced

cultures such as ethnicity and gender, and cultures based around specific leadership.

(Carroll, Quijada, 2004, pii17) These subcultures are the basis for shared

understandings, organising the clinicians into identifiable subgroups, building identity

and managing intra-organisational relationships. (Pepper,1995, p31; Schein 1993, p47-

49) The clinical subcultures share some assumptions, underlying values and motives,

and contribute to the overall hierarchy, defining how clinicians work and relate with each

other. This is important for the functioning of the ward as a whole. (Schein, 1993, p40-

41)

The benefits of the shared reality (sense-making, status) are threatened by the

imposition of 'outsiders' who do not share the paradigm. (Pepper, 1995, p30) In fact, the

Peer Workers are part of a management effort to change the culture and paradigm of the

psychiatric services, but their role seems not to have been supported by any explanation

or protocols to existing clinical team members, or any clear definitions about their status

in the team. If they are unable to become part of the clinical team and share the sense-

making and understanding of the dominant culture, they may become a subversive

subculture. The incident may be an early instance of this.

The medical culture has its own entrenched artefacts, primarily language, but also

uniforms, equipment and ‘office’ space allocated to various levels of the hierarchy.

Language is used to establish authority and exclude ‘non-speakers’. (Schein, 1993, p47-

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49) As well as medical terminology there are TLAs (three-letter acronyms) and

traditionally some unethical acronyms used for passing on coded messages regarding

patients without their knowledge.* (The latter has supposedly been eliminated but most

clinicians still know the acronyms). Some common terms betray paternalistic attitudes –

compliant / noncompliant to denote if the patient is following the clinical treatment

regime. The existence of the unethical acronyms and ‘gallows humour’ binds the

clinicians together by creating a bond of understanding and stress relief, and establishes

where the patients are in the hierarchy.

The job description is another artefact reflecting the cultural truth for the Peer Workers.

The document includes the word "advocacy", yet the behaviour and actions of the

clinical team seem to indicate that their expectation was that this person would interact

only with the "patient / consumer / client" in a form of tokenism – a supernumerary

patient. Using Smircich’s cultural analysis to question the assumptions, the title Peer

Worker clearly defines where this position fits in the hierarchy – as a peer to patients, not

to the clinical team. (Pepper, 1995, p30) (NB – language to describe patients /

consumers / clients is also fraught and changes between setting and clinical profession.)

Schein defines a number of models for group decision-making. (Daniels, Spiker, Papa,

1997, pp141-142) The decision making process of the clinical team is a hybrid model.

Externally, the decision-making process for recommendations for the Guardianship

Board is presented as consensus or at least majority rule. However given the

hierarchical nature of the team, ‘lower’ members opinions would be less weighted than

more senior members. The clinical team is also dominated by one or more powerful

positions, that of the psychiatrist/s. A comparison of the clinician beliefs in hospital

settings found that while nurses were very aware of their subordination and comparative

* FITH syndrome – fucked in the head, FUBAR – fucked up beyond all repair, GOMER – get out of my emergency room, PFO - pissed and fell over, etc.

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status in the hierarchy, the doctors were largely unaware of how dominant they were.

(Degeling, Kennedy, Hill, Carnegie, Holt, 1998, p59-60) The decision making style of the

clinical team would in some instances be more a minority coalition or authority rule.

The ostracising of the Peer Worker by the rest of the clinical team will be considered in

light of Bormann's Symbolic Convergence theory (fantasy theme analysis). This

describes how shared beliefs and values can be mobilised to cast meaning around an

event, creating clear functional identities with simplistic meanings (good v bad) and

rationalises the behaviour of fellow-team members against the ‘intruder’. (Daniels et al

1997, pp212-213) Such a story once reinforced, confirmed and built upon by team

members, can be very difficult to overcome. These fantasy-themes touch deep

understandings (Jung’s archetypes?) and establish thought parameters that guide team

members in how to think about the event.

Hospital Culture

Medical culture offers significant benefits to participants: high prestige, control over

others (particularly in mental health), a sense of professionalism and privileged

information under rules of confidentiality. (Carroll et al, 2004, pii18)

Psychiatric wards receive services from a variety of clinicians: psychiatrists, psychiatric

registrars, general doctors including interns, nursing staff (mental health nurses, ENs,

RNs and agency nurses). Allied health staff include psychologists, social workers, and

occupational therapists. Nursing staff and allied health staff answer to the Clinical Nurse

Consultant (CNC) as team leader. Hospital wards operate 24/7, with nurses rostered at

all times. Therapeutic services from other clinicians generally occur in the daytime on

weekdays1.

1 Knowledge of the clinical setting is from personal experience through my work in the CNAHS Mental Health directorate and through conversations with staff, clinicians, program managers and doctors over many years.

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The hospital hierarchy is rigidly enforced through job descriptions defining lines of

responsibility, privileges, and decision hierarchies. It is reinforced daily through clinical

team meetings and clinical hand-overs between shifts. The psychiatrists are legally

responsible for treatment decisions and are the only staff able to prescribe drugs, for

which they write up orders that other staff must follow. As treatment is the core business

of the ward, psychiatrists are at the top of the hierarchy and enjoy considerable

privileges. A full-time employed psychiatrist is allowed to do up to 0.2FTE of private

practice within their paid public work time, which can be conducted at the hospital, using

public facilities including their offices and personal assistants. Psychiatrists wear casual

clothes; doctors wear white coats (junior doctors usually wear a stethoscope) and ‘lower’

clinicians wear uniforms. Psychiatrists generally spend the least time on the ward and

self-manage their time; allied health clinicians work between several wards and work 9-5

jobs; and nurses work shift work spending all their time on the ward. Doctors have the

courtesy title Dr, but most other clinicians do not have a specific title. Mental health

nurses have undergone additional training, making them specialists amongst the nursing

corps. While psychiatric nursing might be very stressful and occasionally dangerous, it

probably has the least contact with bodily fluids, intimate body contact and the more

menial aspects of general nursing which may accord it more prestige.

The clinical team is arranged in an hierarchy according to qualifications, job classification

and seniority. University qualifications equate a presumption of knowledge and skill,

French and Raven’s ‘expert power’ (Daniel, Spiker, Papa, 1997, p250), establishes their

status in the hierarchy through their job classification and is roughly organised in terms

of the number of years of education required to qualify. This provides a seemingly

objective basis to the hierarchy, a meritocracy that is hard to counter. (Conrad, 1994,

p289-292) This meritocracy supports the evidence-based medicine paradigm and is

enacted as the power of veto or the final word in any disagreement. Other opinions, and

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particularly the patients’, are devalued and the expert’s opinion automatically becomes

imbued with additional value, irrespective of any objective analysis. Expert power is

shared in a graded scale along the hierarchy with the psychiatrists having the most

expert power and a strong emphasis on autonomous decision making. (Carroll et al

2004 pii18, Degeling et al, 2005, p65) There is a level of French and Raven’s ‘legitimate

power’ (Daniels et al 1997, p252) based primarily with the CNC and psychiatrists. This is

based on a group norm underlined by defined roles in job descriptions which site

decision making power and legal responsibility with these parties. The clinicians

themselves have different views of their position on the hierarchy, (Degeling et al, 1998,

p233) which might reflect the complexity of the inter-relations of the hierarchical

subgroups.

The clinicians form a formidable coalition of power (Mintzberg, 1983, p22-30) which

supports them their prestige and power. Their status allows them access to patient

records which contain personal information about the patient and establishes a power

gradient (professional distance requires the professional not to disclose personal

information about themselves). They have control over the activities of the patient, most

obviously through detention orders and Community Treatment Orders upon discharge.

Each of the clinical subgroups has a level of autonomy. While the psychiatrist is

ultimately responsible for the patient’s treatment, nurses control how they enact

treatment, and have a level of autonomous responsibility for the patients’ 24 hour care.

Allied Health Workers make autonomous decisions regarding the therapies that they use

to achieve the defined goal. While this autonomy in context is a cultural strength and is

certainly part of the prestige, status and personal power invested in clinicians, it is also a

barrier to change – people oppose changes that threaten their personal status and

power. (Schein quoted in Carroll et al 2004, pii18)

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The other largely invisible subgroup working on the ward and definitely not part of the

clinical team is the services staff: cleaners, catering service and orderlies. These people

are largely ignored by the clinicians (James, 2006) and yet their interactions with

patients are probably the most normal. While clinicians are aware of the potential for

therapeutic effect in everything they say and do, and are constantly observant for

anything that needs to be reported or recorded on the patient’s condition, the benefit of

having a conversation with people who do not have an ulterior motive could be very

normalising. The status of this group is underlined by their uniforms and their equipment

(cleaning carts, vacuums, floor polishers and food carts) and In some ways parallels the

position of the Peer Workers, whose interactions with clients are more normal.

Another powerful subgroup is administration. The divide between clinicians and

administrators is marked - clinicians generally consider administrators do not understand

the clinical setting. Amongst the administrators, the ex-clinician administrators feel that

non-clinician administrators do not have enough practical knowledge of the ways clinical

setting (Degeling et al, 1998, p129) and non-clinician administrators feel the ex-clinician

administrators don’t have the management skills needed. (As a non-clinician

administrator, the author feels that they are both partly right.)

Underlying the culture clash is that administrators and clinicians speak different

languages and come from different paradigms. (Schein, 1993, p47) Administrators

“value financial realism in clinical decision-making” (Degeling et al, 1998, p105) whereas

clinicians come from a paradigm where treatment of the patient is paramount. Balancing

treatment with cost often conflicts clinician managers. (Degeling et al, 1997 p105, 209)

Degeling et al note that ‘the differences in the frameworks of meaning and value

assumptions....[inform the] medical, nursing and managerial conceptions of what [is]

primary in the [hospital] organisation”. (1998, p247) Even clinicians who become

administrators are viewed with suspicion, although there is less suspicion about ex-9

clinician administrators from the clinical teams. The author witnessed a recent example

of a CNC who became an administrator and was told by clinician friends that the Director

of Nursing had told clinicians not to talk to her. (James 2006)

The criticism of ex-clinicians as administrators is seen academically as having some

merit. Clinicians are trained to make autonomous decisions, to have ‘a reactive

approach to decision-making’, and an individual focus on each patient. Good leaders

tend to build consensus for decisions, think proactively, anticipate problems and

maintain focus on the broader institution or health system. (McAlearney, Fisher, Heiser,

Robbins and Kelleher, 2005, p12) Clinicians are often promoted to management on the

basis of their clinical excellence, not managerial skills. Doctors do have some

experience in building team consensus and team decision making in their roles as team

leaders, but a study of nurse managers found a strong preference for following rules and

a rejection of committee-based decision making. (Degeling et al, 1998, p42-43)

The division into subgroups within the broader culture facilitates sense-making for staff.

(Pepper, 1995, p31; Schein, 1993, p40-41) Replicated approximately across most

hospital settings, newcomers know their role, their required behaviour, their identity in

relation to the patients and other clinicians. As staff clock on at work they assume their

‘clinician’ role, adopt the required attitudes and behaviours, use the appropriate clinical

language to communicate in the ward setting, (Schein, 1993, p40-41) and adopt the

organisational goals.

Paradigms and Paradigm Change

Clinicians are trained in either a reactive medical model (symptom response, cause-

effect), or a psycho-social paradigm (social and psychological context for illness). Peer

Workers represent another paradigm, known as Recovery, which considers that people

have the potential to recover from mental illness, even serious mental illness. Most

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challengingly, this paradigm says that people with mental illness maintain their right to

make their own decisions, even if that decision is to refuse treatment, ie: be non-

compliant (with the exception of those on Community Treatment Orders or Detention

Orders). (Glover 2006) Recovery aims thereby to prevent learned helplessness, where

patients become passive and cede control of their lives to external forces, in this case

the medical institution. In this paradigm, treatment is something the consumer can use

to manage symptoms, that the clinician facilitates.

This shift is supported increasingly by Government policy internationally. (Corben and

Rosen quoted in Kings Fund, 2005, p1; Anthony, 2000, p160-161; Solomon, 2004, p392)

Chronic disease self-management (taking responsibility for recovery) is seen as a partial

solution for health system funding crises, as well as a more user-pays responsiveness –

the treatment and service delivery fits around the needs and lives of the consumer

instead of the other way around. (Corben et al, 2005, p1)

Recovery literature is often challenging to clinicians, advocating that consumers

determine goals, consumers are employed at all levels of the system and are integrally

involved in system and service design. (Anthony, 2000, p165). Where the medical model

is an illness model, recovery is a wellness model. (Lunt, 2000, p401) Clinicians are

therefore challenged by hospital culture, their own paradigms and their clinical /

managerial interactions when assessing the reform processes. (Degeling et al, 1998,

p247)

The term ‘Psychiatric Ward’ emphasises a medical model focus. Deriving from the same

base word as psychiatrist, it restates the link to illness as the focus, and to the

psychiatrist as the prime service deliverer. Most other mental health services have

adopted the term ‘mental health’ - a health focus.

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Peer Workers model hope of recovery in a paradigm where the most important person is

the patient. Their power is from their Lived Experience of being a patient, and from their

close relationships with the patients. This “power” can be undermined by clinicians

though, (one consumer told me of the CNC requiring her to search the belongings of a

patient).

Stigma is often listed as one of the most disabling factors in mental illness (Hocking,

2006) and a significant barrier to recovery and resumption of a normal life. (Anthony,

2000, p160) Staff working in institutional settings, where they see only the most unwell

and disabled patients, often exhibit significant stigma about mental illness (Waghorn,

Lloyd, 2005, p26). The experience of consumers is seen to be characterised by

psychosis and delusion – non-experience. (Lunt, 2000, p403) How then can clinicians

value the Lived Experience of the Peer Worker?

Recovery-paradigm, where the patient is the decision-maker, may be difficult for

clinicians to accept as rational (and also erodes their power over the patients – learned

helplessness keeps patients compliant and not troublesome, and affords the clinicians

personal power). The acceptance of consumers as peers may seem unbelievable (or

insulting) to them. Glover (2006) estimates that mental illness amongst clinicians is

approximately 30% as opposed to 20% in the general community and hence the peer

role may be personally threatening. Peer Workers demonstrate to staff that patients

have the potential to recover and it can be independent of the clinician. (Solomon, 2004,

p396)

The importance of having consumers working as Peer Workers to develop the Recovery

orientation in the acute setting is that they are the only ones with the credibility of Lived

Experience of recovery. Non-consumer professionals might understand and subscribe

at consumer’s request name has been with-held from the reference list12

to recovery framework, but they can only know of recovery in an academic or

observational manner. (This is not to say the Lived Experience replaces clinical

knowledge; both have their place and importance.)

Recovery is the consumers’ view of goals. ‘The defining experience of mental illness [is

often] loss of control over one’s own affairs”. (Lunt, 2000, p402) Despite the best

intentions of clinicians, they often overwhelm the consumers’ sense of self and their right

to succeed or fail.

Clinicians often find the idea of allowing people to fail very challenging to their sense of

duty of care, and yet people have an inalienable right to self-determine, make their own

decisions (unless they are detained). Clinicians often feel that decisions, for instance, to

cease medication constitute a threat to the safety of the consumer, although detention

should really only be used if they are imminently suicidal or a danger to others.

Given the coalition of power, the resistance to changes that might threaten their status

and power, and the shared understandings of the staff, this culture change is a huge

burden to place upon the outnumbered Peer Worker. Significant other efforts to address

stigma in mental health staff have failed. Thalhofer (1993) says that intergroup conflict

can be successfully managed providing the coalitions (or subgroups) have separateness

and equal valuation (Daniels, 1997, p279). In this instance there is separation but no

equal valuation.

The health hierarchy is under constant threat, besieged on all sides – the community,

the media, the tight budgets, health administrators, insurance companies and political

masters criticise and shift blame to staff and units. Staff feel defensive against an

outside world that does not understand what is done or why (that many media reports

are incorrect in the basis of their criticisms does not help staff take on board the need for

change). Change is a constant, particularly in mental health, yet for many staff the

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changes dictated by their administrative and political masters does not lessen the level

of external threat or criticism they experience publicly. A limited budget and a litigious

community have shifted the balance of power toward administrators, policy makers,

treasury and insurance companies. (Carroll, Quijada, 2004, pii16) In many areas of

health, change imposed externally is seen as an unequivocal bad thing. (The term

Change Agents, referring to people within work units whose job is to enact change, is

considered a ‘dirty word’ in health.)

Peer Workers have been imposed upon the clinical team by administrators. In the

instance of Ward G, it was on the basis of an academic theory being investigated and

promoted by a university unit closely associated with the hospital. Although evidence

based medicine (scientifically tested medical guidelines) is an important paradigm in

health, and the university does fund a psychiatrist 0.6FTE in the ward, the direct

intervention of the university with the support of Administration in the working of the ward

and the clinical team has not been welcomed.

Peer Workers (Change Agents by another name)

Peer Workers, whose qualification is their lived experience with mental illness, have

been introduced into the established clinical team to both enact their role in regards to

service delivery to patients, and to introduce change in the form of ‘recovery-oriented

service paradigm’ into the health system and its clinicians. While some Peer Workers

report that their roles are supported and validated in their experiences with clinicians

(Nestor, 2006; Carver et al, 2005, p81-83) this is not a universal experience. This

discussion considers some of the reasons for the negative experiences.

Peer Worker roles are designed for “social emotional support….to bring about a desired

social or personal change”, through offering “support, companionship, empathy, sharing

and assistance” (Gartner & Reissman, 1982, quoted in Solomon, 2004 p93), to counter

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“feelings of loneliness, rejection, discrimination and frustration” (Stroul, 1993, p53,

quoted in Solomon, 2004, p393) often experienced in severe mental illness.

Psychosocial processes underlying Peer Worker roles include : “social support,

experiential knowledge, helper-therapy principle, social learning theory and social

comparison theory”. (Solomon, 2004, p394) Peer Worker roles on the ward include:

Run education and support groups

Talk to inpatients one-on-one about their current mental health issues

Encourage patients to participate in treatment (interesting language in light of the

recovery framework)

Talk about their own personal strategies to stay well and avoid relapse

Talk about how they have dealt with medication side-effects (Lawn et al, 2006, p9)

These roles, and particularly the last two aspects, can be seen as a much more

personally revealing service than is the norm for clinicians. While clinicians maintain a

professional distance and tend not to reveal anything about their personal lives or

struggles, the Peer Workers’ role dictates that they disclose personal information about

their illness, their challenges and strategies. This makes them vulnerable to both the

patients and clinicians, and lessens their power in relation to clinicians (because they

know nothing about the clinician but the clinician knows about their personal life). It also

requires the Peer Worker to dwell on their illness, and crises, a focus that may not be

conducive to ongoing wellness.

Peer Workers come in at the bottom of the hierarchy by virtue of their lack of

qualifications. Their past or present illness puts them on a par with patients. (Patients

may have previous qualifications but by the nature of their mental illness they forfeit this

status when they enter the hospital system.)

The imbalance of power is recognised by the Peer Workers:

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“You don’t have any particular power to ask people to do anything or get people to

do anything.”

“There’s a big tower block that is the service provider…and we are the shed at the

back.” (Carver, Morrison, 2005, p81)

and the ambiguity implicit in being funded to be an advocate

“they fund us to be independent”. (Carver et al, 2005, p81)

Peer Workers internationally report some common negative experiences that

demonstrate how clinicians view them in the clinical setting:

One Peer Worker stated that despite being a qualified social worker, she would have

medication put in her pigeonhole at work (particularly if she had disagreed with a

clinician). (Glover 2006)

Being asked when they last saw their psychiatrist or took their medication

Being asked to perform menial tasks outside their defined role

Being patronised

Being accused of being manipulated by patients

Having their credibility questioned (publicly and privately)

These tactics undermine the credibility (and potentially morale) of the worker, and if

done publicly can reinforce the hierarchy. Being humiliated and having their role

invalidated in front of patients they are working with does not contribute to the

effectiveness of the Peer Worker role.

The instigation of Peer Worker roles in clinical settings has come largely through the

consumer network lobbying health administration, and is often viewed by the clinicians

as tokenistic (Lawn, Hofhuis, 2002, p5). The addition of Peer Workers to the clinical

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team is driven by Administration, and seen as the Administrative subculture enforcing its

supremacy, and interfering in the clinicians' realm.

Peer Workers themselves may be unclear where they sit with the clinical team. One

current proposal suggests that the Peer Workers attend clinical hand-overs but not

Clinical Meetings. (Dawes 2006) While clinicians often socialise together, Peer Workers

sometimes find this inappropriate in their role as patient advocate, which seems to

indicate that they feel their role is in some way potentially advocating ‘against’ the staff.

(Carver et al, 2005 p 82) Peer Workers report feeling unable to contribute to clinical

discussions because they are outnumbered by clinicians who are of high status, speak

authoritatively, and use insider knowledge of language, jargon, procedures and

professional relationships. (Lawn et al, 2006, p5)

One particular issue that clinicians have with Peer Workers is what happens if they

become unwell. To circumvent this, Peer Workers enter into an Ulysses Agreement,

where they record their ‘warning symptoms’ and treatment decisions should they

become unwell, empowering a third party to act on their behalf and inform them if they

do not themselves recognise the symptoms. (Most Peer Workers would be sufficiently

recovered to have insight into their own symptoms.) This facilitates some acceptance of

Peer Workers and the information should be confidential (held by the CNC), however it

is a different standard than is applied to other staff who may also have potentially

performance affecting illnesses. All staff would know that there was an Ulysses

Agreement in place, which could be open to manipulation.

Clinicians may also feel the Peer Worker role erodes their relationship with patients.

Nurses often feel it is their role to act as the patients’ advocate and most clinicians feel

they have the patients’ best interests at heart. (Carver et al, 2005, p82) Advocating on

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behalf of a patient may be the only opportunity a clinician has of challenging those

higher up the hierarchy (subversion under the cloak of a legitimate role).

The job title ‘Peer Worker’ (an artefact) defines their position on the hierarchy. They are

peers with the patients, not the other service providers. Patients are at the bottom of the

hierarchy, and psychiatric patients even more so, as unlike other patients, they can have

their rights removed at any time through detention. In Ward G, a security guard stands

inside the ward near the entrance, further underlining the powerlessness of patients and

a constant reminder that they are viewed as potentially dangerous. The term Peer

Worker on their resume also identifies them as mental health consumers in any

subsequent job applications, essentially removing from them the right to withhold or

disclose their health status that all other job applicants have.

Inasmuch as the Peer Workers are the people who have the closest bond with the

patients, and are put in position to reorient the service to a more client-oriented

paradigm, the Peer Workers have the ‘high moral ground’. This perception of legitimacy

(Mechanic, 1962, pp 349-350) coupled with commitment and willingness to use power,

could explain why a Peer Worker would feel enabled to exercise their personal power

against the established hierarchy and those higher in the order. (The Peer Workers role

can be seen as to be subversive to the dominant culture and change it from the inside –

a big thing to ask of people who are coming in at the bottom of the hierarchy. Peer

Workers recognise their defined role to change opinions and organisational culture but

see themselves as outside the hierarchy rather than at the bottom of it.) (Lawn et al,

2006, p)

While all clinicians to an extent model wellness and ‘normal’ behaviour to their patients,

for the Peer Worker it is a defined part of their role. Unlike other clinicians, the Peer

Workers role is ‘to be’ as well as ‘to do’. The Peer Worker can expect to be being

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watched (and potentially criticised) every moment that they are on the job and possibly

outside.

The experience of Peer Workers parallels affirmative action experiences, where

minorities employed under schemes to encourage fairer representation in the workplace

find that they are subject to additional stigma because they are perceived as not having

won their role on a level playing field. Daniels et al note that in order for the workers to

be successfully integrated into workplaces, those who have power must be willing to

share it. (1997, p241) If they perceive that the newcomer is not ‘worthy’ in their terms (in

this case university qualifications), then why would they be willing to share power –

potentially reducing their own power?

The Incident

Opinion of the incident varies according to the category of worker, demonstrating the

different belief systems at work in the subcultures. (Schein 1993, p40-41) Non-clinical

administrators interviewed felt that the purpose of the Guardianship Board hearing is to

get to the truth (like a coroner’s court) and that there shouldn’t be ‘sides’. Clinicians

(nurses) expressed the opinion that the Peer Worker should not have contradicted the

psychiatrist and had it been a clinician, there would have been disciplinary action. That

this did not result for the Peer Worker may be in recognition of the fact that advocacy is

in the Peer Worker’s Job Description. (SAHS 2005)

Many Peer Workers come from a broader organisational advocacy role as part of

Consumer Advocacy Groups. Advocacy can include a range of behaviours from whistle-

blowers to passing on information at the request of the patient. Glover (2006) argues

that Peer Worker job description should not include the term advocacy because it

a non-statistically viable sample of five non-clinical administrators and three mental health nurse administrators based in the Service Improvement Branch of the CNAHS Mental Health Directorate were polled for this opinion. The non-clinical administrators had no direct experience of Guardianship Board procedures.

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potentially means advocating against the employer organisation, and the clinical team

(workmates) an untenable situation for an employee to be placed. Nurses in particular

are aware of the risks of hospital rules and power relations being questioned and are

risk-averse. (Degeling et al, 1998, p233) Their strength of their reaction as the

omnipresent part of the Clinical Team to the perceived rule-flouting by the Peer Worker

should be considered in this context.

Peer Workers work part time in the ward. There are usually two Peer Workers working

at a time, which has provided an informal buddy system. The Peer Workers do not have

an allocated retreat area and hence tend use the lunch-room, a public space, for

debriefing. At the time of the incident there was no formal support system for peers for

supervision, debrief or skill development, (Lawn et al, 2006, p5) although the emotional

strain of repeatedly exposing one’s story and dealing with people in crisis is recognised.

(Carver et al, 2005, p80) (It is believed that following this incident some formal debrief

and supervision chain has been instituted, as well a crisis counselling and mediation for

the whole team including Peer Workers.)

Unfortunately the Peer Worker’s role in relation to the clinical team is ambiguous.

(Daniels et al, 1997, p270) The Peer Worker does not currently report to the CNC or

anyone in the team, as other team members do, which would seem to indicate they are

not part of the team. Should they be attending clinical meetings – a key rite in the ward?

The answer to this is not specifically defined, making it easy for the team to decide the

answer is no. This decision, whether conscious or not, underlies the original problem

whereby the psychiatrist was (presumably) not aware of the information the Peer Worker

knew about the patient, or the Peer Worker was not aware that the psychiatrist did know

the information and had taken it on board in reaching the decision presented to the

Guardianship Board. (NB: it is not known whether in fact it was the Peer Worker’s input

that changed the outcome of the detention order. The value of the Peer Worker’s input 20

cannot be assessed as the content is confidential. Personal experience does not

necessarily give one expertise.)

The aftermath of this misunderstanding the Clinicians, using their joint social and

authoritative power and their shared understanding of the situation as a challenge to

their authority, enacted their coalition of power to ostracise (punish) the Peer Worker.

Using Bormann’s fantasy theme analysis (Daniels, Spiker, Papa, 1997, p212-213), the

Peer Worker has been cast in the role of villain who had subverted the Guardianship

Board process, confounded the Clinical Team in their decision of what was right for the

patient, embarrassing not only the psychiatrist but the whole clinical team, potentially

endangered the patient and making more work for the psychiatrist who now has to go

back for another hearing in one month. The very thing that bound the team together,

their expert power, was undermined. While from the Peer Worker’s perspective, this

incident might be seen as validating the importance of the Peer Worker’s input to clinical

decision making, from the clinicians’ perspective it was disputing their expertise, the

basis of their status and power. (Daniels et al 1997, p264) Under these terms, the

punishment of ostracism is just and appropriate and may potentially solve the ‘problem’

(albeit by driving the Peer Worker away or making them unwell). While these goals

seem strange for a Clinical Team dedicated to helping those with mental illness, it

perhaps demonstrates that this ‘help’ is only on their own terms.

Core Issues and Recommendations

When considering future Peer Worker roles, a number of lessons from this incident

should be considered:

Peer Worker job description should not include advocacy or should specifically

define it in terms of assisting the patient to access the health system

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Peer Worker job title should be reconsidered to eliminate the term ‘peer’ and provide

a non-disclosing title for those who want to go on to other non-consumer jobs.

The role of the Peer Worker as part of the Clinical Team needs to be specifically

stated. It should include participation in clinical team meetings and hand-overs.

Support systems such as debriefs should be instituted in recognition that working in

mental health can be stressful and taxing, and that the Peer Worker role in particular

demands a lot from incumbents. Private space needs to be allocated for this.

Reporting structures need to be specified and should be as for other clinical team

members.

Education for the Clinicians as to the role of the Peer Worker, the types of work they

will do and how they will work alongside and with them should be started before the

Peer Workers begin.

Support for ongoing education should be available for peer Workers as other

clinicians. This should include joint education with their clinical team workmates.

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