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

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An examination of some of the issues accompanying the introduction of a peer worker program to acute mental health facilities. What works, what doesn't, where are the problems and barriers and who ...

An examination of some of the issues accompanying the introduction of a peer worker program to acute mental health facilities. What works, what doesn't, where are the problems and barriers and who are the drivers of change.

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

  • Organisational Culture and Communication: The introduction of Peer Workers to Psychiatric WardsTerminology: The term Peer Workers in this paper refers to mental health consumerswho are employed in the role Peer Worker. Consumers currently admitted to the wardwill be referred to as patients. The term consumers will refer more generically to anymental health consumer.IntroductionSince the 1960s there has increasingly been a consumer-rights movement in mentalhealth evidenced in a number of ways. Most recently the client-centred service, chronicdisease management and recovery-oriented frameworks have emphasised amongstother aspects, the use of Peer Workers in the care of consumers.Peer Workers are mental health consumers who have recovered or are stable, haveexperience in the mental health system, and are trained to provide support andadvocacy for other consumers during their illness and within the health system. A recentincident highlighted some of the issues about the role of the Peer Workers and theirrelationships with other members of the clinical team.Peer Workers have been employed in an acute psychiatric ward in a major teachinghospital in Adelaide for over a year.Ψ Recently, a detained patient from the acutepsychiatric ward asked a Peer Worker to accompany her when she went to theGuardianship Board for a review of her detention. At the hearing, after the treatingpsychiatrist made his submission and recommendations, the judge asked the PeerWorker her opinions. The Peer Worker told the consumers story, which explained some Identification of the wards and persons involved has been masked. 1
  • of the behaviour the psychiatrist had raised as being of concern. As a result thedetention was renewed for one month instead of the six months that the psychiatrist hadrequested. Upon returning to the ward, the clinical team reportedly ostracised the PeerWorker.This incident (which will be referred to as ‘the incident’ in this document) is the basis ofthe 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, theirrelationship with other clinical team members, whether they are considered part of theclinical team, and their role. It has significant relevance as other organisations arecurrently being funded to train Peer Workers for employment primarily as part of culturechange in the health system but perhaps also in other areas such as the legal system.Theoretical FrameworkThis incident and its wider implications will be considered primarily through a critical-interpretative analysis, with particular emphasis on health system subcultures asevidenced in a high-dependency psychiatric ward.Organisational culture is “shared key values and beliefs” that conveys a sense of identityto participants, facilitates the commitment to the shared goals, enhances social stabilityand directs sense-making. (Smircich, 1983, p345-346) It is a deep phenomenon of basicassumptions 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 atuniversity and developed on the job, in daily procedures and intense, sometimes crisissituations. In the hospital setting the shared culture binds disparate professions together 2
  • into a team, validating their roles and self-images while uniting them to achieve theorganisation goals of delivering healthcare as it is defined within the culture. Theintroduction of a new role, Peer Workers, with ambiguous status to the establishedculture not only threatens the shared beliefs and values, but also threatens socialstability. Established sense-making fails as this role directly challenges the assigned rolethe person would normally take – patient. The Peer Worker also challenges the definedgoals of the organisation because they represent that recovery is a journey theconsumer takes, not something that is ‘done’ to them by the clinical team.From a systems framework perspective, organisational culture is seen as an internalvariable which encompasses goals, administration, socio-cultural system, productionsystem and technology / structure, and provides a normative and symbolic framework forparticipants and onlookers. A strong culture in this context can be used to “rationalizeand legitimate activity” (Smircich, 1983, 344-345) such as the way the clinical team couldrationalise ostracising the Peer Worker who had defied the established norms.Organisation culture will form around any relatively stable work unit where there areshared stresses and experiences. (Schein, 1993, p47-49) The medical culture is stronglyand historically based on an hierarchical structure. From a socio-cultural perspective anexamination of decision making, power and conflict resolution within this hierarchicalculture gives perspective to the incident described. In particular French and Ravensnotions about expert power as the basis for imposing power over decision making asineffective and Mintzbergs notion of coalition of power (Mintzberg, 1983, pp22-30) isevidenced in the joint action of the multi-disciplinary clinical team.The hierarchical structure and the notions implicit in the status of members is based onthe concept of meritocracy, the valuing of having earned a position in the hierarchythrough university education and experience. (Conrad, 1994, p289-292) The imposition 3
  • of Peer Workers who are qualified by virtue of their experience of illness – usuallyconsidered negatively as a defining feature of the "patient / consumer / client" to whomhealthcare is ‘done’ – threatens the basis of status, prestige and power invested inclinical team members.Psychiatric wards have their own culture within the context of the broader hospitalculture. Within the ward culture there are a number of subcultures includingoccupational cultures, speciality subcultures as well as other externally influencedcultures such as ethnicity and gender, and cultures based around specific leadership.(Carroll, Quijada, 2004, pii17) These subcultures are the basis for sharedunderstandings, organising the clinicians into identifiable subgroups, building identityand managing intra-organisational relationships. (Pepper,1995, p31; Schein 1993,p47-49) The clinical subcultures share some assumptions, underlying values andmotives, and contribute to the overall hierarchy, defining how clinicians work and relatewith 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 theimposition of outsiders who do not share the paradigm. (Pepper, 1995, p30) In fact, thePeer Workers are part of a management effort to change the culture and paradigm of thepsychiatric services, but their role seems not to have been supported by any explanationor protocols to existing clinical team members, or any clear definitions about their statusin 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 subversivesubculture. The incident may be an early instance of this.The medical culture has its own entrenched artefacts, primarily language, but alsouniforms, equipment and ‘office’ space allocated to various levels of the hierarchy. 4
  • Language is used to establish authority and exclude ‘non-speakers’. (Schein, 1993,p47-49) As well as medical terminology there are TLAs (three-letter acronyms) andtraditionally some unethical acronyms used for passing on coded messages regardingpatients without their knowledge.* (The latter has supposedly been eliminated but mostclinicians still know the acronyms). Some common terms betray paternalistic attitudes –compliant / noncompliant to denote if the patient is following the clinical treatmentregime. The existence of the unethical acronyms and ‘gallows humour’ binds theclinicians together by creating a bond of understanding and stress relief, and establisheswhere 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 theclinical team seem to indicate that their expectation was that this person would interactonly with the "patient / consumer / client" in a form of tokenism – a supernumerarypatient. Using Smircich’s cultural analysis to question the assumptions, the title PeerWorker clearly defines where this position fits in the hierarchy – as a peer to patients, notto 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 GuardianshipBoard is presented as consensus or at least majority rule. However given thehierarchical nature of the team, ‘lower’ members opinions would be less weighted thanmore senior members. The clinical team is also dominated by one or more powerfulpositions, that of the psychiatrist/s. A comparison of the clinician beliefs in hospital* FITH syndrome – fucked in the head, FUBAR – fucked up beyond all repair, GOMER – get out of myemergency room, PFO - pissed and fell over, etc. 5
  • settings found that while nurses were very aware of their subordination and comparativestatus 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 theclinical 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 inlight of Bormanns Symbolic Convergence theory (fantasy theme analysis). Thisdescribes how shared beliefs and values can be mobilised to cast meaning around anevent, creating clear functional identities with simplistic meanings (good v bad) andrationalises the behaviour of fellow-team members against the ‘intruder’. (Daniels et al1997, pp212-213) Such a story once reinforced, confirmed and built upon by teammembers, can be very difficult to overcome. These fantasy-themes touch deepunderstandings (Jung’s archetypes?) and establish thought parameters that guide teammembers in how to think about the event.Hospital CultureMedical culture offers significant benefits to participants: high prestige, control overothers (particularly in mental health), a sense of professionalism and privilegedinformation under rules of confidentiality. (Carroll et al, 2004, pii18)Psychiatric wards receive services from a variety of clinicians: psychiatrists, psychiatricregistrars, general doctors including interns, nursing staff (mental health nurses, ENs,RNs and agency nurses). Allied health staff include psychologists, social workers, andoccupational therapists. Nursing staff and allied health staff answer to the Clinical NurseConsultant (CNC) as team leader. Hospital wards operate 24/7, with nurses rostered atall times. Therapeutic services from other clinicians generally occur in the daytime onweekdays1.1 Knowledge of the clinical setting is from personal experience through my work in the CNAHS MentalHealth directorate and through conversations with staff, clinicians, program managers and doctors over 6
  • The hospital hierarchy is rigidly enforced through job descriptions defining lines ofresponsibility, privileges, and decision hierarchies. It is reinforced daily through clinicalteam meetings and clinical hand-overs between shifts. The psychiatrists are legallyresponsible for treatment decisions and are the only staff able to prescribe drugs, forwhich they write up orders that other staff must follow. As treatment is the core businessof the ward, psychiatrists are at the top of the hierarchy and enjoy considerableprivileges. A full-time employed psychiatrist is allowed to do up to 0.2FTE of privatepractice within their paid public work time, which can be conducted at the hospital, usingpublic facilities including their offices and personal assistants. Psychiatrists wear casualclothes; doctors wear white coats (junior doctors usually wear a stethoscope) and ‘lower’clinicians wear uniforms. Psychiatrists generally spend the least time on the ward andself-manage their time; allied health clinicians work between several wards and work 9-5jobs; and nurses work shift work spending all their time on the ward. Doctors have thecourtesy title Dr, but most other clinicians do not have a specific title. Mental healthnurses have undergone additional training, making them specialists amongst the nursingcorps. While psychiatric nursing might be very stressful and occasionally dangerous, itprobably has the least contact with bodily fluids, intimate body contact and the moremenial aspects of general nursing which may accord it more prestige.The clinical team is arranged in an hierarchy according to qualifications, job classificationand seniority. University qualifications equate a presumption of knowledge and skill,French and Raven’s ‘expert power’ (Daniel, Spiker, Papa, 1997, p250), establishes theirstatus in the hierarchy through their job classification and is roughly organised in termsof the number of years of education required to qualify. This provides a seeminglyobjective basis to the hierarchy, a meritocracy that is hard to counter. (Conrad, 1994,p289-292) This meritocracy supports the evidence-based medicine paradigm and ismany years. 7
  • enacted as the power of veto or the final word in any disagreement. Other opinions, andparticularly the patients’, are devalued and the expert’s opinion automatically becomesimbued with additional value, irrespective of any objective analysis. Expert power isshared in a graded scale along the hierarchy with the psychiatrists having the mostexpert power and a strong emphasis on autonomous decision making. (Carroll et al2004 pii18, Degeling et al, 2005, p65) There is a level of French and Raven’s ‘legitimatepower’ (Daniels et al 1997, p252) based primarily with the CNC and psychiatrists. This isbased on a group norm underlined by defined roles in job descriptions which sitedecision making power and legal responsibility with these parties. The cliniciansthemselves 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 hierarchicalsubgroups.The clinicians form a formidable coalition of power (Mintzberg, 1983, p22-30) whichsupports them their prestige and power. Their status allows them access to patientrecords which contain personal information about the patient and establishes a powergradient (professional distance requires the professional not to disclose personalinformation about themselves). They have control over the activities of the patient, mostobviously through detention orders and Community Treatment Orders upon discharge.Each of the clinical subgroups has a level of autonomy. While the psychiatrist isultimately responsible for the patient’s treatment, nurses control how they enacttreatment, and have a level of autonomous responsibility for the patients’ 24 hour care.Allied Health Workers make autonomous decisions regarding the therapies that they useto achieve the defined goal. While this autonomy in context is a cultural strength and iscertainly part of the prestige, status and personal power invested in clinicians, it is also abarrier to change – people oppose changes that threaten their personal status andpower. (Schein quoted in Carroll et al 2004, pii18) 8
  • The other largely invisible subgroup working on the ward and definitely not part of theclinical team is the services staff: cleaners, catering service and orderlies. These peopleare largely ignored by the clinicians (James, 2006) and yet their interactions withpatients are probably the most normal. While clinicians are aware of the potential fortherapeutic effect in everything they say and do, and are constantly observant foranything that needs to be reported or recorded on the patient’s condition, the benefit ofhaving a conversation with people who do not have an ulterior motive could be verynormalising. 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 theposition of the Peer Workers, whose interactions with clients are more normal.Another powerful subgroup is administration. The divide between clinicians andadministrators is marked - clinicians generally consider administrators do not understandthe clinical setting. Amongst the administrators, the ex-clinician administrators feel thatnon-clinician administrators do not have enough practical knowledge of the ways clinicalsetting (Degeling et al, 1998, p129) and non-clinician administrators feel the ex-clinicianadministrators don’t have the management skills needed. (As a non-clinicianadministrator, the author feels that they are both partly right.)Underlying the culture clash is that administrators and clinicians speak differentlanguages and come from different paradigms. (Schein, 1993, p47) Administrators“value financial realism in clinical decision-making” (Degeling et al, 1998, p105) whereasclinicians come from a paradigm where treatment of the patient is paramount. Balancingtreatment 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 valueassumptions....[inform the] medical, nursing and managerial conceptions of what [is]primary in the [hospital] organisation”. (1998, p247) Even clinicians who becomeadministrators are viewed with suspicion, although there is less suspicion about ex- 9
  • clinician administrators from the clinical teams. The author witnessed a recent exampleof a CNC who became an administrator and was told by clinician friends that the Directorof Nursing had told clinicians not to talk to her. (James 2006)The criticism of ex-clinicians as administrators is seen academically as having somemerit. Clinicians are trained to make autonomous decisions, to have ‘a reactiveapproach to decision-making’, and an individual focus on each patient. Good leaderstend to build consensus for decisions, think proactively, anticipate problems andmaintain focus on the broader institution or health system. (McAlearney, Fisher, Heiser,Robbins and Kelleher, 2005, p12) Clinicians are often promoted to management on thebasis of their clinical excellence, not managerial skills. Doctors do have someexperience in building team consensus and team decision making in their roles as teamleaders, but a study of nurse managers found a strong preference for following rules anda 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 mosthospital settings, newcomers know their role, their required behaviour, their identity inrelation 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 clinicallanguage to communicate in the ward setting, (Schein, 1993, p40-41) and adopt theorganisational goals.Paradigms and Paradigm ChangeClinicians are trained in either a reactive medical model (symptom response, cause-effect), or a psycho-social paradigm (social and psychological context for illness). PeerWorkers represent another paradigm, known as Recovery, which considers that peoplehave the potential to recover from mental illness, even serious mental illness. Most 10
  • challengingly, this paradigm says that people with mental illness maintain their right tomake 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 DetentionOrders). (Glover 2006) Recovery aims thereby to prevent learned helplessness, wherepatients become passive and cede control of their lives to external forces, in this casethe medical institution. In this paradigm, treatment is something the consumer can useto manage symptoms, that the clinician facilitates.This shift is supported increasingly by Government policy internationally. (Corben andRosen 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 partialsolution 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 consumerinstead of the other way around. (Corben et al, 2005, p1)Recovery literature is often challenging to clinicians, advocating that consumersdetermine goals, consumers are employed at all levels of the system and are integrallyinvolved in system and service design. (Anthony, 2000, p165). Where the medical modelis an illness model, recovery is a wellness model. (Lunt, 2000, p401) Clinicians aretherefore 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 samebase word as psychiatrist, it restates the link to illness as the focus, and to thepsychiatrist as the prime service deliverer. Most other mental health services haveadopted the term ‘mental health’ - a health focus. 11
  • Peer Workers model hope of recovery in a paradigm where the most important person isthe patient. Their power is from their Lived Experience of being a patient, and from theirclose relationships with the patients. This “power” can be undermined by cliniciansthough, (one consumer told me of the CNC requiring her to search the belongings of apatient).ℵStigma 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 unwelland disabled patients, often exhibit significant stigma about mental illness (Waghorn,Lloyd, 2005, p26). The experience of consumers is seen to be characterised bypsychosis and delusion – non-experience. (Lunt, 2000, p403) How then can cliniciansvalue the Lived Experience of the Peer Worker?Recovery-paradigm, where the patient is the decision-maker, may be difficult forclinicians to accept as rational (and also erodes their power over the patients – learnedhelplessness keeps patients compliant and not troublesome, and affords the clinicianspersonal power). The acceptance of consumers as peers may seem unbelievable (orinsulting) to them. Glover (2006) estimates that mental illness amongst clinicians isapproximately 30% as opposed to 20% in the general community and hence the peerrole may be personally threatening. Peer Workers demonstrate to staff that patientshave 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 Recoveryorientation in the acute setting is that they are the only ones with the credibility of LivedExperience of recovery. Non-consumer professionals might understand and subscribe at consumer’s request name has been with-held from the reference list 12
  • to recovery framework, but they can only know of recovery in an academic orobservational manner. (This is not to say the Lived Experience replaces clinicalknowledge; both have their place and importance.)Recovery is the consumers’ view of goals. ‘The defining experience of mental illness [isoften] loss of control over one’s own affairs”. (Lunt, 2000, p402) Despite the bestintentions of clinicians, they often overwhelm the consumers’ sense of self and their rightto succeed or fail.Clinicians often find the idea of allowing people to fail very challenging to their sense ofduty of care, and yet people have an inalienable right to self-determine, make their owndecisions (unless they are detained). Clinicians often feel that decisions, for instance, tocease medication constitute a threat to the safety of the consumer, although detentionshould 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 statusand power, and the shared understandings of the staff, this culture change is a hugeburden to place upon the outnumbered Peer Worker. Significant other efforts to addressstigma in mental health staff have failed. Thalhofer (1993) says that intergroup conflictcan be successfully managed providing the coalitions (or subgroups) have separatenessand equal valuation (Daniels, 1997, p279). In this instance there is separation but noequal valuation.The health hierarchy is under constant threat, besieged on all sides – the community,the media, the tight budgets, health administrators, insurance companies and politicalmasters criticise and shift blame to staff and units. Staff feel defensive against anoutside world that does not understand what is done or why (that many media reportsare incorrect in the basis of their criticisms does not help staff take on board the need forchange). Change is a constant, particularly in mental health, yet for many staff the 13
  • changes dictated by their administrative and political masters does not lessen the levelof external threat or criticism they experience publicly. A limited budget and a litigiouscommunity have shifted the balance of power toward administrators, policy makers,treasury and insurance companies. (Carroll, Quijada, 2004, pii16) In many areas ofhealth, change imposed externally is seen as an unequivocal bad thing. (The termChange Agents, referring to people within work units whose job is to enact change, isconsidered a ‘dirty word’ in health.)Peer Workers have been imposed upon the clinical team by administrators. In theinstance of Ward G, it was on the basis of an academic theory being investigated andpromoted by a university unit closely associated with the hospital. Although evidencebased medicine (scientifically tested medical guidelines) is an important paradigm inhealth, and the university does fund a psychiatrist 0.6FTE in the ward, the directintervention of the university with the support of Administration in the working of the wardand 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, havebeen introduced into the established clinical team to both enact their role in regards toservice delivery to patients, and to introduce change in the form of ‘recovery-orientedservice paradigm’ into the health system and its clinicians. While some Peer Workersreport 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. Thisdiscussion considers some of the reasons for the negative experiences.Peer Worker roles are designed for “social emotional support….to bring about a desiredsocial or personal change”, through offering “support, companionship, empathy, sharingand assistance” (Gartner & Reissman, 1982, quoted in Solomon, 2004 p93), to counter 14
  • “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 socialcomparison 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 morepersonally revealing service than is the norm for clinicians. While clinicians maintain aprofessional distance and tend not to reveal anything about their personal lives orstruggles, the Peer Workers’ role dictates that they disclose personal information abouttheir illness, their challenges and strategies. This makes them vulnerable to both thepatients and clinicians, and lessens their power in relation to clinicians (because theyknow nothing about the clinician but the clinician knows about their personal life). It alsorequires the Peer Worker to dwell on their illness, and crises, a focus that may not beconducive to ongoing wellness.Peer Workers come in at the bottom of the hierarchy by virtue of their lack ofqualifications. Their past or present illness puts them on a par with patients. (Patientsmay have previous qualifications but by the nature of their mental illness they forfeit thisstatus when they enter the hospital system.) 15
  • The imbalance of power is recognised by the Peer Workers:• “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 thatdemonstrate 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 ifdone publicly can reinforce the hierarchy. Being humiliated and having their roleinvalidated in front of patients they are working with does not contribute to theeffectiveness of the Peer Worker role.The instigation of Peer Worker roles in clinical settings has come largely through theconsumer network lobbying health administration, and is often viewed by the cliniciansas tokenistic (Lawn, Hofhuis, 2002, p5). The addition of Peer Workers to the clinical 16
  • team is driven by Administration, and seen as the Administrative subculture enforcing itssupremacy, and interfering in the clinicians realm.Peer Workers themselves may be unclear where they sit with the clinical team. Onecurrent proposal suggests that the Peer Workers attend clinical hand-overs but notClinical Meetings. (Dawes 2006) While clinicians often socialise together, Peer Workerssometimes find this inappropriate in their role as patient advocate, which seems toindicate 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 clinicaldiscussions because they are outnumbered by clinicians who are of high status, speakauthoritatively, and use insider knowledge of language, jargon, procedures andprofessional relationships. (Lawn et al, 2006, p5)One particular issue that clinicians have with Peer Workers is what happens if theybecome unwell. To circumvent this, Peer Workers enter into an Ulysses Agreement,where they record their ‘warning symptoms’ and treatment decisions should theybecome unwell, empowering a third party to act on their behalf and inform them if theydo not themselves recognise the symptoms. (Most Peer Workers would be sufficientlyrecovered to have insight into their own symptoms.) This facilitates some acceptance ofPeer Workers and the information should be confidential (held by the CNC), however itis a different standard than is applied to other staff who may also have potentiallyperformance affecting illnesses. All staff would know that there was an UlyssesAgreement 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 feelthey have the patients’ best interests at heart. (Carver et al, 2005, p82) Advocating on 17
  • behalf of a patient may be the only opportunity a clinician has of challenging thosehigher 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 arepeers with the patients, not the other service providers. Patients are at the bottom of thehierarchy, and psychiatric patients even more so, as unlike other patients, they can havetheir rights removed at any time through detention. In Ward G, a security guard standsinside the ward near the entrance, further underlining the powerlessness of patients anda constant reminder that they are viewed as potentially dangerous. The term PeerWorker on their resume also identifies them as mental health consumers in anysubsequent job applications, essentially removing from them the right to withhold ordisclose their health status that all other job applicants have.Inasmuch as the Peer Workers are the people who have the closest bond with thepatients, and are put in position to reorient the service to a more client-orientedparadigm, 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 poweragainst the established hierarchy and those higher in the order. (The Peer Workers rolecan 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. PeerWorkers recognise their defined role to change opinions and organisational culture butsee 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 PeerWorkers role is ‘to be’ as well as ‘to do’. The Peer Worker can expect to be being 18
  • watched (and potentially criticised) every moment that they are on the job and possiblyoutside.The experience of Peer Workers parallels affirmative action experiences, whereminorities employed under schemes to encourage fairer representation in the workplacefind that they are subject to additional stigma because they are perceived as not havingwon their role on a level playing field. Daniels et al note that in order for the workers tobe successfully integrated into workplaces, those who have power must be willing toshare it. (1997, p241) If they perceive that the newcomer is not ‘worthy’ in their terms (inthis case university qualifications), then why would they be willing to share power –potentially reducing their own power?The IncidentOpinion of the incident varies according to the category of worker, demonstrating thedifferent belief systems at work in the subcultures. (Schein 1993, p40-41) Non-clinicaladministratorsξ interviewed felt that the purpose of the Guardianship Board hearing is toget 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 thepsychiatrist and had it been a clinician, there would have been disciplinary action. Thatthis did not result for the Peer Worker may be in recognition of the fact that advocacy isin the Peer Worker’s Job Description. (SAHS 2005)Many Peer Workers come from a broader organisational advocacy role as part ofConsumer Advocacy Groups. Advocacy can include a range of behaviours from whistle-blowers to passing on information at the request of the patient. Glover (2006) arguesthat 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 nurseadministrators based in the Service Improvement Branch of the CNAHS Mental Health Directorate werepolled for this opinion. The non-clinical administrators had no direct experience of Guardianship Boardprocedures. 19
  • potentially means advocating against the employer organisation, and the clinical team(workmates) an untenable situation for an employee to be placed. Nurses in particularare aware of the risks of hospital rules and power relations being questioned and arerisk-averse. (Degeling et al, 1998, p233) Their strength of their reaction as theomnipresent part of the Clinical Team to the perceived rule-flouting by the Peer Workershould be considered in this context.Peer Workers work part time in the ward. There are usually two Peer Workers workingat a time, which has provided an informal buddy system. The Peer Workers do not havean allocated retreat area and hence tend use the lunch-room, a public space, fordebriefing. At the time of the incident there was no formal support system for peers forsupervision, debrief or skill development, (Lawn et al, 2006, p5) although the emotionalstrain 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 debriefand supervision chain has been instituted, as well a crisis counselling and mediation forthe 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 oranyone in the team, as other team members do, which would seem to indicate they arenot 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 theanswer is no. This decision, whether conscious or not, underlies the original problemwhereby the psychiatrist was (presumably) not aware of the information the Peer Workerknew about the patient, or the Peer Worker was not aware that the psychiatrist did knowthe information and had taken it on board in reaching the decision presented to theGuardianship Board. (NB: it is not known whether in fact it was the Peer Worker’s inputthat 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 notnecessarily give one expertise.)The aftermath of this misunderstanding the Clinicians, using their joint social andauthoritative power and their shared understanding of the situation as a challenge totheir authority, enacted their coalition of power to ostracise (punish) the Peer Worker.Using Bormann’s fantasy theme analysis (Daniels, Spiker, Papa, 1997, p212-213), thePeer Worker has been cast in the role of villain who had subverted the GuardianshipBoard process, confounded the Clinical Team in their decision of what was right for thepatient, embarrassing not only the psychiatrist but the whole clinical team, potentiallyendangered the patient and making more work for the psychiatrist who now has to goback 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, thisincident might be seen as validating the importance of the Peer Worker’s input to clinicaldecision making, from the clinicians’ perspective it was disputing their expertise, thebasis of their status and power. (Daniels et al 1997, p264) Under these terms, thepunishment 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 goalsseem strange for a Clinical Team dedicated to helping those with mental illness, itperhaps demonstrates that this ‘help’ is only on their own terms.Core Issues and RecommendationsWhen considering future Peer Worker roles, a number of lessons from this incidentshould 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 21
  • • 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. 22