Peer Specialists and Carer Consultants Working in Acute Mental Health Units: An Initial Evaluation of Consumers, Carers, and Staff Perspectives

The International Journal of Psychosocial Rehabilitation

Peer Specialists and Carer Consultants Working in Acute Mental Health Units: An Initial Evaluation of Consumers, Carers, and Staff Perspectives

Leonard W Kling
B. Psych. (Hons.), M. Psych. (Clin)
Clinical Psychologist, Central Northern Adelaide Mental Health Directorate
83 Currie Street, Adelaide SA 5000.
leokreug@hotmail.com

Fiona J Dawes
B.S.W., Grad Dip Ad. Ed., M. Ed.
Senior Project Officer, Central Northern Adelaide Mental Health Directorate

Paul Nestor
Peer Specialist Coordinator Central Northern Adelaide Mental Health Directorate

Citation:
Kling LW, Dawes FJ, Nestor P (2008). Peer Specialists and Carer Consultants Working in Acute Mental Health Units: An Initial Evaluation
of Consumers, Carers, and Staff Perspectives International Journal of Psychosocial Rehabilitation. 12 (2), 81-95

ACKNOWLEDGEMENTS: The authors would like to extend thanks to all Central Northern Adelaide Health Service consumer, family, and staff participants whose contributions of wisdom and time are appreciated.

Abstract
The purpose of this project was to evaluate the impact of introducing Peer Specialists (PS) and Carer Consultants (CC) as employees in the targeted acute units of CNAHS. A random sample of 30 consumers and 25 carers completed questionnaires as did 58 volunteer pre-existing staff members and 12 newly employed PS and CC. To provide further information, appointed PS and CC mentors also participated in a discussion group. Overall, data indicated that the employment of PS and CC was positively associated with various consumer, carer, organisational, and personal gains. Reported issues are consistent with existing literature and such information is being used to direct future endeavours and positively reorient existing systems.
Keywords: Mental Health, Peer Specialist, Carer Consultant, CNAHS

Introduction
The effective delivery of mental health services continues to evolve and services often experience both structural and cultural shifts. In

Australia

and many other countries, the trend to integrate consumers and carers into the development, implementation, delivery, and evaluation of mental health services is articulated through ongoing policy changes (Australian Health Ministers, 1992, 1998, 2003; Commonwealth of Australia, 1997, National Mental Health Working Group, 1996). Furthermore, it is evident that consumers demonstrate an ongoing desire to have greater representation and involvement in all aspects of mental health service provision (Berger, Carter, Casey. & Litchefield, 1996; Meehan, Bergen, Coveney & Thornton, 2002; Connor 1999).

Minimal research has been conducted in the developing area of consumer and/or carer inclusion on acute units. However, an expanding literature consistently indicates that service provision can be improved with the addition of such, “lived experience” staff. An increasing number of people who experienced or continue to experience episodes of mental illness are successfully working as trained staff (e.g., Peer Specialists) within mental health areas. The unique insight gained through being a former client of mental health services is potentially valuable and associated with numerous positive consumer, organisational, and personal, gains (Lawrence, 2004; McAllistster & Walsh, 2004). Research indicates a positive correlation between involvement with a Peer Specialist and gains in both consumer welfare (Soloman, 2004; Voelker, 1994) and the mental health delivery system (Soloman, 2004).

Additionally, research evidence suggests that carer involvement (e.g., Carer Consultants) in the workforce is beneficial to the consumers they are working with, the employing organisations, and to the individuals themselves. For example, the Mental Health Branch, Victorian Government Department of Human Services reported that the involvement of carers in mental health services contributed to overall improvements in consumer’s treatment adherence, quality of life, social adjustment, family functioning, and periods of wellness (2004).

Although the additional benefits of employing the services of consumers and carers are evident, researchers have also identified particular barriers that impede effective consumer and carer participation. Such barriers include the negative attitudes of pre-existing professional staff members (Gordan 2005; Happell & Roper, 2006. Lammers & Happell, 2004) and insufficient training/support for newly employed consumers and/or carers (Happell & Roper, 2006; Middleton, Stanton, & Renouf, 2004; Roper, 2003). Research evidence also suggests that consumers may lack the unique knowledge and skills set required of mental health care staff (Campbell, 1990; Miller & Katz, 1992; Pyke et al, 1991). However, such a barrier can be overcome with adequate training and studies also reported that the psychological well-being of appropriately trained consumers providing acute services was not adversely impacted (Meehan, Bergen, Coveney, & Thornton, 2002).

Literature continues to explore strategies for overcoming barriers to consumer and carer participation in service delivery and new mental health initiatives continue to expand service provision to include such strategies. In 2006 as a new mental health service innovation, Central Northern Adelaide Health Service (CNAHS) employed Peer Specialists and Carer Consultants into each permanent acute unit within the region (i.e., Cleland and C3 in the East, 1G and Woodleigh House in the North and Cramond Unit in the West) and several state-wide specialist services (e.g., Forensic).

The general purpose of the current report was to evaluate the impact of introducing Peer Specialists and Carer Consultants as employees on the targeted acute units within CNAHS. The specific aims were to evaluate the impact of newly employed Peer Specialists and Carer Consultants on consumers and carers and to gauge any pre- to post-employment perceptual shifts among existing staff and newly employed Peer Specialists and Carer Consultants.

Method
Participants
Participants included consumers and carers, pre-existing staff, newly employed staff, and their mentors. To assure anonymity at time of participation, specific demographic details were not obtained from volunteers.

A random sample of 30 consumers and 25 carers who utilised acute services of the targeted units were invited to complete a questionnaire during telephone contact. Each Peer Specialist and Carer Consultant maintained client contact sheets and members of the research team obtained such records at 6-months post-employment for each new staff member. Thus, consumer and carer participants were drawn from a 2-week time period either side of the respective 6-month post-employment client contact pool. The required pool of participants required for adequate research power was based on in-patient and discharge statistics reported by the Clinical Evaluation Unit and the Clinical Nurse Consultants of each targeted acute unit.

Additionally, prior to the formal introduction of the newly employed Peer Specialists and Carer Consultants, 58 pre-existing staff members working on the targeted acute units volunteered to complete pre-questionnaires. For various reasons (e.g., staff absences, resignations) 46 pre-existing staff members completed post-questionnaires. A broad range of professionals participated from each unit (e.g., Psychiatrists, Nurses, Occupational Therapists, Psychologists, and Social Workers).

After screening and interviewing of applicants, the newly employed Peer Specialists and Carer Consultants attended various training and induction workshops (e.g., 2-day Helen Glover Recovery Workshop, 3-day Orientation to CNAHS Workshop). At the time of writing, such staff were reported to continue with ongoing training and development since being employed (e.g., Certificate 3 in Mental Health: Non-Clinical, additional Helen Glover workshops). Twelve of the new employees completed both pre- and 6-month post-employment questionnaires.

Finally, Peer Specialists and Carer Consultants also had a respective staff mentor appointed by Carers SA and Baptist Community Services (i.e., non-government organisations supporting the current initiative). Both mentors were involved in the process of recruiting, training, and sustaining the newly employed staff. Broadly, both mentors conducted monthly small groups with staff to discuss their experiences, associated feelings and issues. However, they were also available for individual support.

Specifically, the mentor program for Carer Consultants commenced with and sustained a strongly educational approach and provided high levels of information on new resources and programmes available to carers. The initial mentor program for Peer Specialists focused on problem solving and support in a group format however evolved to one-on-one mentoring. At approximately six months post-employment of Peer Specialists and Carer Consultants, the appointed mentors participated in an hour-long discussion focus group coordinated by a member of the research team.

Design
The current project utilised a pre- and post non-experimental design. Information was gathered from consumers, carers, and staff mentors at approximately 6-months post-commencement of duties for Peer Specialists and Carer Consultants.

Pre-existing staff and newly employed Peer Specialists/Carer Consultants completed questionnaires prior to the commencement of the new staff’s ward duties and then again at approximately 6-months post. All relevant ethics committees approved the current project there are no disclosures to be made.

Measures
Consumers and Carers Questionnaire. This purpose designed 14-item, telephone conducted questionnaire was used to ascertain consumers and carers perceptions regarding their experiences with either Peer Specialists or Carer Consultants while utilising the services of their respective acute unit. Distinct forms were used to gather information from consumers (e.g., “How good was the Peer Specialist at increasing your sense of hope for recovery”) and carers (e.g., “How good was the Carer Consultant at reducing your distress by sharing their coping strategies”) where 0 = very poor, 4 = very good. Two open-ended questions invited qualitative data regarding perceived unique contribution of such staff and suggestions for improving such services.

Pre-existing Staff Questionnaire. This purpose designed 20-item, self-report measure was used to gauge participant’s perceptions regarding the introduction of Peer Specialists and Carer Consultants as employees of acute units within CNAHS. Two forms of this questionnaire were used prior to induction (e.g., “Peer Specialists will foster hope for recovery in consumers”) and again at approximately 6-months post-induction (e.g., “Peer Specialists foster hope for recovery in consumers”.) where 1 = totally disagree, 10 = totally agree. Four open-ended questions invited qualitative data regarding perceived benefits, difficulties, potential resolutions, and additional comments.

Newly Employed Peer Specialists and Carer Consultants Questionnaire This purpose designed 18-item, self-report measure was used to gauge participant’s perceptions regarding the introduction of Peer Specialists and Carer Consultants as employees within acute units. Two forms of this questionnaire were used prior to commencing ward duties (e.g., “Carer Consultants sharing their strategies will reduce carer distress”) and again at approximately 6-months post commencement of unit duties (e.g., “Carer Consultants sharing their strategies reduces carer distress”) where 1 = totally disagree, 10 = totally agree. Four open-ended questions invited qualitative data regarding perceived benefits, difficulties, potential resolutions, and additional comments.

Procedure
Depending on the medium of contact (i.e., face-to-face, telephone), potential participants were provided with either a letter of introduction or a verbal report that detailed the aims of the current study and advised of ethics approval from relevant bodies. All potential participants were ensured of confidentiality, advised that participation was voluntary, and that they could discontinue at any time.
Consumers and Carers.
Both the Peer Specialists and the Carer Consultants maintained contact records in regards to the consumers and carers they worked with. From such records, a random sample of potential participants was collated from a two-week block either side of the 6-months post-employment period for each new staff member. Consumers and Carers were contacted via telephone and invited to verbally respond to a questionnaire.

Pre-existing Staff.
Prior to commencement of unit duties for newly employed Peer Specialists and Carer Consultants, CNAHS representatives involved with the implementation of such an initiative toured the targeted acute units and spoke with staff members. Pre-existing staff were provided with information regarding the new roles and had the opportunity to have their questions answered.
At pre- and post-assessment, Clinical Nurse Consultant’s on targeted acute units were contacted to arrange appropriate times to approach potential participants and invite them to complete a questionnaire. Such questionnaires were predominantly completed prior to ward rounds and returned to the researcher, however some staff opted to forward the completed questionnaires via internal mail.

Newly Employed Peer Specialists and Carer Consultants.
Peer Specialists and Carer Consultants were invited to complete pre- questionnaires during a CNAHS orientation workshop and the research team collected completed questionnaires. Post-questionnaires were posted to prospective participants and were returned via reply-paid envelopes.

Peer Specialist and Carer Consultant Mentors.
Appointed mentors for the Peer Specialists and Carer Consultants were asked to provide their feedback on the experience of mentoring via a discussion focus group. Topics covered included: emotional support, structural issues, planning, and recommendations.

Results
Consumers in Response to Contact With Peer Specialists
Of the 30 consumers who participated in the telephone conducted questionnaire, 25 recalled having contact with a Peer Specialist while utilising acute services. Four of the five consumers who did not recall contact with a Peer Specialist reported not knowing of such a staff member and did not recall being offered such services. The fifth participant declined to engage with such services. Additionally, of the 25 participants, 10 reported being aware of a Carer Consultant on the ward.

Descriptive statistics of consumer response scores post-contact with Peer Specialists are summarised in Table 1. Overall, such results were positive. The highest ratings indicated that Peer Specialists were considered good or better at helping the consumer feel supported, helping them identify their coping strategies, and increasing the consumer’s sense of hope for recovery. Additional ratings indicated that Peer Specialists were considered better than acceptable at encouraging consumer self-management, increasing consumer understanding of experienced symptoms, sharing their personal coping strategies, and connecting the consumer to community resources.

Table 1
Descriptive Statistics of Consumer Response Scores Post-contact with Peer Specialist

	Mean	SD	Min	Max
Response Items
Increasing understanding of symptoms	2.88	.83	1	4
Sharing their personal coping strategies	2.76	1.13	0	4
Helping to identify consumer coping strategies	3.04	1.10	0	4
Increasing sense of hope for recovery	3.16	.90	1	4
Helping consumer feel supported	3.00	1.04	0	4
Encouraging self-management	2.96	.98	0	4
Connecting with community resources	2.64	.70	2	4

Note. Participants (N = 25) were asked to rate their responses on a scale where responses ranged from 0 = very poor to 4 = very good

Qualitative data was obtained through open-ended questions and many respondents commented on the helpful nature of all staff with one respondent reporting the received acute services to be better than associated services obtained in the private sector.

Participating consumers were also asked if they found anything to be different or special about working with a Peer Specialist in comparison to other staff. Obtained comments reflected quantitative data with the dominant theme being that the Peer Specialist’s lived experience normalised situations, promoted a greater sense of feeling understood, of feeling comforted, and exemplifying the potential for recovery. For example, statements provided by interviewed consumers included: the Peer Specialist “Understood what we were going through and helped me understand”, “Made that stay the best one. I felt really comfortable”, and “Knew what it was like. They lived it and got better enough to work”.

Conversely, two respondents reported conflicts in personality. However, when asked how the Peer Specialist service could be improved, most respondents encouraged employing more Peer Specialists and/or increasing their working hours. One respondent suggested that promoting the valuable role of Peer Specialists to the broader community could reduce the stigmatisation surrounding mental health.

Carers in Response to Contact With Carer Consultants
Of the 25 carers who participated in the telephone conducted questionnaire, 21 recalled having contact with a Carer Consultant while utilising acute services. The four carers who did not recall contact with a Carer Consultant reported not knowing of such a staff member and did not recall being offered such services. Additionally, of the 25 participants, four reported being aware of a Peer Specialist on the ward. One such respondent attributed the compliance of her family member to the helpful efforts of the Peer Specialist.

Descriptive statistics of carer response scores post-contact with Carer Consultants are summarised in Table 2. Overall, such results were positive. The highest ratings indicated that Carer Consultants were considered better than good at helping carers feel supported and reducing carer distress by sharing their coping strategies. Additional ratings indicated that Carer Consultants were better than acceptable at increasing carer’s sense of hope for the recovery of the consumer being cared for, helping carers identify and build upon their personal coping strengths in their caring role, assisting carers in learning about the hospital system, and explaining the Well Ways Program.

Table 2
Descriptive Statistics of Carer Response Scores Post-contact with Carer Consultant

	Mean	SD	Min	Max
Response Items
Assisting with learning about hospital system	2.86	1.24	0	4
Explaining the Well Ways Program	2.76	1.48	0	4
Helping carer feel supported	3.57	.68	2	4
Increasing sense of hope for consumer’s recovery	2.95	.92	1	4
Reducing carer distress	3.24	.89	1	4
Helping to identify carer coping strategies	2.90	1.00	1	4

Note. Participants (N = 21) were asked to rate their responses on a scale where responses ranged from 0 = very poor to 4 = very good.

Participating carers were also asked if they found anything to be different or special about working with a Carer Consultant in comparison to other staff. Many respondents acknowledged the good work of all unit staff with comments such as, “all staff were professional and relaxed”. However, obtained comments reflected quantitative data with the dominant theme being that the Carer Consultant’s personal experience with similar issues provided them with a knowledge and insight that helped carers feel more comfortable and supported.

One carer summed up her experience as follows: the Carer Consultant “Explained their experience very well. It was nice to know that someone knew what I was experiencing” and another who reported, “After 10 years, it was the first time I ever felt a connection”. Overall, comments suggested that the Carer Consultants provided a worthwhile service.

Respondents were also asked for suggestions on how the Carer Consultant service could be improved. All reported suggestions involved more available time with the Carer Consultant through ongoing follow-up post-discharge, providing a country service, employing more Carer Consultants, and making their positions full-time.

Pre-existing Staff Perceptions Regarding Peer Specialists Roles
A paired-samples t-test was conducted to evaluate shifts in pre-existing staff perceptions of Peer Specialists and Carer Consultants from pre- to post-commencement of duties. With the exception of reporting a greater understanding of their role, participant’s scores declined on nearly all measured items from pre- to post-commencement of Peer Specialist employment duties (see Table 3). There was a statistically significant decrease in scores, indicating less favourable perceptions over time for the following:

Table 3
Descriptive Statistics of Pre-existing Staff Perceptions Regarding Peer Specialists (PS) Roles

	Pre M (and SD)	Post M (and SD)	Min	Max
Response Items
Benefits consumers	7.89 (1.55)	7.09 (1.91)	5	10
Understanding of their role	6.28 (2.58)	6.39 (2.34)	1	10
Foster hope for recovery	7.48 (1.29)	6.67 (1.90)	5	10
Encourage personal responsibility	7.17 (1.68)	6.52 (2.30)	3	10
Enhance connection to resources	7.48 (1.41)	6.72 (2.14)	5	10
Benefits other unit staff	7.20 (1.66)	6.30 (2.56)	3	10
Feel confident to make referrals to PS	6.54 (2.40)	6.46 (3.02)	1	10
Will offer support to PS	8.93 (1.07)	7.93 (2.02)	6	10

Note. Participants (N = 46) were asked to rate their responses on a scale where responses ranged from 1 = Totally Disagree to 10 = Totally Agree.

Firstly, Peer Specialists working within acute mental health units was perceived as less beneficial to consumers from pre- (M = 7.89, SD = 1.55) to post-evaluation (M = 7.09, SD = 1.91), t(45) =2.26, p<.05. The eta squared statistic (.10) indicated a moderate effect size. Secondly, Peer Specialists working within acute mental health units was perceived as less beneficial to other staff from pre- (M = 7.20, SD = 1.66) to post-evaluation (M = 6.30, SD = 2.56), t(45) = 2.17, p<.05. The eta squared (.10) statistic indicated a moderate effect size, Thirdly, Peer Specialists were considered less able to enhance a consumer’s connection to community resources from pre- (M = 7.48, SD = 1.41) to post- evaluation (M = 6.72, SD = 2.14), t(45) = 2.04, p<.05. The eta squared (.09) statistic indicated a moderate effect size. Finally, pre-existing staff reported less willingness to offer support to Peer Specialists from pre- (M = 8.93, SD = 1.07), to post-evaluation (M = 7.93, SD = 2.02), t(45) = 3.07, p<.005. The eta squared (.18) statistic indicated a large effect size.

Although some summary comments obtained through open-ended questions implied non-existent benefits to consumers and somewhat reflected the above data, the majority of comments were positive and optimistic. In collating such comments a recurrent theme of empathy arose whereby the consumer was consistently reported to benefit from liaising with a staff member who had lived experience. For example, one respondent commented, “Peer Specialists can support consumers on a personal level that can not be matched by mental health professionals”.
Additionally, pre-existing staff consistently reported consumers to benefit from Peer Specialist interactions through the varied information provided during group processes, one-on-one sessions, and through first-hand knowledge of available community resources. Further comments suggested that pre-existing staff also benefited from Peer Specialists who provided another support outlet and constructively occupied consumer time.

The information provided regarding difficulties arising from the introduction of Peer Specialists was mixed. Encouragingly, the substantial difficulties first projected at pre-assessment were not founded. At post-assessment, some pre-existing staff reported “nil difficulties” while others on the same ward reported numerous difficulties. The majority of difficulty appeared to arise in the areas of role clarity and communication with pre-existing staff. Furthermore, Peer Specialists were reported to have limited understanding of the mental health system and the varied roles of staff members. Pre-existing staff were forthcoming with information and offered valuable resolutions for reported difficulties (e.g., further training).

Pre-existing Staff Perceptions Regarding Carer Consultants Roles
With the exception of a slight increase on scores in understanding of the Carer Consultants role and pre-existing staff’s confidence in making referrals to such services, participant’s scores declined on most measured items from pre- to post-commencement of Carer Consultant duties (see Table 4). There was a statistically significant decrease in scores, indicating less favourable perceptions over time for the following.

Table 4
Descriptive Statistics of Pre-existing Staff Perceptions Regarding Carer Consultant (CC) Roles

	Pre M (and SD)	Post M (and SD)	Min	Max
Response Items
Benefits carers	7.87 (1.50)	7.20 (1.85)	1	10
Understanding of their role	6.15 (2.62)	6.59 (2.40)	1	10
Reduce carer distress	7.30 (1.31)	7.13 (1.80)	1	10
Assist with acute service pathways	7.28 (1.54)	6.72 (2.12)	1	10
Enhance connection to resources	7.61 (1.47)	7.02 (2.01)	1	10
Benefits other unit staff	7.37 (1.54)	6.80 (2.43)	1	10
Feel confident to make referrals to CC	6.74 (2.23)	6.85 (2.78)	1	10
Will offer support to CC	8.85 (1.15)	7.96 (1.87)	4	10

Note. Participants (N = 46) were asked to rate their responses on a scale where responses ranged from 1 = Totally Disagree to 10 = Totally Agree.

Firstly, Carer Consultants working within acute mental health units were perceived as less beneficial to carers from pre- (M = 7.87, SD = 1.50) to post-evaluation (M = 7.20, SD = 1.85), t(45) =2.02, p<.05. The eta squared statistic (.08) indicated a moderate effect size.

Secondly, pre-existing staff’s willingness to offer support to Carer Consultants declined from pre- (M = 8.85, SD = 1.15) to post-evaluation (M = 7.96, SD = 1.87), t(45) = 1.49, p<.005. The eta squared (.05) statistic indicated a small effect size.

Information gathered through open-ended questions qualified the above data. However, mixed among comments that reported non-existent benefits of employing such staff members, some pre-existing staff from each site also indicated favourable experiences attributed to the role of Carer Consultants. For example, respondents made comments such as, “Carer’s appear less frustrated with the system” and their role “does lift some of the load from other staff”. Another participant wrote, “Carer Consultants provide enhanced support for families”. Finally, one respondent wrote, “I refer a lot of families to Carer Consultants – all of whom have given very positive feedback regarding their contact”.

The information provided regarding difficulties arising from the introduction of Carer Consultants was also mixed. For example, some staff reported no apparent difficulties while others on the same ward commented on communication barriers, training requirements, and insufficient role clarity.

Newly employed Peer Specialists and Carer Consultants
A Wilcoxon Signed Rank Test was conducted to evaluate shifts in newly employed Peer Specialists and Carer Consultants perceptions of their respective roles. Overall, participant’s scores increased on all measured items from pre- to post-commencement of employment duties (see Table 5). There was a statistically significant increase in scores indicating more favourable perceptions over time for the following two areas.

Table 5
Descriptive Statistics of Newly Employed Staff Perceptions Regarding Carer Consultant (CC) and Peer Specialist (PS) Roles

	Pre M (and SD)	Post M (and SD)	Min	Max
Response Items
Feel positive about employment of PS	9.00 (0.94)	9.25 (2.00)	3	10
Understanding role of PS	8.40 (0.52)	9.42 (0.90)	8	10
PS foster hope for consumer recovery	8.70 (0.95)	9.33 (0.89)	7	10
PS encourage consumer responsibility	8.10 (0.88)	9.08 (1.00)	7	10
PS enhance connection to resources	7.80 (0.42)	8.25 (1.36)	6	10
PS role benefits other unit staff	7.70 (0.68)	8.75 (1.82)	4	10

Feel positive about employment of CC	8.58 (1.08)	8.75 (1.66)	5	10
Understanding role of CC	7.33 (1.23)	8.58 (1.44)	5	10
CC reduce carer distress	8.17 (1.27)	8.33 (1.88)	5	10
CC help carers navigate service paths	7.67 (1.16)	8.00 (1.35)	5	10
CC enhance connection to resources	8.00 (0.95)	8.08 (1.17)	6	10
CC role benefits other unit staff	7.83 (0.94)	8.42 (1.57)	6	10

Feel confident about receiving referrals	7.58 (1.08)	8.17 (2.95)	1	10
Feel confident about being supported	6.83 (1.19)	7.33 (2.74)	1	10

Note. Participants (N = 12) were asked to rate their responses on a scale where responses ranged from 1 = Totally Disagree to 10 = Totally Agree.

Firstly, obtained scores indicated a greater understanding of the new role Peer Specialists have in promoting consumer recovery from pre- (M = 8.40, SD = .52) to post-evaluation (M = 9.30, SD = .95), z = -2.08, p < .05. Secondly, the perception that Peer Specialists encourage personal responsibility by modelling coping strategies increased from pre- (M = 8.10, SD = .88) to post-evaluation (M = 8.90, SD = 1.0), z = -2.06, p < .05.

Information gathered through open ended questions substantiated the above data and maintained an air of optimism from pre- to post-assessment. The predominant theme of responding indicated substantial gains achieved through consumers identifying with the lived experience of the newly employed staff. Consumers were reported to confide with Peer Specialists and Carer Consultants thus providing additional information that helped inform other staff on treatment and follow-up options.

The majority of difficulties were similar to those addressed by pre-existing staff (e.g., role clarity and communication between staff members working with the same consumer). Additional areas of concern related to fitting in with pre-existing team dynamics and the unexpected pressures of working within an acute environment. Both groups of Peer Specialists and Carer Consultants reported the need for a referral system that better informed them of consumer needs and appropriateness for making initial contact.

Mentors for Peer Specialists and Carer Consultants: Discussion Focus Group
The two assigned mentors participated in an hour-long discussion focus group chaired by a member of the research team. In considering the impact of introducing Peer Specialist positions, it was evident that such positions are highly sought after and help reinforce consumers hope for recovery.

In regards to the impact of introducing Carer Consultant positions, mentors reported that the carer community felt “heartened” and the provision of such positions is acknowledgement of their valuable carer role. Carers SA particularly noted an increase in referrals to carer agencies since the inception of Carer Consultants.

Mentors also reported the educational component of their role to be most valuable and effective in enhancing staff’s competencies. They reported to observe a strong within group support process develop which both Peer Specialists and Carer Consultants valued. Consequently, the mentors collaborated on developing a Mentor Training Program by which peer-to-peer mentoring processes will be formalised and inclusive of relevant training.

Discussion
Central Northern Adelaide Health Service (CNAHS) employed Peer Specialists and Carer Consultants on five permanent acute units within the region. The current report aimed to summarise and evaluate information obtained from consumer/carer feedback, pre- and post-employment staff questionnaires, and Peer Specialist/Carer Consultant mentor discussion.

Overall, the feedback provided from consumers and carers was consistently positive. Both groups of Peer Specialists and Carer Consultants were reported to be effective supports for increasing hope for recovery. Above all, the lived experience of such staff members was repeatedly commented to be a valuable and appreciated source of acknowledgment and understanding.

Conversely, pre-existing staff on the targeted acute units perceived the introduction of Peer Specialists and Carer Consultants less favourably over time. However, such staff also reported a greater understanding of the respective roles. Such results are influenced by numerous factors including the following.

Firstly, pre-existing staff provided surprisingly high pre-assessment scores. To the contrary of reports which cited the negative attitudes of mental health professionals as a major barrier to effective consumer participation (e.g., Gordan 2005; Happell & Roper, 2006. Lammers & Happell, 2004) the high initial scores reported in this paper implied a degree of optimism and acceptance among pre-existing staff.
It is also possible that inflated initial scores were reflective of the information provided during pre-employment introduction sessions. Although there was limited scope for an increase in such scores over time, the average reported scores remained in the positive response domain.

Secondly, it is possible that the systemic and cultural adjustment challenges faced by introducing a novel and inexperienced group of staff was overlooked by everyone involved with such an endeavour. It is believed that the experience of such challenges contributed to less favourable perceptions over time among pre-existing staff that held high initial expectations. Specifically, it is hoped that the reported decline in pre-existing staff’s willingness to offer support to either Peer Specialists or Carer Consultants will improve as all staff and coordinating bodies endeavour to further implement positive change and address restraints.

Finally, both the pre-existing and newly employed staff participants reported difficulties with cross-communication. Both groups desired more opportunity and/or an agreed upon structure to liaise with each other at various stages of consumer and family care (i.e., initial referral, pre-contact, follow-up debriefing). With such communication issues, it is possible that the involvement and value of Peer Specialists and Carer Consultants was not questioned or expressed by various parties. For instance, consumers and carers who utilised the services of Peer Specialists and Carer Consultants predominantly reported positive experiences and valued the inclusion of such staff on the acute units. Possibly, the pre-existing staff who reported nil benefits of employing the newly introduced staff were not provided with opportunity to receive such feedback.

Conversely, Peer Specialists and Carer Consultants perceived their role more favourably over time. The overall buoyancy of the pre- and post-assessment scores suggests a resilient optimism by the Peer Specialists and Carer Consultants regarding the value of the lived experience roles and this is supported by the reported consumer and carer feedback. Interestingly, the newly employed Peer Specialists and Carer Consultants also had high pre-assessment scores and despite aforementioned challenges, their scores increased over time. It is possible that an increase in scores is also associated with such staff receiving ongoing positive reinforcement from the consumers they worked with, the peers they received support from, their mentors, and the ongoing training/education offered them.

The newly employed Peer Specialists and Carer Consultants who reported greater understanding of their respective roles evidently embrace the premise of the recovery framework adopted by CNAHS. As further experience of the role continues, Peer Specialists and Carer Consultants are also refining their practice skills in promoting consumer recovery and encouraging personal responsibility by modelling coping strategies.

As would be expected with such an endeavour, particular difficulties were addressed and continue to be addressed with the progress of time and experience. In general, pre-existing staff articulated difficulties arising in areas of selection, training, and management of additional staff. At the time of writing, the developing mentor program endeavours to provide sustained role and skill development approaches for any new Peer Specialist and Carer Consultant staff.

Acknowledging that no new staff member without previous experience is fully skilful at service delivery, the Peer Specialist and Carer Consultant will continue to develop a broad base of competencies, skills, and evolving practice standards. In order to overcome the knowledge and skill gaps reported by and affecting existing unit staff. more extensive training and orientation is planned for the new Peer Specialists and Carer Consultants prior to commencement on any unit.

Furthermore, as developing positions, the unique roles of Peer Specialists and Carer Consultants were reported as misunderstood and potentially under-utilised (i.e., lacking referrals). Such issues are consistent with the initial restraints of many newly developing employment positions and the informal qualitative reports of similar interstate roles suggests that the initial 12-18 month timeframe is a period of augmenting role clarity and embedding systemic change. It may be beneficial for pre-existing staff to be informed of similar interstate projects and to be given the opportunity to openly discuss logistics. Finally, both groups of Peer Specialists and Carer Consultants reported an overall personally rewarding employment experience.

In summary and coinciding with existing literature, the current evaluation indicated that the employment of Peer Specialists and Carer Consultants within various CNAHS acute units was positively associated with consumer, organisational, and personal gains. For example, the lived experience of additional staff was reported as beneficial to everyone involved and was viewed as providing a valuable connection point for consumers and carers. The consumer and carer feedback suggested that the inclusion of Peer Specialists and Carer Consultants was a worthwhile and appreciated venture. Additionally, participating consumers and carers provided consistently positive feedback whereby they reported feeling more supported and experienced a greater sense of hope for recovery for respectively themselves or the person they care for.

Although pre-existing staff’s perceptions somewhat deteriorated over time, their average ratings were still of a positive and/or agreeable nature. Genuine incorporation of new team roles usually takes considerable time to embed, so a settling process is natural. The ongoing action of pre-existing staff and newly employed staff to effectively problem solve issues arising clearly reflects a solid commitment to genuinely and fully incorporating such lived experience roles into the team. While the complications inherent with the experience of a structural and cultural shift were evident, numerous gains were reported from the organisational perspective. For example, the introduction of Peer Specialists and Carer Consultants was reported to alleviate time and resource constraints.
The information gathered via this evaluation is being used to direct future endeavours and to address identified issues. An impetus to integrate consumers and carers into all aspects of mental health service exists. The aim is to benefit everyone involved, however it can be speculated that the ultimate driving force is to provide the best possible care for current consumers and their families. CNAHS continues to strive toward optimal service delivery and the current initiative contributes to the growing body of national findings that supports the inclusion of Peer Specialists and Carer Consultants as valuable mental health team members. CNAHS is committed to the best possible mental health service provision and anticipates further developments as lived experience and trained staff coalesce to provide cutting edge services.

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