Module 4: Supporting, Supervising, and Retaining Peer Staff
Importance of relevant support and supervision
Adequate support and quality supervision are keys to the development, and retention, of a competent and effective peer workforce. Unfortunately, the provision of supervision has diminished somewhat in behavioral health over the last two decadesdue to productivity demands and lack of emphasis on supervisor competencies. It should be no surprise, then, that turnover rates for the behavioral health workforce have been cited at higher than 60% in recent years.[1]Despite this historical trend, supervision remains the backbone of clinical practice and should likewise be considered a key foundation for ensuring effective practice among all staff, whether peer or non-peer.
Effective supervision of peer staff in particular may help improve communication between peer and non-peer staff, enhance opportunities for professional development, encourage self-care strategies that fend off emotional exhaustion, increase the alliance between supervising champions and peer staff, contribute to greater job satisfaction of peer workers, and ultimately contribute to higher quality care.In the case of peer staff, it is important that the people providing supervision are well-versed in the nature and benefits of peer support, understand and appreciate the central role of self-disclosure in the peer relationship, and are strength-based and oriented toward supporting the peer staff in maximizing their contributions to the overall life and work of the agency. In addition to supervision, peer staff are increasingly finding co-supervision with their peers to be a highly valuable resource and instrumental in their professional growth and development, as well as in the provision of quality care to their clients. This module will discuss both supervision and co-supervision approaches.
Planning Related to Organizational Placement and Policy Considerations
Where in the organizational structure will the new peer staff positions be situated? In considering potential placements, it is preferable for the first peer positions within your organization to be in a unit or program that has strong recovery champions and an identified supervisor that believes in the value of peer support. It also is important not to hire only one peer staff member, either for the agency as a whole or for any program or unit within the agency. As stressed earlier in this toolkit, it is not advisable early in the process of hiring peers for any individual staff member to be the only peer on his or her unit, team, or program. This will make the work of integration especially difficult on all parties, and runs a higher risk of failure for the agency as a whole.
Once a determination is made about who will be supervising the new staff, it will also be important to include these persons in other aspects of the planning and culture change efforts. Especially if potential supervisors have not been involved in any earlier recovery-oriented change efforts, they will need to become involved as early as possible in preparing for the hiring and orientation of the staff they will be supervising. This may include involvement in the drafting of job postings and descriptions, interviewing potential candidates, and becoming conversant with the unique aspects of peer support, such as the central roles of experiential knowledge and self-disclosure.
For supervisors who are not themselves peer staff, and for whom peer support may be a new form of service delivery, there is an excellent on-line resource that covers many of the basic issues that such supervisors will face early in the process of supervising peer staff. This on-line training is part of Magellan’s Recovery and Resilience E-Learning Center Training Module – Peer Specialist Course 7: Effective Supervision and can be accessed at:
What do We Mean By “Supervision”?
In health care settings, the term “supervision” refers to comprehensive supervision provided to employees who work directly with individuals served by the organization. A recent review of the literature on supervision[2]provided in health care settings found agreement on the following points:
- The purpose of supervision has two primary dimensions: 1) to ensure the safety of persons served and 2) to promote professional development of the recipient while serving as a basis for performance evaluation.
- There are three types of supervision provided to support the dimensions described above: 1) Administrative/day-to-day supervision; 2), Educational supervision; and 3) Supportive/managerial supervision. With administrative supervision, the staff member is provided basic support related to work coordination, communication, and administration. Educational supervision is intended to help the worker develop knowledge related to the role and profession that she or he occupies. With supportive supervision, which many people associate with clinical supervision, the supervisor works with the individual to strengthen interpersonal and self-awareness skills that enable him or her to effectively work with people. The activities performed in each of the types of supervision are described in more detail in the following table.
A Framework for Supervision
Supervision Framework[3]Administrative Supervision / Educational Supervision / Supportive Supervision
◊ Staff orientation and placement
◊ Work planning
◊ Work assignment
◊ Work delegation
◊ Monitoring, reviewing, and evaluating work
◊ Coordination of work
◊ Communication
◊ Administrative buffer
◊ Community liaison / ◊ Identification of knowledge and skills necessary to do the work
◊ Provision of teaching/ training/learning resources
◊ Socialization to professional values and identity / Provides psychological and interpersonal "supplies" that strengthen capacity of worker to deal with job demands, job stresses, and workplace tensions. These include:
◊ reassurance
◊ encouragement
◊ recognition
◊ approval
◊ opportunity to "vent"
◊ perspective
◊ containment
◊ flexibility
Given the complexity and multiple forms of supervision, there may be uncertainly related to who should provide which form of supervision for peer staff. Because educational and supportive supervision largely serve to educate staff and supply them with tools specific to their roles and activities, many people advocate that only experienced peer providers can provide appropriate supervision to new peer staff. The ideal situation is one in which a more seasoned peer support provider who has received training on supervision supervises other peer staff. For a variety of reasons, however, this is often not the case in Philadelphia (as well as elsewhere). Peer support staff, particularly when first being introduced within an organization, are often supervised by another staff member who is educated in a different discipline, such as social work, psychology, nursing, or counseling. It is for this reason, and for these staff, that we recommended the Magellan on-line training above.
Given the division of labor outlined in the above table, however, it may also be possible in such cases to assign more than one supervisor to new peer staff so that different areas can be addressed by different people. This would allow a member of a clinical team to provide the day-to-day administrative supervision, for example, and for the peer staff to receivesupportive and/or educational supervision from a more experienced peer who may work on a different team, in a different program, or even, perhaps, for a different agency. In cases in which the work of the peer staff is to be reimbursed (my Medicaid or other payer), and therefore requires oversight by a licensed professional, such a professional may need to provide administrative supervision but may not be required to provide educational or supportive supervision, which may be provided in a group format.
Supervision, Psychotherapy, and the Provision of Reasonable Accommodations
Becausesupportive supervision involves addressing workplace tensions or conflicts and at times requires self-reflection on the part of the staff being supervised, confusions occasionally arise between the role of the supervisor and the role of the psychotherapist. And while these confusions might arise for any staff member and his or her supervisor, peer or non-peer, they are more likely to occur, at least early in the process of hiring peers, in the case of peer staff. This is not necessarily because peer staff have more of such issues to deal with, but rather because of their history of previous treatment, their familiarity with the role of client, and the stigmatizing stereotypes often held by staff, including supervisory staff. As a result of the convergence of these various factors, supervisors who are new to supervising peer staff may find themselves at times on the edge of stepping into the role of psychotherapist for peer staff they supervise. Doing so, however, is neither necessary nor appropriate.
The line between reflective supervision and psychotherapy or counseling is the same for peer staff as for non-peer staff. In both cases, supervisors may identify personal issues that impede the person’s job performance and may make the person aware of the presence and impact of these issues. If the person is not already engaged in his or her own psychotherapy or counseling outside of the job, the supervisor may even recommend the person do so in order to improve his or her job performance. In such cases, supervisors may recommend that staff make use of an Employee Assistance Program or seek their own care as covered through their health insurance. Under no circumstances, though, does it become the supervisor’s job to offer the psychotherapy or counseling him or herself.
Where this may become especially confusing is in the realm of “reasonable accommodations,” as described in the previous module. It is quite possible that a need for an accommodation may first emerge or be identified within the context of supervision, and that a supervisor correctly understands initiating a process for providing such an accommodation to be part of his or her role. That does not mean, however, either that the supervisor is necessarily the person in the best position to provide the accommodation or that psychotherapy or counseling on the job site can qualify as such an accommodation. In fact, psychotherapy and counseling do not qualify as “accommodations” per se, and should not be provided either on-site or by the person’s supervisor. Should having access to a psychotherapist or counselor be requested as an accommodation, this would only require the supervisor to ensure that the employee can take breaks and can either call or visit his or her personal counselor or psychotherapist as and when needed. Securing such a therapist or counselor, and arranging for such access during the work week, is the person’s own responsibility.
The provision of other accommodations are typically to be arranged by an agency’s Human Resources staff when requested by a staff member. Accommodations are modifications to the person’s work environment and/or routine that enable him or her to perform the essential functions of his or her job effectively. They are not disciplinary measures taken when an employee functions below expected levels, nor are they remedial measures taken to improve an employee’s job performance. As they are intimately connected to the nature of the employee’s disability, they are to be requested by the employee him or herself and designed in collaboration by the employee and human resources specialists who are trained in these matters. Examples of the kinds of reasonable accommodations requested by peer staff include being sensitive to late/early arrival or “standard” schedule to accommodate appointments, offering longer or more frequent breaks, providing task lists in writing, accepting alternative formats for work, e.g., typed/hand-written/or recorded notes if submitting written work, providing access to a partitioned work space or more private work area, allowing use of white noise technology, providing increased supervision, or designating co-worker mentors.
Supervision and Advocacy
Peer staffmay raise issues in supervision that do not reflect as much on their own personal struggles as they reflect on changes that may need to be made to agency policies, practices, or culture. We mentioned this possibility in the previous module, when describing the role of peer staff as change agents. Even when being a change agent is not an explicit part of their role, it is common for peer staff to face, and to identify, discriminatory and stigmatizing beliefs and attitudes on the part of other staff. They also frequently are the first staff to raise concerns about long-standing practices or policies that impede, rather than promote, the resilience and recovery and clients. In these instances, it is not helpful or productive for supervisors to view the concerns being raised as reflecting the peer staff member’s personal history or issues (e.g., as being “hyper-sensitive”). Rather it is important for supervisors in these cases to demonstrate tangible support for the peer staff by advocating for changes to be made in response to these concerns.
One common such instance is the use of language. Peer staff may raise concerns, for example, about the ways in which some staff refer to service recipients, whether this be by diagnosis (e.g., “schizophrenics,” “borderlines,” or “bipolars”), by “street” terminology (e.g., “junkies” or “addicts”), or by service use characteristics (e.g., “retreads,” “frequent flyers,” or “double trouble”). Rather than suggesting the peer staff be less sensitive to this kind of language, that they not be so “picky” or act as “language police,” it is incumbent upon supervisors to raise this issue with the agency leadership, to educate staff about the need for person-first language (as described in the first module), and to establish policies or expectations that such offensive and dehumanizing terms not be tolerated. It also is important for the supervisors or agency leadership, when they respond in this way, not to attribute the reason for these changes to the peer staff but to make clear that these changes are required in order to show proper respect to the persons being served (and so would be required even if there were no peer staff).
In general, the kinds of issues that peer staff are likely to raise fall into two broad categories. The first category has to do with ways in which staff may be paternalistic or may exercise inappropriate authority over clients, viewing clients as incapable as making their own decisions. The second category has to do with ways in which staff may be maternalistic, may expect too little of clients, or may feel the need to protect them, viewing clients as fragile, vulnerable, or unable to take care of themselves. In such cases, supervisors may need to encourage peer staff to raise these issues first in a constructive and congenial fashion directly with their colleagues before intervening him or herself, but then it will be important for the supervisor to support the peer staff’s perspective him or herself as well, assuming that he or she concurs that the identified staff are not acting in a given client’s best interest. Finally, supervisors should be attentive to addressing both sides of any conflicts that arise between or among staff, rather than assuming that the bulk of the responsibility lies with the peer staff member simply because he or she is in recovery.
Co-Supervision, Peer Consultation, and Opportunities for Networking
One of the most commonly cited strategies for building a strong peer workforce is the creation of opportunities for consultation and networking.[4][5][6][7] Particularly when an organization is first introducing peer staff and there may be just a couple of individuals as peer workers in a setting, the issue of working in isolation is a significant risk. As any professional working directly with individuals understands, ethical issues typically arise when someone is working in isolation—the perspective of colleagues can reveal new dimensions to a situation, introduce ideas, and help unpack complex developments. Peer staff can seek supervision from supervisors from other professions and backgrounds, but it also is important for peers to consult together to consider issues through the specific lens of their training and experience; this is known as co-supervision.
Although all staff may be seeking to create an environment that promotes resilience and recovery through changing attitudes and perspectives on positive risk-taking, authentic partnership, increased choice, and a focus on strengths, peer staff often also find themselves advocating more passionately for recovery-oriented change than some of their colleagues. Opportunities to discuss this frustration, as well as several other issues, may become very important for long-term retention. Consider the following questions as to what you are already doing to enable these discussions:
How often do peer staff meet together each week? Each month? Is there a specific time set aside for these discussions, or is it on an ad hoc basis? Do you need to set aside specific times for such meetings to take place?
What is the process for peer staff within your organization when they are confronted with an ethical dilemma? How do you ensure that peers communicate concerns to supervisors, but also work through concerns as a cohort together to build competency with ethical decision-making and problem solving?