Workforce outcomes among substance use peer supports and their contextual determinants: A scoping review protocol

Background Peer recovery support services are a promising approach for improving harm reduction, treatment, and recovery-related outcomes for people who have substance use disorders. However, unique difficulties associated with the role may put peer recovery support staff (i.e., peers) at high risk for negative workforce outcomes, including burnout, vicarious trauma, and compassion fatigue, which impact one’s personal recovery journey. Little is known about the extent to which peers experience such negative outcomes or the influence the service setting context has upon them. This scoping review aims to describe the nature and extent of research evidence on peers’ workforce outcomes and how these outcomes might differ across service settings. Methods A scoping review will be conducted with literature searches conducted in PsycINFO®, (EBSCO), Embase® (EBSCO), CINAHL® (EBSCO), Web of Science™ (Clarivate), and Google Scholar databases for relevant articles discussing US-based research and published in English from 1 January 1999 to 1 August 2023. The study will include peer-reviewed and grey-literature published materials describing the experiences of peers participating in recovery support services and harm reduction efforts across a variety of service settings. Two evaluators will independently review the abstracts and full-text articles. We will perform a narrative synthesis, summarizing and comparing the results across service settings. Conclusions This review will assess the state of the literature on peer workforce-related outcomes and how outcomes might vary by service setting context. Exploration will include individual characteristics of peers that moderate workforce outcomes, and workforce outcomes that mediate personal recovery outcomes. Results will inform the field regarding future directions for research in this area. Systematic review registration Submitted to Open Science Framework, August 22nd, 2023.


Introduction
Peer recovery support services (PRSS) for substance use disorder (SUD) have expanded over the past two decades, and the most recent National Drug Control Strategy recommends continuous development of the PRSS workforce (e.g., peers) [1].PRSS interventions are also a current research priority of the National Institute on Drug Abuse [2], with several systematic reviews providing support for peer effectiveness related to such outcomes as decreased substance use, increased rates of abstinence-based recovery, strengthened treatment retention, improved provider-participant relationships, and increased treatment satisfaction [3][4][5][6][7].However, studies suggest workforce-related challenges associated with peer roles, including a lack of clarity and high potential for burnout and vicarious trauma exposure [8,9].When considering workforce outcomes for peers, it is important to remember that many peers are, themselves, living in recovery or successfully managing their substance use through harm reduction strategies.While previous studies have tended to focus on those certi ed peer workers or peer recovery coaches who are in active recovery, they have neglected those who might be actively using drugs but are engaged in harm reduction service environments [10][11][12].Overall, the eld must develop a stronger understanding of the impact this work has on all peers' professional and personal lives, and how the impact might vary by service setting context.
The PRSS workforce comprises both certi ed and non-certi ed peers who work in paid or volunteer positions to deliver a range of support along the continuum from harm reduction to abstinence-focused recovery [13].It is important to note that people with lived experience have been involved in supporting those who use substances since the beginning of mutual-aid groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, Medication Assisted Recovery Anonymous).However, while peers are involved in sponsorship activities through these mutual support groups, positions of this sort should not be considered PRSS because they exist outside a formal paid or volunteer work environment [14].People with lived experience have also been highly represented among treatment professionals like addiction counselors [13,15] and, while such experience may be helpful for their work, they do not interact with participants in a peer capacity.The development of PRSS as a profession can be traced to 1999, when Georgia became the rst state to allow peer support as a billable provider type for both mental and behavioral health [15].As of 2019, 39 US states offered reimbursement for peer services, with training and certi cation requirements that typically include a speci ed recovery time, a criminal background check, varied training and exams, and continuing education or recerti cation [15,16].Various professional organizations and state-level boards approve these certi cations, with as many as 45 distinct categories of certi ed peers eligible for Medicaid reimbursement [5,16].This lack of standardization for PRSS certi cation has generated confusion regarding certi ed peers' minimal required training and education, role, and scope of work [17].
Understanding workforce outcomes for PRSS is essential for supporting this growing eld and ensuring peers' continued wellness and professional growth.These outcomes encompass a wide variety of factors related to peer employment experiences that include burnout, job satisfaction, role clarity, secondary trauma, turnover, and absent/presenteeism [18][19][20].The relationship between workplace context and workforce outcomes is well-supported within health professional literature.For example, burnout among health care workers is associated with perceptions of inequity within their organization, perceived job support, supervisory support, and workload [21,22].Previous reviews have noted those in the PRSS workforce have high burnout potential due to emotionally laborious conditions rooted in role ambiguity, limited resources, di culties establishing boundaries, and vicarious trauma exposure [8,15].These PRSS outcomes may be moderated by individual characteristics such as coping skills and personal recovery orientation (e.g., abstinence-only vs. harm reduction), but may also be in uenced by workplace factors like belongingness or supervisory support [23][24][25].Likewise, it is worthwhile to understand the extent to which peers' well-being both mediates and is mediated by workforce outcomes [26].
The COVID-19 pandemic likely exacerbated factors that can lead to negative peer workforce outcomes.With the sharp increase in drug overdose deaths that started during the pandemic [27], peers report greater stress than ever in their roles [28].Research notes a high potential for 'dual trauma' during this time, as peers faced pandemic stressors in their personal lives and recovery while simultaneously supporting a population at high risk for adversity and death [25].These compounding factors make it critical to better understand how peer workplace conditions may contribute to negative outcomes currently associated with this workforce.
The aim of this scoping review is to explore the nature and extent of research focusing on PRSS workplace contexts that either support or interfere with peer work.Questions guiding this review include: 1) What is known about workforce-related outcomes for peers working in the substance use eld? 2) What is known about how the structure of work impacts these outcomes?and 3) How do these outcomes differ by service setting type?This effort builds on prior published reviews of the PRSS experience or effectiveness by targeting how the context of a workplace impacts PRSS outcomes and how these outcomes might vary by workplace type (e.g., clinical, harm reduction settings).Additionally, we will explore individual-level characteristics of peers (e.g., demographics, training, attitudes) that may moderate workforce outcomes.Finally, workforce outcomes will be explored as potential mediators of peers' personal recovery outcomes.A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, and Joanna Briggs Institute (JBI) Evidence Synthesis was conducted and no current or underway scoping reviews on this topic were identi ed.

Eligibility criteria
We will assess peer-reviewed and grey literature describing the experiences of peers participating in substance use disorder recovery support services (PRSS) and harm reduction efforts across a variety of workplace settings.PRSS is de ned as care delivered by someone who has similar lived experience as the target population [29].For this review, the term 'peer' is inclusive of individuals in recovery from an SUD who have state or organizational certi cation, those in recovery without certi cation, and people who currently use drugs (PWUD).All quantitative and qualitative study designs will be included.We include studies that capture workforce outcomes experienced by peers, and report individual or organizationallevel variables that in uence these outcomes.We consulted previous reviews of healthcare workforce outcomes to develop a list of workforce outcomes for our search strategy [18][19][20].Corresponding with the advent of formal peer certi cation, studies will be restricted to those published from 1 January 1999 to 1 August 2023 and only to settings within the United States.We will exclude studies focusing on similar 'sponsorship' positions in mutual aid organizations, which involve bidirectional support relationships outside a supervised context [30].We will also exclude studies focusing on peer support outside the substance use recovery and harm reduction elds (e.g., peers focusing on mental or physical health issues).Finally, due to potential inaccuracies in translation that may hinder data extraction, we will exclude papers not published in English.

Study selection
We will use Rayyan [32] and MAXQDA [33] to manage title/abstract and full-text screening, respectively, eliminating duplicates with Rayyan's duplicate detection function.Two independent reviewers will further evaluate titles and abstracts of peer-reviewed articles to determine inclusion based on our eligibility criteria.Citations meeting the eligibility criteria will undergo a second stage, full-text screening by the reviewers.Agreement between the reviewers will be required for inclusion with a third reviewer resolving any disagreements.Level of consensus between reviewers will be assessed by calculating Cohen's Kappa statistic, with values above 0.6 indicating suitable agreement [34].If scores fall below 0.6, disagreements will be discussed and resolved, Kappa will be recalculated, and the process repeated until greater than 0.6 is achieved.We will utilize the PRISMA ow diagram to document search outcomes and report the rationale for exclusion of articles.

Data extraction
identi ed for inclusion, articles will be assigned a unique identifying number, then coded, extracted, and compiled using MAXQDA (a qualitative data analysis software), based on previous recommendations for systematic, scoping reviews [35,36].One member of the research team will conduct data extraction and another team member will check 10% of the articles for consistency of approach.The following will be extracted from each eligible article: a) bibliographic information (publication type, year); b) study location; c) authors' thesis and research objectives; d) sample size; e) sample information, including peer de nition and role type; f) study methodology; g) and context and workplace setting (e.g., rehabilitation center, recovery community organization, etc.).In addition, our primary outcomes will be recorded from each eligible article: h) workforce outcomes (e.g., burnout, job satisfaction, vicarious trauma); i) individual and organizational-level contributors to workforce outcomes, as well as additional outcomes; and j) author conclusions related to the support of peers within recovery and harm reduction organizations to reduce negative workforce-related outcomes.We will pilot the extraction template with an initial ve studies, during which we will adjust extracted information based on the content of the articles.The template will undergo continuous review and be revised, as necessary.If additional extraction categories are introduced, already extracted papers will be revisited for a second iteration.

synthesis and presentation
Results will primarily be in narrative form, supplemented by a table highlighting major themes and sub-themes which emerged through the effort.Two reviewers will code the articles in MAXQDA utilizing a deductive coding scheme generated from workforce outcomes along with contributors to these outcomes speci ed in reviews of the healthcare and general workforce [18-20, 37, 38].The reviewers will independently code 10% of documents, aiming for a Cohen's Kappa statistic above 0.06 before dividing and independently coding the remaining documents.The analyzed results will then be presented through thematic analysis, with reference to the objectives of our study.Furthermore, we will interpret relationships between synthesized themes and subthemes, as well as the signi cance of our ndings and any identi ed gaps in knowledge.We will provide an overview of the descriptive variables of the included studies, such as the research method employed, participant characteristics, and other relevant details.In line with previous recommendations for scoping reviews, we will not undertake an evaluation of individual study quality or conduct a risk-of-bias assessment [36,39].Substantial amendments to this protocol will be described in the nal manuscript.

Discussion
This is the rst scoping review to systematically explore the characteristics of PRSS and its impact on peer workforce outcomes, extracted from the available literature.Results will identify PRSS across multiple substance use and harm reduction service settings, characterizing the rapid expansion of peer support in substance use services.The described review process has noted limitations in that it may fail to capture or fully evaluate certain unpublished materials or forthcoming publications.Additionally, ensuring a comprehensive search poses a challenge due to diverse terminologies used to index the PRSS workforce.This review will serve as a foundation for identifying workforce outcomes and potential mediators of peers' personal recovery and health outcomes.Developing a well-supported workforce is an essential component of the expansion of peer services recently called for by policymakers and researchers [1,2].Results of this effort could inform development of more supportive contexts across the spectrum of peer work.This review may identify qualities that promote the success of peer workers or supervisors and locate potential avenues for recruitment.In training, identi cation of workforce issues can inform strategies to address challenges like burnout and boundary setting.In the workplace, organizational design can better support the retention of peers, including developing opportunities for advancement and career mobility.Findings will aid intervention development by clarifying how such interventions should be adapted to various workplace contexts.Finally, we will identify gaps in the literature and avenues for future research.

Declarations
Ethics approval and consent to participate applicable.

Consent for publication
Not applicable.

Availability data and materials
[31]e 1 displays our inclusion and exclusion criteria.State-by-State Directory of Peer Recovery Coaching Training and Certi cation Programs[31].The planned line-by-line search strategies for each database is outlined in Appendix A.
not limited to a) Recovery Research Institute, b) Addiction Policy Forum, c) Peer Recovery Center of Excellence, d) SAMHSA, e) Faces and Voices of Recovery, f) National Harm Reduction Coalition, and g) Pure Support.Additional organizations will be included if identi ed through our publication and database searches.Finally, we will review online materials provided by state-level peer certi cation organizations, as speci ed by SAMHSA's