The ROSE model stands for R: Recognition of Peer Work, O: Organizational Support, S: Skill Development and E: for Everyone (Fig. 1). The overarching aim of the ROSE model is to increase support for peer workers in overdose response settings. The objectives of the ROSE model are to: 1) Facilitate equitable access to resources for peer workers, enabling them to stay motivated and work optimally in a stressful work setting, with reduced emotional, mental and social stress, 2) Provide training and education for peer workers to improve their skills and gain professional self-confidence, and 3) Increase awareness and recognition among individuals without lived/living experience about the crucial work done by peer workers in overdose response settings.
Through these objectives, the ROSE model aims to facilitate culture change within organizations, leading towards a more equitable and just workplace. This, in turn, will lead to a positive impact at various socio-ecological levels, including improved self-confidence of peer workers at the individual level, formation of social networks and relationships with colleagues and other professionals at the interpersonal and community levels, more equitable and just workplaces at the organizational level, and ultimately a more accepting and less stigmatizing society.
Each component of the ROSE model consisted of several strategies informed by theory, evidence, and the lived/living experience of PRAs (Fig. 1). Details of the strategies within each component are specified below.
Recognition of Peer Work
As described in another paper (37), one of the top issues encountered by peer workers is that they felt they are not taken seriously or given due respect by their work colleagues or other professionals they encounter in their work. This is manifested in various forms, including inequity in the workplace, lack of basic workplace resources, and strained relationships with other service providers (37).
To address this issue, three primary strategies were identified and implemented under the “Recognition” component of the ROSE model. First, peer workers identified the need for basic resources such as photo identity cards (ID cards) and business cards as tangible symbols of professionalism, authority and validity within their roles. Pilot sites were provided with portable ID card printers and business card templates so that all peer workers employed could receive their individual photo IDs and business cards.
Secondly, to create awareness about the work done by peer workers, a video titled #PeerLife, featuring a day in the life of a peer worker, was developed (50). This video featured the story of four peer workers, one from each of the pilot sites, and their day-to-day work in the face of the overdose crisis. The video highlights the harsh realities faced by peer workers and encourages recognition and appreciation for their work. This video is available on YouTube, has been promoted through social media, and featured on the Toward the Heart website.
A third strategy that was recommended was meet and greet events between peer workers and other professionals including police and paramedics. The purpose of these events was to foster relationship-building and to raise awareness about the crucial roles fulfilled by peer workers.
The strategies under the “Recognition” component span across multiple levels of the socio-ecological model. Provision of photo IDs and business cards to peer workers, for example, constitute organizational-level interventions, while meet and greet events foster inter-personal relationships between peer workers and other professionals. These relationships, in turn, can help to improve peer workers’ work experience (organizational-level) and may address negative attitudes and stigma towards peer workers (societal-level). Similarly, the #PeerLife video, which creates awareness about the role of peer workers is a societal-level intervention since it is a first step towards addressing stigma and negative attitudes towards PWUD (see Table 2).
Peer workers indicated that their work is stressful and despite their wholehearted commitment to the job (36, 37), their lack of organizational and mental health supports to mitigate their stresses creates notable dissatisfaction. Lack of such resources often led to low morale and burnout (37).
As highlighted in another paper, many peer workers indicated a lack of job clarity and formalized contracts with their organizations, leading to poor working conditions and relegation to menial labour by supervisors and co-workers (37). Inequitable pay, despite the similar nature of work done by support workers without lived/living experience, was another issue.
The “Organizational Support” component of the ROSE model consists of several strategies to address these issues. To create role clarity, formal job descriptions were created, which solidified the role of peer workers and suggested a living wage based on BC’s peer worker pay standards (23, 51). Formal employment contracts which detailed the terms and expectations of employment were also developed. These documents were implemented at the pilot sites and templates of these documents were compiled into a Best Practice Manual to Support Peer Workers and made publicly available for other organizations to adapt based on their needs (52).
Additionally, two roles were created at one of the pilot sites which is a peer-led organization. The first one was the role of the Peer Supporter. A person with lived/living experience of substance use was hired into this role to provide a listening ear and peer-to-peer debriefing. This role was informed by literature which indicates that shared experience helps to facilitate trust, understanding and a special bond of care and comfort (36).
The second role was that of a Systems Navigator. A person with lived/ living experience of substance use was hired as a Systems Navigator to support peer workers in navigating access to external services. These included a variety of supports such as assisting with access to harm reduction services, accompanying peer workers to healthcare visits, providing legal support, supporting peer workers to apply for their government identification cards, providing assistance to complete housing applications and income assistance forms, providing referrals and reference letters for housing applications, and referring peer workers to detox or treatment, if desired. The Systems Navigator also builds relationships with external service providers and researching services to acquaint themselves with these systems and provide easy referrals to peer workers. As such, the Systems Navigator can assist in decolonizing access to external resources by acting as the stepping stone that is absent for people who use substances in most administrative systems.
Another strategy under the “Organizational Support” component included teambuilding days. These were organized to boost the morale of peer workers and allow them to de-stress and unwind. For each pilot site, teambuilding days were organized twice a year and included fun and celebratory activities, such as bowling and holiday parties.
In addition to addressing the needs of the peer workers identified during the focus groups, the “Organizational Support” component of the intervention also provided resources that were identified during the bi-weekly check-in and progress meetings with the whole team, including the PRAs. One such resource was the need for pulse oximeters in response to increasing reports in BC of substances containing mixtures of opioids and benzodiazepines and the identification of unregulated etizolam in urine drug screens (53–55), causing people to remain unconscious long after blood oxygen levels have returned to the normal range after naloxone administration (53–55). Pulse oximeters aid in identifying when oxygen levels are within normal range and rescue breaths are not needed, which is of particular importance since the onset of the COVID-19 pandemic.
Like strategies in the “Recognition” component, the “Organizational Support” interventions span across multiple levels of the socio-ecological model. For example, the Peer Supporter role is an organizational-level intervention, however, peer workers may realize improved mental health through engagement with the role, which is an individual-level factor. Similarly, the hiring of a Systems Navigator is done at the organizational level, but through relationship-building and referrals, this role is able to increase peer workers’ access to external community resources, thus also operating at the community level. Teambuilding days help to improve relationships between colleagues (interpersonal) and boost morale and motivation (individual). Through the implementation of organizational supports, the ROSE model has the potential to challenge the norms and address the negative attitudes and stigma towards peer workers both within the organization (organizational) and in society in general (societal) (See Table 2).
During the focus groups, peer workers identified skill development as a need and suggested the topics they would find helpful in their work. As described in another paper, peer workers felt that organizations tend to value formal education and certification over their lived/living experience (37). As such, peer workers were keen to gain some formal training and certifications to increase their self-confidence and capacity. Identified training needs ranged from technical skills to people skills and self-care skills. Technical skills identified included first aid and CPR, recognition of signs and symptoms of mental health disorders, naloxone administration and use of pulse oximeters. Under people skills, peer workers identified the need for training in conflict resolution and de-escalation, communication skills, peer debriefing skills and cultural safety. Self-care skills included mindfulness and self-defence.
For some topics, such as first aid, well-recognized external training already existed. In such cases, peer workers were supported to attend these external trainings and earn certification. In addition to providing peer worker training on topics identified during the focus groups, several other training materials were developed to meet the circumstantial needs of peer workers. For example, with the onset of COVID-19, information sheets and training videos on responding to overdoses in light of COVID-19 were developed.
For topics which lacked existing training tailored for peer workers, the team is currently developing a standardized BC peer worker training curriculum. It is critical that peer worker training or capacity-building be tailored to the realities of people who use substances as many workplace training programs are designed for people without lived/living experience of criminalization or other impacts of drug use.