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International Journal of Nursing Studies 40 (2003) 321332

Peer support within a health care context: a concept analysis


Cindy-Lee Dennis*
Faculty of Nursing, University of Toronto, 50 St. George Street, Toronto Ont., Canada M5S 3H4

Received 22 April 2002; received in revised form 22 April 2002; accepted 10 October 2002

Abstract

Peer support, and the integration of peer relationships in the provision of health care, is a concept of substantial
signicance to health scientists and practitioners today, as the focus shifts from the treatment of disease to health
promotion. If the nursing profession is to effectively incorporate peer relationships into support-enhancing
interventions as a means to improve quality care and health outcomes, it is essential that this growing concept be
clearly explicated. This paper explores the concept of peer support through the application of Walker and Avants
(Strategies for Theory Construction in Nursing, 3rd Edition, Prentice-Hall, Toronto, 1995) concept analysis
methodology. This analysis will provide the nursing profession with the conceptual basis to effectively develop,
implement, evaluate, and compare peer support interventions while also serving as a guide for further conceptual and
empirical research.
r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Peer support; Concept analysis; Theory development; Nursing science

1. Introduction Recognition of peer supports salutary impact on


health outcomes (Lakey and Cohen, 2000) is reected in
The importance of social relationships in the treat- recent trends where health care has become more health-
ment of disease and the maintenance of health and well- promoting and disease-preventing (Stewart and Tilden,
being has drawn the attention of scientists and practi- 1995). Acknowledging the greater benets of preventing
tioners across a large number of behavioural science and illness rather than treating it, health promotion not only
health disciplines. Prospective population studies have encompasses nutrition, weight control, exercise, and
established associations between measures of social stress management but also the enhancement of
relationships and mortality, psychiatric and physical supportive relationships within an interpersonal net-
morbidity, and adjustments to and recovery from work (Stewart and Tilden, 1995). To substantiate this
chronic diseases. Furthermore, interventions designed view, the World Health Organization (1998) has
to alter the social environment and the individuals identied strengthening social relationships as a health
transactions within it have been successful in facilitating promotion strategy, while the augmentation of suppor-
psychological adjustment, aiding recovery from trau- tive resources, through health promotion mechanisms
matic experiences, and even extending life for indivi- such as mutual aid and healthy environments, has been
duals with serious chronic disease (Cohen et al., 2000). endorsed by the Ottawa Charter for Health Promotion
Theoretically embedded within the social relationship (Epp, 1986).
construct (Fig. 1), peer support is a salient concept for While health-promoting strategies continue to under-
the nursing profession. pin the contemporary health-care system, nances have
led the delivery of health services in another direction.
*Tel.: +1-416-946-8608. Rapidly expanding medical specialization and technol-
E-mail addresses: cindylee.dennis@utoronto.ca ogy, while raising the quality of care for some
(C.-L. Dennis). individuals, has also led to less desirable effects

0020-7489/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 9 2 - 5
322 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332

Fig. 1. Social relationship classication.

including upwardly spiralling costs, shortened hospital application is vague and highly variable, although its
stays, limited access to care, and reduced interpersonal benets continue to be sought after as a means for
communication between health professionals and their improving health outcomes. The purpose of this paper is
clients (Eng and Young, 1992). Consequently, during to provide an enhanced understanding of peer support
times of need individuals turn to social relationships for using Walker and Avants (1995) concept analysis
support in response to barriers or deciencies encoun- methodology as a general guiding framework. In
tered in the present health-care system. Accompanying particular, dening attributes, antecedents, conse-
nancial limitations, changing population demo- quences, and related concepts will be discussed following
graphics, longer life expectancy, and an increase in a wide-ranging literature review. The goal of the analysis
chronic, long-term illness have resulted in the shift of is to provide conceptual renement in order to assist the
responsibility for care to communities, again situating nursing profession in the development, measurement,
social relationships central to the delivery of health-care and evaluation of peer interventions. This analysis will
(Stewart and Tilden, 1995). Recognizing that health also promote consistency in the implementation of these
professionals alone are unable to address evolving interventions, thereby aiding in the comparability of
health needs, consumers have brought the self-help research ndings and program evaluations.
movement centre stage in the health care arena (Stewart
and Tilden, 1995). This movement specically incorpo-
rates peer lay individuals with experiential knowledge 2. Methods
who extend natural (embedded) social networks and
complement professional health services. In recognition Using the concept analysis methodology proposed by
of the importance of social relationships, a proliferation Wilson (1969) and described by Walker and Avant
of health-care services that incorporate peers in the (1995), several steps are performed beginning with
delivery of support-enhancing interventions has been concept selection and purpose delineation. After all the
instituted in industrialized countries to meet consumer uses of the concept are dened within an outlined
demand. context, diverse cases are constructed, antecedents and
Within this dynamic environment, peer support has consequences are identied, and related concepts are
become a signicant element in the delivery of quality described. However, according to Walker and Avant
health care (Cox, 1993; Eng and Young, 1992). As such, (1995), there are no rules for accomplishing this analysis
it is essential that the nursing profession have a clear and and the steps above should been viewed as a guideline
concise understanding of this concept. Unfortuna- for the intellectual work. Thus, in this concept
tely, peer support is a complex phenomenon whose analysis, no cases are constructed but rather a detailed
C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332 323

description of the literature is presented and an strengthen morally; to be or provide an argument in


enhanced discussion of the consequences and related favour of or additional evidence for; to bear, endure; to
concepts are offered. bear the cost of providing for; to give assistance to; to
Peer support has been the focus of commentary and act with in a secondary role; to second and (b)
investigation by varied disciplines for several decades. supporting or being supported; someone who or
To delineate the current use of peer support within the something which supports; a means of sustenance.
health care arena, only literature published primarily Similarly, the Oxford Dictionary of Current English
within the past 1015 years from the social-psychologi- (1991) denes support as: (a) carry all or part of
cal, health-care, and medical domains were reviewed. weight of, keep from falling or sinking or falling;
Coopers (1982) ve approaches were used to retrieve provide for; strengthen, encourage, give help or corro-
the sample of studies for this concept analysis: the boration to; speak in favour of; be actively interested in;
ancestry approach, descendancy approach, on-line take secondary part to; endure, tolerate and (b)
computer search, and to a lesser extent, informal supporting or being supported; someone who or
contacts and abstracting services. The following on-line something which supports; a means of sustenance.
databases were searched for the 15-year period: Similarly, the Oxford Dictionary of Current English
CINAHL, Medline, Psych Info, and Social Work (1991) denes support as: (a) carry all or part of
Abstract. Due to the vastness of the literature, studies weight of, keep from falling or sinking or falling;
demonstrating conceptual complexity or intervention provide for; strengthen, encourage, give help or corro-
diversity were selected to provide the broadest depiction boration to; speak in favour of; be actively interested in;
of peer support. Moreover, this literature addressed the take secondary part to; endure, tolerate and (b)
concept in relation to several distinct populations, which supporting or being supported; person or thing that
were classied into the following three domains: supports. Synonyms for support include: hold up,
(a) transitional stressors (e.g. childbirth, bereavement), sustain, aid, encourage, fortify, endorse, and advocate
(b) situational stressors (e.g. chronic and acute), and (c) (Landau and Bogus, 1990).
health promotion (e.g. healthy behaviours). Finally, Based on these linguistic denitions, the concept peer
because peer support has not been explicitly dened in support could be dened as the giving of assistance and
the literature, specic activity and intervention descrip- encouragement by an individual considered equal.
tors are presented. However, this rudimentary interpretation is too simplis-
tic to be meaningful, leading to the further exploration
of peer support as dened in the health literature.
3. Result
3.2. Literature review
3.1. Defining peer support
3.2.1. Transitional stressors
Etymological investigation of the noun peer leads to A myriad of research has focused on the relevance of
par, the Latin word for equal. The New Lexicon peer support with individuals who have undergone
Websters Encyclopaedic Dictionary (Cayne and maturational or developmental life transitions. In
Lechner, 1988) denes the noun term as follows: a particular, childbearing women have received consider-
member of one of the British degrees of nobility: a duke, able attention centring on the use of peer interventions
marquis, earl, viscount, or baron; a nobleman of any to enhance prenatal care among low-income women
country; someone having the same status in rank, age, (Lapierre et al., 1995) and improve perinatal outcomes
ability, etc. as another. The Oxford Dictionary of in teenagers (Heins et al., 1987), Hispanic migrant
Current English (Allen, 1991) denes the noun peer as farmworkers (Warrick et al., 1992), and high-risk
one who is equal to another in rank, standing, merit, mothers (Snyder, 1988). Integrated into the postpartum
etc.; member of one of the degrees (duke, marquis, earl, period, the augmentation of social relationships through
viscount, baron) of nobility in the United Kingdom. In general mother-to-mother support groups (Cronenwett,
addition to lexicon denitions, synonyms for peer 1980) and telephone interactions (Gosha and Brucker,
include: equal, equivalent, match, colleague, and com- 1986) have been advocated, while diverse breastfeeding
peer (Roget, 1990). peer support interventions have been shown to signi-
Likewise, the term support is etymologically derived cantly improve breastfeeding outcomes among middle-
from the Old French word supporter, originally income Caucasian mothers (Dennis et al., 2002) and
acquired from the Latin word porto which means to low-income Native American (Long et al., 1995),
carry. The New Lexicon Websters Encyclopaedic African-American (Cauleld et al., 1998), Mexican
Dictionary (1988) notes two uses of the term support: (Morrow et al., 1999), urban (Kistin et al., 1994) and
(a) to carry the weight of; to prevent from falling, rural (Schafer et al., 1998) women. Peer support also has
sinking, etc.; to be actively in favour of; to assist or been employed to facilitate adjustment in women
324 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332

suffering from postpartum depression (Jones et al., individuals with psychiatric disabilities prepare for and
1995), enhance coping and behavioural management maintain employment (Mowbray et al., 1994, 1996).
skills with mothers of excessively crying infants (Wolke Transcending traditional health care delivery settings,
et al., 1994), and improve the mental health of mothers unique peer interventions have been developed to
and young children by buffering the effects from families address distinctive needs such as community-based
with signicant psychosocial morbidity (Cox, 1993). HIV walk-in clinics for gay men (Levinson and Miller,
Peer interventions also have been applied to indivi- 1992) and on-line computer-mediated support groups
duals experiencing signicant losses. Community-based for women with breast cancer (Weinberg et al., 1996). In
peer support organizations have been developed to comparison to client-oriented care, peer interventions
augment embedded social networks and alleviate social have emerged for caregivers such as family members of
isolation while indirectly reducing the number of stroke victims and parent-to-parent support programs,
physician visits (Tudiver et al., 1995). For example, an which offers personalized services by incorporating
independent charitable organization entitled Commu- veteran parents of children with disabilities (Santelli
nity Contacts for the Widowed (Roger et al., 1980) et al., 1997; DeNardo et al., 1995; Hartman et al., 1992).
offered group and one-to-one support through the Although not as targeted as the chronic domain,
employment of peers called widow contacts. Simi- health professionals have investigated the effects of peer
larly, hospital-based interventions, such as group grief support on acute stressors. For example, Taylor and
therapy, have been suggested to promote coping and Bledsoe (1986) examined the efcacy of peer support, in
surviving strategies in gay men experiencing multiple combination with other treatments, on health outcomes
losses (Maasen, 1998). of women experiencing premenstrual syndrome. Peer
interventions also have been applied to address social
3.2.2. Chronic and acute situational stressors problems such as substance abuse and homelessness
Facilitating adjustment to long-term disabilities or (Galanter et al., 1998) and retention in a cocaine
chronic diseases, in both individuals and caregivers, is aftercare program for recovering women (Coughey
another area where the benets of peer support have et al., 1998). Henderson (1995) examined abused women
been advocated (Olsson et al., 1997; Payne, 1995). and the effect of both individual and group peer-
Within the traditional self-help/support group setting, provided social support in a crisis setting. It is
peer interventions have been used with adults managing noteworthy to mention that while the division into
diabetes mellitus (Powell, 1988), adolescents experien- stressor types is useful, it is important to consider that
cing chronic renal failure (Gorynski and Knight, 1992), some problems have various stages to resolution. For
individuals suffering from head injuries (Schwartzberg, example, substance abuse could be a transitional (e.g.
1994; Schulz, 1994), and couples coping with a cardiac transition to sobriety), acute (e.g. drug rehabilitation),
condition (Stewart et al., 2001). In addition, distinct or chronic (e.g. as per the AA model) stressor.
programs have incorporated one-to-one sessions be-
tween peers and individuals who have experienced breast 3.2.3. Health promotion
cancer (Rinehart, 1994) and the loss of vision (Kleinsch- Health promotion interventions embody a unique
midt, 1996). While peer-based home visits have been application of peer support. Within such interventions,
used with individuals who suffer from long-term mental peer roles are immensely diverse with typically a
illness (Bradshaw and Haddock, 1998) and renal disease heightened emphasis on the diffusion of information
(Roy and Atcherson, 1983), telephone-based interven- and positive encouragement and a diminished accent-
tions have been applied to lonely low-income elderly uation on emotional counselling. While Albrecht and
women (Heller et al., 1991) and individuals aficted with Peters (1997) integrated peers as case managers to
haemophilia and HIV/AIDS (Stewart et al., 2001). Some address an extended array of health problems ranging
peer interventions are part of a long-term program, from substance abuse to gang violence, the majority of
while other are time-limited, such as the school-based health promotion interventions focus on a specic health
self-management series for youth with chronic health behaviour. Of particular interest is the use of peers in
conditions (Magyary and Brandt, 1996) and the AIDS and STD prevention among African-American
healthy bladder habits course for seniors suffering drug-dependent women (Harris et al., 1998), middle
from urinary incontinence (Newman et al., 1996). school youth (Kirby et al., 1997), adolescent females
Contrary to the familiar volunteer role, peers have been (Guthrie et al., 1996), and prison inmates (Vaz et al.,
paid by health professionals to function as team 1996). Cancer screening and prevention are other
members. This specic type of peer support has been prevalent health promotion interventions that incorpo-
applied in the Parent Advocate Program, as part of a rate aspects of peer support. Within these community-
paediatric haematology/oncology service (Carpenter based programs, peers have been utilized to increase
et al., 1992) and in the Work Incentives and Needs colorectal cancer screening among socio-economically
Study (WINS), where peer counsellor specialists help disadvantaged elderly individuals (Weinrich et al., 1993),
C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332 325

mammography use among women aged 65 and older may be differentially useful for various stressors and
(Janz et al., 1997), and cancer-screening examinations health outcomes. For example, peer interventions with a
among Latinos (Navarro et al., 1995). Peer interventions health promotion focus typically have a stronger
with adolescent and school age populations are also informational component originally and later integrate
prevalent; these programs have addressed the develop- appraisal and emotional support for reinforcement,
ment of healthy coping patterns (Carty, 1991), conict while programs for newly diagnosed individuals provide
resolution skills (Giuliano, 1994), and injury prevention increased emotional support initially. Despite the
attitudes (Tenn and Dewis, 1996), and facilitated various combinations, all peer interventions include
comprehensive violence (Kelder et al., 1996) and drug some degree of informational, appraisal, and emotional
prevention interventions (Dorsch, 1997; Klepp, 1986). support. It is noteworthy to mention that instrumental
support (e.g. the provision of practical help or tangible
3.2.4. Summary aid) (Wills and Shinar, 2000) does occur rarely as a
The preceding literature review highlights the multi- supportive function in peer relationships but due to its
faceted nature of peer interventions. Peer support can be infrequency it is not a dening attribute. In particular,
provided through multiple modes of interaction (e.g. the literature clearly demonstrated that peer support
individual one-to-one sessions, self-help/support groups, primarily occurs without the provision of instrumental
on-line computer-mediated groups, or within an educa- support.
tional milieu), in diverse settings (e.g. home, hospital,
walk-in clinic, community organization, school, prison, 3.3.1. Emotional support
or via telephone/computer) through various providers During the course of life, individuals encounter
(e.g. community- or hospital-based professional pro- threats to ones self-esteem that raise doubts about
grams or volunteer organizations), and incorporate a ability, social attractiveness, or career performance
variety of roles (e.g. educator, advocate, leader, coun- (Wills, 1985). The availability of an individual to discuss
sellor, mediator, linking agent, or cultural translator) personal difculties with is a strong interpersonal
with varying degrees of involvement (e.g. as the primary resource to counteract the effects of self-esteem threats;
intervention or part of a comprehensive program) and this supportive function has been termed emotional or
structure (e.g. highly formalized versus informal indivi- esteem support (Wills and Shinar, 2000). While the
dualized interventions). In addition, peer interventions specic mechanisms through which emotional support
extend across numerous demographic variables and assists to enhance or restore self-esteem is uncertain,
encompass disease-related, illness-preventive, and researchers suggests that emotionally supportive inter-
health-promoting topics. Even though there are multiple actions generally include expressions of caring, encour-
applications, the actual provision of peer support agement, attentive listening, reection, reassurance, and
comprises of specic common attributes that span all commonly avoid criticism or exhortatory advice-giving
settings, structures, and modes of delivery. (Helgenson and Gottlieb, 2000). Such exchanges foster
the experience of feeling accepted, cared for, admired,
3.3. Defining attributes empathized, respected, and valued despite profound
personal difculties (Cronenwett, 1983; House, 1981;
Through an in-depth examination of the literature, Norbeck et al., 1981; Cobb, 1976).
three critical attributes emerged repeatedly in the
descriptors of peer interventions: emotional, informa- 3.3.2. Informational support
tional, and appraisal support (Fig. 2). These attributes If difculties cannot be readily resolved, individuals
are the supportive functions of peer relationships and frequently seek information (Wills, 1985). Through the

Fig. 2. Conceptual distinctions of peer support.


326 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332

mechanisms of advice, suggestions, factual input, and understand the target populations situation in a way
feedback (Burleson et al., 1994), informational support that naturally embedded social networks may not.
is the provision of knowledge relevant to problem- Researchers suggests that in distressing times, social
solving and includes (a) availability of relevant re- network members may not respond positively, partly
sources, (b) independent assessments regarding problem from an inability to appreciate the stressful experience
aetiology, (c) alternative courses of action, and (d) and partly from feeling threatened (Helgesson and
guidance about effectiveness (Wills and Shinar, 2000). Gottlieb, 2000). Furthermore, assimilating new knowl-
edge and appraisals through the mutual exchange of
3.3.3. Appraisal support wisdom (Borkman, 1976) occurs more effectively when
Many life stressors are not effortlessly resolved, have presented by peers with whom individuals identify with
considerable future implications, and necessitate persis- and share common experiences. As research has
tence and endurance. Appraisal support, also referred to demonstrated, the more homogeneous the peer relation-
as afrmational support, involves the communication of ships are, the more likely the support will lead to
information that is pertinent to self-evaluation and understanding, empathy, and mutual help (Helgesson
encompasses expressions that afrm the appropriateness and Gottlieb, 2000). These peer interventions give
of emotions, cognitions, and behaviours (House, 1981; credence to personal involvement and experiential
Kahn and Antonucci, 1980). Specic mechanisms include knowledge, which in turn facilitates a cathartic and
motivational aspects such as encouragement to persist in empathetic dimension to the interventions (Stewart,
problem resolution, reassurances that efforts will result in 1990). Founded on this mutual identication, shared
positive outcomes, assistance to endure frustration, and experience, and sense of belonging, there is evidence to
communication of optimism (Wills, 1985). Together, suggest that peer support positively affects psychological
these interactions generate positive future expectations. and physical health outcomes (Cohen et al., 2000;
Helgesson and Gottlieb, 2000) via direct, buffering,
3.4. Antecedents and mediating effect models.

Prior to the provision of peer support, specic 3.5.1. Direct effect model
activities are required to transpire. Due to the diverse This model posits that peer support directly inuences
application of peer support in various health situations, health outcomes through various mechanisms. One such
antecedent specicity has been kept sufciently broad to method is social integration and the extent to which an
facilitate generalizability. For a peer relationship to individual participates in a broad range of social
ensue at least two individuals are united in a health- relationships. Incorporation into peer relationships can
related situation and willing to participate in, and have enhance social integration, which has been linked to
the ability to receive and respond to, a social interaction improved longevity and survival from myocardial
involving personalized symbolic, dialogic, and non- infarction and breast cancer and decreased depression,
verbal communications (Stewart, 1990). The peer is a reoccurrence of cancer, and susceptibility to infectious
created source of support, internal to a community (Hill illnesses (Berkman, 1985; Helgeson et al., 1989; Seeman,
et al., 1996), who shares salient target population 1996). Similarly, peer relationships may reduce feelings
similarities (e.g. age, ethnicity, health concern, or of isolation, a condition associated with increased
stressor) (Giblin, 1989) and possesses specic knowledge negative affect and sense of alienation and diminished
that is concrete, pragmatic, present-oriented, and feelings of control and self-esteem (Cohen et al., 2000).
derived from personal experience rather than formal Participation in peer relationships also provides ex-
training (Borkman, 1976). This experiential knowledge panded access to multiple sources of information,
and target population representation determine peer thereby increasing the probability of receiving appro-
appropriateness and selection is based on self-referral or priate information to inuence health behaviours while
assessments by health professionals/program develo- subjecting individuals to social controls and pressures
pers. Training is structured to orient the peer to program that induce normative behaviours through the regula-
objectives and the promotion of skills that enable the use tion of responses and prevention of extreme reactions
of experiential knowlege and peers unique understand- (Rook; 1990; Rook et al., 1990). Finally, peer relation-
ing of the target population. While program-specic ships may offer informal health care, which may prevent
training is essential, minimization should be practiced to minor illnesses from developing into more serious
ensure the preservation of peerness (Giblin, 1989). diseases, encourage help-seeking behaviours, ensure
adherence to medical regimes, and increase motivation
3.5. Consequences for self-care (Brissette et al., 2000; Cohen et al., 2000;
Cohen, 1988). In summary, within the direct effect
The rationale for incorporating peers in support- model, peer support can inuence health outcomes
enhancing interventions rests on the notion that peers by: (a) decreasing isolation and feelings of loneliness,
C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332 327

(b) swaying health practices and deterring maladaptive oneself for causing the stressor or adversity thus
behaviours or responses, (c) promoting positive psycho- preventing active coping efforts to be hampered by
logical states and individual motivation, (d) providing self-recriminations (Cohen and Syme, 1985; Gottlieb,
information regarding access to medical services or the 1985; Lakey and Cohen 2000; Thoits, 1995).
benets of behaviours that positively inuence health
and well-being, and (e) preventing the risk for, progres- 3.5.3. Mediating effect model
sion of, and recovery from physical illness. The mediator model predicts that peer support acts as
an intervening variable indirectly inuencing health
3.5.2. Buffering effect model through emotions, cognitions, and behaviours (Stewart
The buffering effect model proposes that peer support and Tilden, 1995). One way to clearly demonstrate the
either protects individuals from potentially harmful health enhancing effects of this model is to analyse the
inuences of stressful events or determines individual self-efcacy concept. Based on Banduras (1977, 1986)
responses to potentially stressful events (Cohen et al., social cognitive theory, self-efcacy is dynamic cognitive
2000; Cohen and Syme, 1985). This model is guided by process in which individuals evaluate their perceived
Lazarus and Folkmans (1984) theory where coping ability to perform a specic task or behaviour. This
involves the changing of cognitive and behavioural perception is a salient variable in that it predicts (a)
efforts to manage specic external environmental and/or whether an individual chooses a particular behaviour,
internal demands that are appraised as taxing or (b) how much effort they will expend, (c) whether they
exceeding the resources of the individual. The coping will have self-enhancing or self-defeating thought
process incorporates the dual goals of problem-resolu- patterns, and (d) how they will emotionally repond to
tion and emotion-regulation while employing affective, difculties encountered. As such, highly efcacious
cognitive, and behavioural response systems. individuals are more likely to master behaviours due
Chronologically, the cognitive system is rst engaged to increased initiation and perseverance in attempts than
when the individual is exposed to a stressor. Here, the those individuals with low self-efcacy who tend to
individual attempts to discern the signicance of the avoid situations that stress their capabilities (Bandura,
stressor for their well-being, interpreting it as either a 1977).
source of harm, threat, or challenge. This primary In choosing, performing, and maintaining a beha-
appraisal process precedes secondary appraisals where viour, individuals weigh four sources of self-efcacy
an individual assesses the availability of coping information: (a) performance accomplishments (e.g.
resources, both personal and environmental. It is here previous attempts), (b) vicarious experiences (e.g. ob-
that peer support may play a pivotal role in moderating servation of others), (c) verbal persuasion (e.g.
the individuals behaviour, and thus, their ability to encouragement from inuential others), and (d) physio-
master stressor demands. Peer relationships may inu- logical responses (e.g. fatigue, stress, anxiety) (Bandura,
ence the primary appraisal process not only through 1986). Peer relationships can modify an individuals self-
direct responses, such as the provision of information efcacy through inuencing these sources of self-efcacy
about the nature of the stressor and active efforts to information.
alleviate or diminish it (e.g. the suggestion of problem- Personal experiences are often the most immediate
solving techniques), but also indirect responses involving and powerful source of efcacy information as success-
social comparison. In particular, comparison of emo- ful performances increase self-efcacy, whereas repeated
tional responses may augment or diminish an indivi- failures diminish it (Bandura, 1986). However, the effect
duals condence in their ability to overcome a threat of actual experience on self-efcacy is modied by
depending on how the reference group reacts. For individuals interpretations of their performance and the
example, if a peer responds calmly, it increases the desired outcome. Attention to successful or improved
chance that the stressor will be interpreted more aspects of performance or outcomes tends to enhance
benignly; however, if the peer shows signs of arousal it perceptions of self-efcacy, whereas observance to
is probable that the stressor will be subjectively unsuccessful aspects of the performance has a diminish-
interpreted as more threatening. Within this model, ing effect (Bandura, 1986). As such, performance
peer support can buffer the inuence of stress on health appraisals from peers can have a colossal effect on
by: (a) redening and reducing the potential for harm self-efcacy perceptions.
posed by the stressor, (b) broadening the number of The impact of observational learning is contingent on
coping resources, (c) discussing coping strategies, role model attributes as well as on the manner in which
problem-solving techniques, and counter-responses demonstrations are performed. The most effective role
thereby moderating the initial appraisals of the stressor, models are those who are most similar yet more
(d) highlighting norms through social comparison which competent at the modelled behaviour (Perry and
prescribe adaptive behaviour, (e) inhibiting maladaptive Furukawa, 1986). In particular, individuals more readily
responses, and (f) counteracting the propensity to blame assimilate new knowledge when presented by peers in a
328 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332

context where there is the promotion of mutual to indigenous qualities or target population repre-
identication and shared common experience (Stewart, sentation.
1990). This vicariously derived information can alter
perceived self-efcacy not only through social compar- 3.6. Related concepts
ison but also through teaching effective coping strategies
and conveying information about the ability to control The foregoing discussion describes multiple facets of
and predict behaviour performance. Furthermore, in- peer support, contextual factors salient for its occur-
dividuals often accept appraisals and verbal persuasion rence, and potential health consequences. However,
from similar others as valid assessments of their own conceptual discrepancies are apparent in the literature
abilities (Bandura, 1986); the more credible the indivi- particularly in relation to the provision of peer support.
dual providing verbal persuasion, the greater the While the two following conceptsnatural lay helpers
potential to affect perceptions of self-efcacy. Finally, and paraprofessionalseach comprise of a specic type
individuals make inferences about their abilities from of social relationship, there is no proffering of peer
emotional arousal and other physiologic cues experi- support. To clarify any misconceptions, these two
enced while enacting a behaviour or anticipating its related concepts will be described and the conceptual
performance (Bandura, 1986). Positive interpretations of differences delineated.
arousal, such as excitement or satisfaction, enhance self-
efcacy while negative interpretations, such as pain, 3.6.1. Natural lay helpers
fatigue, anxiety, or stress, can reduce ones sense of self- Natural lay helpers are individuals to whom others
efcacy. Through anticipatory guidance and normal- naturally turn for advice, emotional counselling, and
izing specic arousals, peers can positively inuence tangible aid (Eng and Smith, 1995). In most commu-
individuals interpretations. nities, these individuals have a reputation for good
Within the mediating effect model, peer relationships judgment, sound advice, a caring ear, and discretion.
can indirectly inuence health by: (a) assisting in the People often turn to such individuals embedded in their
interpretation and positive reinforcement of perfor- social network as a rst contact person when
mance accomplishments, (b) providing vicarious experi- addressing health concerns prior to, or in lieu of,
ence and observational learning through role modelling, seeking professional help and accessing the formal
(c) offering opportunities for social comparisons to health-care system. Often a neighbour, friend, or co-
promote self-evaluations and motivation, (d) teaching worker, these natural lay helpers are different from peers
coping strategies and conveying information about in that (a) experiential knowledge or mutual idenitica-
ability, (e) positively interpreting emotional arousal, tion are not dening attributes of the support provided,
and (f) encouraging cognitive restructuring through (b) they are not created social networks, and (c) they
anticipatory guidance. generally do not work in professional programs or
community organizations, extend existing services, or
3.5.4. Adverse outcomes reach and motivate the population to use and comply
While peer support has numerous favourable con- with existing regimens of care (Eng and Smith, 1995). As
sequences, modest attention has been paid to the noted by Israel (1985), their usual helping is so
potential adverse outcomes. These negative results may embedded in their daily lives that it is often an
incorporate conict, criticism, failed social attempts, unrecognised function. An example of the use of natural
emotional over-involvement resulting in contagion lay helpers can be found in the Save Our Sisters
stress, reinforcement of poor behaviors, diminished Project (Eng, 1993), which aimed to reach older, black
feelings of self-efcacy, lack of stability, and shadow women through existing kin, friendship, and job net-
work in which an informal, parallel economy supports works to inuence breast cancer screening.
the formal, market-based economy (Heller et al., 1991;
Illich, 1981; Marshal et al., 1990; Rook, 1984; Stewart 3.6.2. Paraprofessionals
and Tilden, 1995). Furthermore, while potentially a When developing interventions, the training of peers
cost-effective intervention, the possibility of exploitation is a necessary condition that requires caution in order to
or overburdening exists through the inappropriate avoid professionalisation and the subsequent creation of
use of peers as a replacement for professional services. paraprofessionals. When peers are professionalized,
Pragmatic issues are also of consequence as poor their talents and accountability to the target population
work habits, such as assignment neglect, inadequate are shifted to the health-care system, diminishing their
communication, and short notice of vacations or mutual identication, credibility, and commonality with
resignations, have been reported (Giblin, 1989). clients (Eng and Smith, 1995). Unfortunately, the
However, selection of peers should not be based on amount of training required to create a paraprofessional
middle-class work ethics, which may be compatible is uncertain, necessitating additional research. An
with meeting program objectives but antagonistic example is McFarlane and Wiists (1997) mentor
C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332 329

mother program to prevent abuse during pregnancy profession is to effectively incorporate peer relationships
where experienced mothers from the community were into support-enhancing interventions as a means to
hired and an initial 23-h training session consisted of improve quality care and health outcomes, it is essential
three parts: (a) advocacy preparation, (b) counselling that this concept be clearly explicated. To address this
and crisis intervention, and (c) philosophy and process need, the preceding concept analysis was conducted and
of peer advocacy. Following this classroom training the following denition has been determined: peer
were weekly educational seminars and eld trips to support, within the health care context, is the provision
referral agencies and organizations. In addition, the of emotional, appraisal, and informational assistance by
experienced mothers received specialized domestic vio- a created social network member who possesses
lence instructions by the district attorneys ofce and experiential knowledge of a specic behaviour or
police department to learn how to assess protective stressor and similar characteristics as the target popula-
orders, magistrates orders, and implications of the tion, to address a health-related issue of a potentially or
states new spousal exemption law. With all this training actually stressed focal person. Antecedents of peer
were these experienced mothers still peers or were they support have been delineated and the potential positive
now paraprofessionals? health consequences have been explored through direct,
buffering, and mediating effect models. While the
benets of peer support have been highlighted, attention
4. Conclusion was also given to the possible adverse effects. Finally, it
was noted that conceptual inconsistencies in the
This paper highlights one possible strategy towards an literature have led to diverse applications of peer
enhanced understanding of the peer support concept. support interventions. As such, conceptual clarity has
However, some reection on the results of this analysis been established between the provider of peer support
should be presented. While determining the dening and the related concepts of natural lay helpers and
attributes of peer support was not overly difcult, as paraprofessionals. This concept analysis presents the
those proposed occurred frequently both explicitly and nursing profession with the conceptual basis for
implicitly, regularity is no guarantee that a concept is improving the development, implementation, evalua-
more precise and less ambiguous. Several criticisms of tion, and comparison of peer interventions and their
Walker and Avants (1995) methodology have been impact on health, health behaviours, and health-service
highlighted (Morse, 1995; Paley, 1996) suggesting that utilization.
simplifying the complexity of concepts produces a trivial
result. Therefore, the analysis presented here was
performed using both a quantitative (denitions of peer Acknowledgements
support) and an interpretive (description of peer support
interventions and their contexts) approach, allowing for I gratefully acknowledge the Canadian Institutes for
the internal dialogue and the re-analysis originally Health Research (CIHR) for the provision of a
described by Wilson (1969) that Hupcey et al. (1996) postdoctoral research fellowship (19992001) and Pa-
suggests is lost using Walker and Avants (1995) analysis mela Ratner, RN, Ph.D., Associate Professor, School of
methods. Nursing, University of British Columbia for her
Apart from the method described by Walker and editorial suggestions.
Avant (1995), several other approaches have been
developed to conduct a concept analysis (Chinn and
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