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Training Guide

Peer Delivered Syringe Exchange (PDSE) Toolkit

“Listen to what peers say rather than being top-down. Involve peers in decision-making. Say, ‘We’re thinking about doing this. What do you think?’ The peers are directly on the street, and they know. Harm reduction became successful because it was done by people on the street. It’s a balance.” 

— Anonymous Peer

All supervision should be supportive, developmental, and non-judgmental. Supervision is an opportunity for peers to reflect on, evaluate, and share their experiences; whenever possible, supervisors should take direction from peers.

Supervision can be formal (scheduled, individual PWUD or group, in a closed setting away from active work) or informal (spontaneous, either one-on-one or with others around, during work). A combination of different types of supervision may be beneficial. Regardless of structure, supervision should always be an ongoing process; it should establish clear goals, promote frequent communication so that issues may be addressed as they arise, and stress mutual accountability. Be careful that supervision does not become a chore, but is rather a source of support.

Informal supervision happens “in the moment”. As the peers’ supervisor, it is ideal if you can work alongside them from time to time. By doing so, you can make constructive suggestions as well as offer positive feedback.

The supervisor should strive to:

• Be consistent
• Offer support and constructive feedback
• Model expectations (make appointments, be on time, call if running late, etc.)
• Be as honest and transparent as possible
• Ask peers what they want/need in a supervisor and from their supervision meetings

 

Key Areas of Supervision

It is helpful to think of supervision within three key areas: 

1. Administrative Supervision: Dealing with scheduling, timekeeping, pay, paperwork, etc.
2. Supportive Supervision: referring to how the peer is handling the work, boundaries, issues they are facing, workplace relationships, and, if need be, time management and budgeting
3. Skills Development: learning specific skills, such as communication, health-related  top- ics (such as disease prevention), and computer literacy

 
The person who does the supportive supervision with a peer may be different from the supervisor who fulfills an administrative role. This structure is helpful in cases when you think peers might not feel comfortable talking to a “boss” about sensitive issues; it ensures that they still have an avenue to access services support.

Programs with experience running PDSS programs have learned through trial and error some “best practices” for supervising peers. Though we have separated the three purposes below, the reality is that supervision will involve a blend of all three at different times. you might, however, find it helpful at times to clearly separate them.

Administrative Supervision

Administrative supervision is the “nuts and bolts” support that helps peers get the job done.

This includes working with peers on meeting dead- lines, on having the knowledge needed for good performance, on setting professional goals, etc. In administrative meetings with peers, you will go over paperwork, reports, data quality, etc. See the Appendix for sample forms.

 Scheduling: Hours Worked and How to Track Them

Generally, most peers are expected to work a minimum number of hours per week, though for peers who exclusively work in the social network model, this may not be true. How many hours per week a peer works (if hours are tracked at all) varies by program arrangement. Peers may work independently, with another peer, during a scheduled outreach shift with a SSP staff member, or in the SSP office. you may have different ways of tracking hours for each of these scenarios.

For those peers whose hours will be tracked, you’ll want to decide how to track hours – through log- books, the “honor system”, or checking in with supervisors before and after scheduled hours. If logbooks are kept, it’s necessary to decide where the books are kept, how often they are due, and what to do if the books are late or incomplete. Some programs using a low threshold social network access services model do not track hours at all.

 Paperwork: Tracking Interactions and Syringe Transactions

Regardless of how your program is funded, most require a minimum amount of reporting on the work that is done. Because peers operate in environments that are not always conducive to the same type of paperwork completion that is possible at a SSP site, it is important to balance the need to capture data with the need to have paperwork that is as easy to fill out as possible.

Be aware of potential literacy limitations and make sure to explain forms to new peers rather than assuming that they will be intuitive for everyone. You might go over each form with peers line-by-line and have them watch others fill them out, or you could do a role-play with peers so they have a realistic scenario in which to practice completing the forms.

You may want to discuss how peers approach their encounters. Do they have a duffel bag and sit on a corner in public for people to come by to pick up syringes? Do they go to PWUD houses, or do friends or family come to their house? Depending on these different scenarios, the peers may collectively want to discuss how to track transactions and what is most convenient for them. For example, some peers may not feel comfortable having a clipboard and a full piece of paper in public for fear that PWUD watching may think they are documenting more information than they are. Some programs have small, wallet-sized outreach books to make completing documentation less conspicuous. These books are also easier to carry around for peers on the go, compared to storefront-based syringe access services, where the size and weight of the paperwork is less of an issue.

It is important to make sure that peers document transactions clearly and consistently at the same time that they are delivering services. As mentioned, it may be wise to work one-on-one with each peer to role-play various situations. For example, the peer supervisor may play the role of a new participant and ask questions about HCV prevention. The peer will respond and answer questions, then write the transaction in the book. This is a good opportunity to review accuracy of both health information and documentation procedures.

It is important to get peer feedback when developing reporting forms on issues such as language, structure, and content. English-only language requirements can pose a barrier to consistent and accurate completion of documentation. Explore whether your agency has the capacity to receive documentation in multiple languages. If your program uses forms or checklists, you may want to have these forms translated into the primary languages of your peers to make documentation easier for them.

Paperwork: Oversight

It is important to establish quality assurance in the reporting system your agency uses. The work that peers do will ultimately be reflected in the reports you submit. It is recommended that the supervisor in charge of the peer program regularly pull a percentage of transaction records and check them against that week’s schedule. You can also have staff accompany peers periodically to “calibrate” with peers on paperwork completion. Again, this is something a supervisor would do with all staff, not only with peers.

Supportive Supervision

Consider building time into each supervision meeting to check in with peers about their goals and possible needs.

Topics that fall under supportive supervision include, but are not limited to:

• Boundary management
• Burnout prevention
• Conflict management
• Professional and personal development
• Drug use
• Health and well-being

 
When providing supportive supervision to peers, be mindful that peers may still be interested in accessing services at your agency. Make sure the peer knows they can still utilize these services and make additional referrals available as needed. remember that when a peer access services, as with any participant, he or she is entitled to the same level of confidentiality.

 PWUD Supportive Supervision

In PWUD supervision, you may vary your style according to the peers’ learning and interpersonal style. In some cases, peers will have specific issues that they want to discuss. Other times, it is helpful to prepare questions or topics to guide the discussion. In either situation, peers should be given the lead in supportive supervision. Doing this effectively requires active listening, so that you can explore issues that the peer raises, rather than bounce superficially and rigidly through a list of prepared questions. The supervisor, in turn, can use open- ended questions to help stimulate dialogue. It is important to communicate that there are no right answers to any of your questions or reiterate that the question can just be something to think about for now and maybe discuss at a later time.

“We need long-term peer support – this can help us deal with things we experience. For example, when a participant you work with for a long time dies, and then another dies soon after, you feel a little isolated.” 

— Anonymous Peer

Group Supportive Supervision

Formal group supervision can be highly effective. These meetings are a great time for peers to bring up problems with work and to hear from their fellow peers for ideas and solutions, as well as to reinforce that their fellow peers support them and empathize with them. It is also an opportunity for peers to share positive experiences and moments of growth, pride, and satisfaction. It can help everyone in the room think more reflectively about their own experiences with the work.

Some agencies bring in an outside clinical social worker to facilitate group supervision. Decide for your program how often this should occur, but also consider asking the group how often they would like to have a group peer meeting. Twice a month may be sufficient, or weekly meetings may be more suited to your particular program.

Boundary Management

Boundary management is an area of potential conflict between peers and participants. Where traditional helping professions (physicians, nurses, psychologists, social workers, addiction counselors) emphasize hierarchical boundaries and maintaining detachment and distance in the service relationship, peer-based services rely on reciprocity and minimizing social distance between the helper and those being helped. Peer programs are effective because those being helped (participants, patients, etc.) can identify with the helper because they are peers: the peer demonstrates that positive behavior change and harm reduction is possible for the participant, that it does not imply immediate cessation of a pleasurable and familiar activity, that it does not necessarily lead to complete severing of ties with, and rejection from, a familiar community, and that rewards such as a position in a peer program are feasible and tangible goals. Peers, however, must maintain a level of professionalism when they are acting in the role of peers and treat all participants equally and with respect, regardless of personal relationships. It is also encouraged that peers take advantage of opportunities to provide harm reduction education.

 Drug Use

Syringe access services programs originated because people who use drugs took control of their own health needs. It is important to maintain this spirit of self-determination and respect for participants’ expertise. An SSP should be a place where people who use drugs – peers and participants alike – feel safe and supported as PWUD. Unfortunately, stigma around drug use, especially in the workplace, is so pervasive that some peers may be unable or unwilling to discuss their use, especially in cases where it becomes problematic or interferes with their job performance. Supervisors should respect peers’ boundaries when talking about drug use while creating a safe, confidential and supportive environment for people to explore these issues if and when they choose. Supervision within this context requires a commitment at every level of the agency to challenge drug-related stigma and discrimination and should not be limited to the PDSS program. Additional training and support may be necessary to increase cultural competency across the agency.

It is important that supervisors do not make assumptions that job performance issues are related to drug use. There is no expectation that workers will abstain from or change their drug use, however there is an expectation that they will fulfill the responsibilities of their job. Supervisors should work with peers to address any potential issues related to job performance. In cases where drug use management is identified by the peer as a concern, supervisors should help to identify resources and support.

Though PWUD programs should determine how to approach the topic of peers and drug use, most programs do have explicit rules with regards to certain issues. For example, peers cannot conduct any illegal behaviors on the job such as buying or selling drugs, bringing drugs into the agency, or accepting drugs from participants. During employment orientation, expectations need to be made clear along with any relevant consequences. This issue is addressed in greater detail in the section Addressing Job Performance Problems and Termination.

It is possible that a peer’s relationship to drugs may have an impact on the way they provide services to others. For example, it is not uncommon for former people who use drugs to exhibit heightened judgment toward current users. Former users may have a difficult time supporting the struggles and experiences of participants who are actively using drugs. While often well-intentioned, some former people who use drugs can further marginalize participants by over-identifying with them or by projecting their own path to abstinence. In addition, the SSP environment may pose obstacles or particular difficulties for some former people who use drugs if abstinence from drugs is their goal. Again, supervision and training will be important to avoid potential problems and to provide a supportive work environment for former people who use drugs. In cases where the peer is no longer a good fit for the PDSS program, you may need to help them identify other peer opportunities.

Supervision for Skill Development
One of the goals of PDSS is to encourage the per- sonal and professional development of peers.

Skill development involves building on what was learned in initial training and orientation and expanding according to interests and needs. it is a broad category and can include:

• Cultural competency: Working with people of different ages, ethnicities, sexual orientations, gender identities, and drug user communities, etc.
• Outreach techniques: engagement, counseling, conveying health and harm reduction messages, safety, interacting with law enforcement, etc.
• Technical skills: Data collection, data entry, computer literacy, etc.
• Topical knowledge: Subjects such as hepatitis, HIV, legal rights, safer injection, etc. 

 
Skill development should focus on the PWUD interests of peers as much as possible so that they can use the position to further their own career goals. Search for trainings, meetings, and events that pertain to the specific interests of peers; encourage them to participate, to network with other peers and to deepen their practice. As peers continue to develop more skills, they may feel increasingly empowered to talk to participants. Sometimes, SSP peers and staff can feel overwhelmed by how many topics there are to cover in a brief access services – safer use, Hepatitis C, treatment alternatives, overdose prevention, “know your rights”, safer sex, etc. With additional training, peers can feel confident initiating a conversation while remaining responsive to each PWUD participant’s needs. It is also important to encourage peers to feel comfortable saying “I don’t know” when necessary and to help them identify resources so that they can provide accurate information. Encourage dialogue between staff and peers so that they can benefit from shared expertise and knowledge.

Staff can either conduct trainings in-house or peers can be sent to outside trainings. For more information, see the section Getting Peers Started: Training New Peers.

 

CASE STUDY: Skill Development with Specializations

NYHRE: NYHRE assigns each peer a specialization based on the interest and knowledge that he or she exhibits during the training portion of the program, including: HCV Peer Specialist, Overdose Prevention and Response Peer Specialist, Drug User Rights

and Safer Use Peer Specialist, Sex Worker Rights and Safety Peer Specialist, Political Action Leader, and Know Your Rights Peer Specialist. This can be a great way to support peers’ passion about certain issues and to affirm their sense of leadership in that area. UPRISE and Peer Specialists are scheduled for NYHRE outreach, group facilitation, office-based and community building and organizing activities that include attending NYC planning council meetings; attending press conferences and meeting with legislators and to advocate for funding and/or improved policies for our communities.

 

NOTE: Supervision Scenarios

• Program A

• Program A pays peers a small stipend and asks them to perform duties that may overlap with those of full- or part-time staff who earn more and receive health care benefits.

• This situation could easily contribute to peer burnout, high turnover, and erosion in the quality of harm reduction services delivered without proper supervision that communicates appreciation and the value of peer work. adequate support, advancement opportunities for peers into staff roles, and setting limits on hours worked are crucial for sustaining the quality of PDSS.

• Program B

• At Program B, peers work alone to deliver PDSS in their communities.

• Peers assigned to work outside of an office setting, particularly those working alone, need increased support to counter the particular stressors inherent in this role. Such support can include special training related to safety management, regular check-ins and training opportunities, technical supports (cell phones, two-way radios), etc.

• Program C

• Program C is an SSP that provides harm reduction services through a team of volunteers from the drug-using community. A participant with a reputation for being inappropriate with women applies for a peer position.

• The screening of peers and staff is designed in part to protect the hiring agency and its participants. This protective function must be balanced with agency standards of fairness in their selection procedures (e.g., not excluding someone based only on second-hand gossip).

• Exploitive and inappropriate behavior within the community is unacceptable and can be grounds for disqualification. The purpose of such disqualification would be the protection of both participants and the reputation of the agency, assuring that people will feel safe and comfortable seeking services at the organization. In this scenario, the program may opt to select a different applicant who is better qualified in certain areas. That said, it is vital that information be based in facts, not rumors or word of mouth. Talk to the peer, and be transparent and clear about concerns and expectations. Provide scenarios to see how peers would respond and offer guidance when necessary. Additional training may be necessary to deepen people’s understanding of respecting personal space and boundaries. If the program does not have proof of any particular behavior and thinks the applicant has significant strengths to bring to a peer position, partner him with another staff member or peer so that he does not interact with participants alone until the program is satisfied that the behavior is no longer a concern.

• Program D

• Mary has functioned as an exceptional peer for Program D for the past two years, but is currently going through a very difficult divorce. The strain of the divorce has resulted in sleep difficulties, significant weight loss, and concern expressed by Mary about control over her drug use.

• It is important to consider when events in our personal lives become professional practice issues. Events in our personal lives are of unique concern when they ripple into how we perform on the job. All of us experience periods of vulnerability that require focused self-care and may temporarily diminish our capacity to serve others. Mary and her supervisor need to consider what would be best for her, for the agency’s participants, and for the agency itself. One option is for Mary to adjust her hours and to get increased supervisory or peer support for a period of time. Another option would be for Mary to take a leave from work as a peer to focus on getting her personal life back in order. Reinforce during supervision with Mary that bringing up issues such as drug use and personal challenges that may have an impact on her work demonstrates responsibility and commitment. This is actually the mark of service excellence—making sure that one’s own periodic difficulties do not spill into the lives of those we are committed to helping.

• Program E

• Robert has volunteered as a peer with Program E for the past 1-½ years, working extensively with participants. In recent months, he has noticed that he is bringing less energy and enthusiasm to his work as a peer and is dreading seeing certain participants in the street.

• Emotional and physical disengagement can do a great disservice to those in need of peer-delivered syringe access services. Robert is exhibiting signs of burnout, which need to be acknowledged and addressed in supervision. It is important to talk to Robert to understand what the problem is. It is also important to reflect on any potential role your agency could play in Robert’s burnout. Perhaps the program is not providing enough support or doing a good job at integrating peers into agency culture. Alternatively, Robert may want a break in his peer activities, and together you might consider adjusting his hours or activities for a period of time. If Robert does want to shift his duties temporarily, his supervisor should ask what Robert thinks will “recharge” him. It might also be a good time for Robert to refresh his stress management skills via training or by accessing supportive services. Peers need the option of taking sabbaticals from their work, but they also have a responsibility to recognize this need early enough to plan an orderly transition or termination process for those with whom they are working. Agencies also have a responsibility to seek input from peers about how to best manage the program and support peer needs.

• Program F

• Stella was a participant with Program F for a number of years, and six months ago she became a peer. Recently, her diabetes and hypertension have worsened, and she is having difficulty getting around. She is seeing her doctor and, while she expects to recover, she can no longer go on walkabouts as other peers do.

• Have a conversation with Stella to discuss whether there are other duties within the program that might be more appropriate given her current health situation. Depending upon the resources of the SSP, it may be possible to shift Stella’s hours to in-house work such as assembling kits. Participants she works with can be told that she provides supplies on-site and can come to her, or peers with capacity can also visit Stella’s previous walkabout route to provide services. Stella can also assist the SSP with groups and administrative tasks. Be mindful to provide support to other peers who may be taking on Stella’s previous responsibilities; include Stella in discussions about how to make sure her participants are still receiving the services they need.

 

Recognizing and Showing Appreciation to Peers

The work that peers do – including outreach and engagement with the community – is a critical element of harm reduction programs and services. Peers are often the first point of contact with the SSP. They are a vital resource for community members and SSP staff alike. Peers provide a heightened level of insight into drug using communities and trends that SSPs rely on to be responsive to shifting needs within the community. They work in constantly shifting, fast paced and sometimes stressful environments which often provide far less structure and support than traditional outreach or fixed-site SSPs. it is critical that programs recognize and show appreciation for the work that peers do.

Peers have reported that they do not always feel appreciated or fully recognized for their work. Supervisors need to remain mindful of the sources of potential discontent. Peers are in a unique position within many agencies – they are not quite staff and not quite participants. They often perform many tasks similar to those of staff, however are not always given the same level of acknowledgment whether through compensation or inclusion. Some agencies have struggled to fully integrate peers into the professional and social culture of the SSP. The distinction between participant, peer, and staff is sometimes unclear and can create confusion for peers and staff alike. Peers who transition from participant to peer take on new responsibilities and expectations, while also negotiating shifting relationship dynamics in their social networks and at the SSP.

Peers should be involved in the structuring and revising of the PDSS program and given real voice in development of policies that will affect them most such as compensation schedules, travel reimbursement, data collection and general operations. When programs include peers in program management, they are often able to prevent potential problems.

 

NOTE: What Does/Would Make You Feel Appreciated?

Here are suggestions from a group of ten peers at NYHRE when asked “What does/would make you feel appreciated?”

• Honesty, clear communication, and respect from staff.
• When staff ask my advice or opinion about how program-related things should be done.
• When staff introduce peers to participants as being part of the team.
• Staff knowing peers’ strengths and weaknesses – providing constructive criticism and acknowledging a job well done.
• Having clear rules and the consequences for breaking those rules.
• For those of us who are “in recovery,” don’t put too much pressure on us.
• Being flexible, supportive, accommodating peoples’ schedules and stated preferences for hours (i.e., after a daily visit to a methadone program or to comply with parole stipulations) and locations (i.e., not in the spot where i used to cop drugs, or near the home of a former abusive partner).
• Invite peers to staff events. Where possible, have parties, lunches, celebrations, etc. specifically for peers.
• Having the support of my fellow peers.
• When peers acknowledge each other’s work.
• Getting positive feedback from participants.

 

Addressing Job Performance Problems and Termination

Problems occur on the job with all programs, and addressing them is a part of routine program man- agement. Dealing with issues quickly and consistently can prevent them from developing into even bigger issues. Problems of job performance, no matter how major or minor (e.g., breaching rules, provision of misinformation to participants, confusion about role as peer) should be addressed as soon as possible.

When addressing personal or potentially difficult issues, a supervisor should never confront a peer in front of other staff, participants, or other peers. Most programs institute a disciplinary process that distinguishes both by the seriousness of the issue and involves progressive stages of action based on repeated problems. For example, if peers violate agency policy, they will receive a written warning. if the problem persists, a second warning is received, followed by a one-week suspension. Termination may follow if a problem continues after suspension. There may be certain behaviors that your program has identified as particularly serious, and can warrant more serious disciplinary measures, such as immediate termination. Whatever process is decided upon by the agency, it must be clearly outlined during peer orientation and should be applied consistently. It is also important to emphasize that when a policy is breached, a tailored plan should be developed with the peer to identify ways of preventing future incidents and which clearly outlines expectations and consequences.

When a peer is terminated, it is important to reinforce that they will still be able to access the full range of services available at the SSP. It is the supervisor’s job to ensure that staff know to reach out to the peer as they would any other participants, regardless of why the peer was terminated.

Below we provide some examples of job performance problems that have been experienced by SSPs in the past. Some of these situations resulted in peer termination. In other instances, peers received a verbal or written warning, or other disciplinary action was taken. These examples are being provided to help program managers anticipate potential concerns that could arise in any SSP and are not necessarily specific to peers.

• Violence
• Hateful or derogatory language
• Selling drugs while on the job
• Stealing property
• Peers misrepresenting their role within the agency
• Forging staff signatures on timesheets
• Any illicit activity that could bring a felony or misdemeanor charge while on the job
• Using syringes as leverage to get something from a participant, selling syringes, or bargaining with participants. [Note: If a peer is selling syringes, discuss why he or she needed to do this and what support your program can offer, especially if he or she felt compelled to do so out of financial need.]
• Faking transactions: For example, recording trans- actions that didn’t take place or taking syringes out of the packet and putting them into sharps containers to give the appearance of syringe col- lection. [Note: This may be rooted in a concern that if syringe collection or access services numbers are not high enough it will reflect poorly on job perfor- mance. It is the responsibility of the supervisor to clearly communicate any relevant expectations related to the quantity of syringes access services.]

Peer Absence

Situations may arise in which peers may be out of contact with the program for periods of time for any number of reasons, such as health issues, family emergencies, lack of transportation, phone problems, arrest, concerns or conflicts with the agency, or other personal issues. Regardless of the reasons, there should be clearly stated policies and procedures for addressing periods of absence without communication. Programs should have emergency contact information for each peer; there should be contingency plans in place to address any administrative issues (return of supplies, cell phones, etc.) and for ensuring that participants will not be left without services (whenever possible). Reinforce the importance of regular communication and check with the peer to make sure that there aren’t programmatic issues contributing to the absences. Consequences for peer absence will vary by program and circumstance. your program should determine its policy in advance of any problems. 

Ensuring Smooth Transitions When Peers Leave

Some peer positions are cyclical and have a set start date and a set end date. Other programs do not have time limits. The departure of a peer can present problems because there may not be anyone taking over provision of services to this network of users.

Peer departures can have a significant negative impact on the participants they see; those partici- pants may no longer have access to clean syringes or other services. This underscores that one of the primary purposes of PDSS is not just the distribution of syringes, but also the engagement of partici- pants with your program. Where possible, ask a peer to identify a potential replacement or at least to provide information on how you can outreach to his or her network. Likewise, peers and staff should be sure to inform their participants of alternative ways to access syringe services, such as pharmacy access services and alternate syringe service programs. Programs should decide how much notice they would like to receive from peers who want to leave the program and communicate this expectation with them during orientation.

 

In Conclusion

Peer-delivered syringe access services as a formal model for syringe access services is still in the beginning stages. It is our hope that by sharing some of our successes, challenges and overall experiences implementing the model, we will be able to support both existing and new PDSS (or similar peer-driven) programs.

One of PDSS’s greatest strengths is its capacity to change and adapt to best meet the ever-shifting needs of our communities. It is the challenge of syringe service programs to support and empower PDSS peers throughout the process. To do this successfully, it will be necessary for each program to change and adapt PDSS to best meet the ever-shifting needs of your agency, participants and peers. This toolkit has been created to offer guidance and suggestions; however it will be up to each individual program to figure out what works best for them.

We dedicate this toolkit to peers, both formal and informal, who have paved the way. Thank you!

 

QUESTIONS TO CONSIDER – Module 4: Supervising Peers

Supervising Peers

• How often will the supervisor(s) meet with peers?
• Who will provide consistent supervision? Have you identified other staff and peers who are available for additional (informal) supervision and guidance?
• Will there be different supervisors for different areas of supervision, such as Administrative and Supportive?
• Will there be peer group meetings to provide additional peer support?

Drug Use

• Can you identify appropriate supervisors who will be able to create a safe, supportive, nonpunitive environment for peers to talk about their drug use?
• How do you transition PDSS peers who are no longer using or connected to the same social networks?
• Does your agency have different expectations around drug use among peers versus staff?
• What sort of supportive services does your agency have available for peers and staff related to their drug use (current or former)?
• How do you maintain records of confidential information, including discussions of peer drug use?