Understanding workplace peer support among healthcare assistants providing palliative and end-of-life care at home: A realist review

Step 1: Locate existing initial programme theories

Exploratory database searches informed the development of the preliminary programme theory and search strategy. The lead author (KP) consulted with the research team, Research Advisory Group, information specialists and Patient and Public Involvement (PPI) groups to identify search terms, drawing on their experiential and content expertise. Based on this input and the findings from scoping searches, the search strategy was adapted and KP developed the preliminary programme theory of workplace peer support intervention, which was refined against evidence gathered in subsequent stages of the review.

Step 2: Searching for evidence

Evidence was sourced to confirm, refute, or refine elements of the preliminary programme theory. ⁵³ Academic literature searches were conducted across CINAHL, MEDLINE, AMED and Scopus, from their inception to the present, using controlled vocabulary and targeted keywords (Supplemental material).

A broad definition of ‘healthcare assistant’ was adopted, as demonstrated by the extensive list of search terms (Supplemental material) as multiple role definitions and descriptions are used worldwide. ⁹ All studies involving healthcare assistants providing care for people who were dying in their own homes were considered, regardless of the underlying condition or the primary service involved–whether hospice care, long-term home care, dementia services or support for individuals with learning disabilities.

To supplement database searches, we employed forward and backward citation tracking and consulted expert stakeholders to identify additional relevant sources. Grey literature has also been included to capture contextual and evaluative insights not found in peer-reviewed sources. ⁵⁴ Searches were conducted via Google, Trip and National Institute for Health and Care Excellence (NICE), with alerts set through Google Scholar and library services.

Step 3: Selection and appraisal of evidence

To ensure consistency, KP conducted identification, selection, and appraisal steps, with FH independently assessing a random 10% sample of excluded and included papers for quality assurance. ⁵⁵ Papers were screened by title and abstract, then by full text using Covidence software, applying the inclusion and exclusion criteria listed in Table 1. In line with realist review methodology, appraisal was not applied as a threshold for inclusion or exclusion but was conducted iteratively during analysis to assess each source’s contribution to the programme theory. Following Wong et al.’s criteria, ⁵⁶ each source included in the review was assessed for its relevance to the programme theory, its interpretive contribution as context, intervention, mechanism or outcome data, and the trustworthiness of the evidence to warrant changes to configurations or the programme theory.

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Table 1.

Inclusion and exclusion criteria for identified literature.

Inclusion criteria
• Only articles in English included due to resource constraints for translation • All study designs and grey literature • Involving Healthcare Assistants or equivalent roles • Palliative and end-of-life care delivery within community settings to adult populations • Any documents including data related to peer support • Documents containing outcomes of interest
Exclusion criteria
• Any evidence which does not contain data to help test and refine the programme theory • Studies including other healthcare professionals or those including mix of Healthcare Assistants and other healthcare professionals where data specifically related to Healthcare Assistants cannot be extracted • Care delivered in institutional settings, i.e. care homes, residential homes, nursing homes. • Paediatric care

Step 4: Extracting and organising the data

Full text documents were uploaded to Zotero and read thoroughly by KP, who made initial reflective notes regarding content relevance to the programme theory. Documents were then uploaded to NVivo 15 for coding in alphabetical order by first author surname. Coding was both deductive (against preliminary programme theory categories from Step 1) and inductive (for data not fitting existing categories). Codes served as descriptive ‘conceptual buckets’ for evidence gathering (Supplemental material). Codes were refined, merged and reorganised during analysis. Document characteristics were exported from NVivo 15 to Microsoft Excel (Supplemental material), with relevance, trustworthiness and rigour assessed using Wong et al.’s criteria. ⁵⁶

Step 5. Data analysis and synthesis

Coded data was extracted from NVivo 15 into Microsoft Word files to enable flexible exploration of causal configurations and synthesis narrative development. ⁵⁷ We applied a realist logic of analysis using ‘context-intervention-mechanism-outcome’ (CIMO) framework, which originated in evidence-based management and design science literature as a means of developing solution-oriented knowledge. ⁵⁸ We adapted the context-mechanism-outcome (CMO) framework ⁴⁵ to include intervention components, allowing a clearer distinction between modifiable intervention factors and contextual factors.^59–61 Within this framework, we define contextual conditions as the pre-existing social norms, organisational cultures, leadership arrangements, and structural resources that are already present within a given setting in which the intervention operates. These are not easily amenable to change through intervention design alone. Intervention components, by contrast, refer to the elements that are actively introduced, designed, or modified as part of the workplace peer support intervention. We acknowledge that in practice some elements may function simultaneously as enabling contextual conditions and as modifiable intervention components. Data used to construct configurations was drawn from multiple sources, as individual documents rarely contained all the necessary elements. Synthesising information across various texts allowed for greater explanatory power in developing a more complete and robust list of configurations. Quotations directly extracted from the included documents and coded in NVivo were gathered to help clarify and exemplify the configurations, contributing to the depth and coherence of the synthesis.

Discussion with stakeholders and members of the public

A Research Advisory Group was established comprising members of the public, researchers, healthcare assistants, managers and other relevant stakeholders. KP also consulted established Patient and Public Involvement group Marie Curie Research Voices. The groups were consulted during Step 1 and Step 5 to develop programme theory, inform search strategy, suggest additional sources of evidence to complement the formal literature search, contextualise findings and refine emerging insights.

Engagement with substantive theory

As the analysis evolved, we explored a range of substantive theories proposed by stakeholders and found in the literature. Substantive theories are well-established theories from different fields that help explain why phenomena occur the way they do and provide researchers with a theoretical lens to produce insights on social behaviour. ⁶² There is flexibility in how to use theories in realist reviews, though most commonly they are used to make sense of the patterns found in the data or to provide a framework to help pull together seemingly unrelated findings and increase the explanatory power of programme theories.^63,64 In this review we incorporate reference group theory^65,66 and community of practice theory^67–69 within the results section to substantiate the extrapolations made during the data analysis about contexts, mechanisms and outcomes. ⁷⁰ We then use self-determination theory^71,72 within the discussion section to provide a theoretical framework to bring together and explain the importance of the intervention outcomes.

Search results

In total 1027 articles were identified through database searches, with an additional 18 articles identified from other sources: grey literature and citation searches, stakeholder recommendations, relevant literature known to authors, Google (in incognito mode) searches and library alerts. There were 71 full text articles assessed, with 24 articles included in the review. The screening and selection process is outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram ⁷³ (Figure 1).

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Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Overview of included evidence

The literature included in this review reflects the diversity of healthcare system delivery across different countries and encompasses a diverse international body of research focused on healthcare assistants in the context of palliative and end-of-life care at home. Of the included evidence, twelve were qualitative^{11,12,21,23,27,32,34,74–78}, five were quantitative^79–83, three were mixed-methods^13,22,84, two were reviews.^17,20 Studies were conducted across countries such as the UK,^{11–13,74,80,84} US,^{21,32,34,77,78,81–83} Canada,^22,76 Sweden,^23,75,79 and South Africa. ²⁷ These studies explore a range of themes related to peer support and the effectiveness of specific interventions such as COMPASS program^34,82,83 and Computer-Mediated Sharing Circles.^32,77,78 Included papers contain both published and unpublished work such as theses and project reports, all assessed for their trustworthiness, rigour and relevance to programme theory.^56,85 Information on the characteristics of the studies included and mapping of overarching context-intervention-mechanism-outcome configurations to included papers are shown in Supplemental material.

Findings

Findings are presented according to four main outcomes directly influenced by peer support intervention: enhanced wellbeing and resilience, reduced loneliness and isolation, the emergence of a sense of community of practice and strengthened role identity. The intervention itself comprises three interrelated components – peer-facilitated group meetings, informal peer mentorship and 24/7 peer support via chat, calls or text messaging, which operate in combination rather than in isolation (Figure 2). Table 2 presents the twelve Context-Intervention-Mechanism-Outcome (CIMO) configurations, which are detailed causal explanations underpinning the four outcomes. Each outcome is then explored in turn through descriptive narrative and supporting extracts from the included literature.

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Figure 2.

The three components of workplace peer support intervention for Healthcare Assistants identified in this review. The components operate in combination rather than in isolation, with each contributing to the four workforce outcomes described in the findings.

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Table 2.

Context–Intervention–Mechanism–Outcome (CIMO) configurations.

CIMO 1. Safe group spaces If healthcare assistants who face high emotional demands from managing complex situations and witnessing death and dying (C), join regular peer meetings with a trained facilitator, delivered online or in-person, with clear rules, topic discussions, open sharing sessions within a safe space (I), then their emotional wellbeing may improve, including decreased stress, better coping, and feeling more supported (O), because peer facilitators with shared experience create safe spaces where healthcare assistants can validate each other’s feelings, show empathy, and develop emotional coping strategies together through sharing stories and reflection (M). CIMO 2. Immediate access to emotional support If healthcare assistants who face high emotional demands from managing complex situations alone (C), have 24/7 access to peer support through ‘easy-access’ communication channels (phone, text, chat) with clear guidelines about who to contact, when, and for what support needs (I), then they may better manage their emotions and reduce work stress (O), because peers who know the unique emotional demands can offer immediate active and empathetic listening, validation and advice which help to reduce emotional overwhelm (M). CIMO 3. Informal peer mentorship If healthcare assistants who experience uncertainty about decision-making and their competence due to their limited experience (C), can access peer mentorship which includes regular check-ins and ‘as needed’ contact (I), then they will develop stronger emotional resilience and professional confidence in managing emotional demands (O), because experienced peers provide role models for emotional management, validate normal grief responses, and help less experienced peers learn healthy boundaries and practical strategies for managing the emotional demands of work (M). CIMO 4. Guidelines for peer support If healthcare assistants hesitate to contact colleagues for fear of being a burden or disturbing them during time off, despite having support needs (C), and structured communication systems are put in place (regularly updated staff contact lists and shift information sharing) with clear guidelines for peer contact (who to contact, when, and for what reasons) (I), then they will feel more confident seeking support when needed (O), because clear communication systems remove practical and emotional (fear of being a burden) barriers to peer contact and provide safe and accessible ways to get quick support and advice during challenging situations (M). CIMO 5. Organisational endorsement If healthcare assistants hesitate to contact colleagues for fear of being a burden or disturbing them during time off, despite having support needs, and they work within organisations where leadership is receptive to supporting staff wellbeing (C), and receive formal organisational endorsement of peer support as professional practice, designated protected time for peer interaction, and explicit communication that peer contact is valued and expected (I), then healthcare assistants will be more likely to reach out to peers and feel less isolated (O), because organisational endorsement makes peer support part of professional practice, giving permission to seek help and reducing guilt about contacting colleagues (M). CIMO 6. ‘Safety net’ If lone working healthcare assistants experiencing uncertainty and stress during challenging situations without immediate supervisor support (C), have access to established peer networks through various communication methods (voice calls, texts, instant messaging) that enable contact with trusted colleagues who share similar role boundaries and challenges (I), then they may feel less lonely and isolated, and experience an enhanced sense of peer connection (O), because knowing responsive peers are accessible provides a ‘safety net’ that reduces decision-making stress when facing complex situations alone (M). CIMO 7. Sense of community of practice If healthcare assistants lack structured ways to share with peers knowledge gained through experience (C), and they participate in regular peer-facilitated group meetings using structured formats (ground rules, topic discussions, scenario-based learning, summary statements, and reflection sessions) that create safe spaces for collaborative problem-solving and knowledge sharing (I), then a sense of community of practice will begin to emerge characterised by shared learning, mutual support, and collective role identity (O), because repeated structured interaction in psychologically safe environments allows healthcare assistants to share tacit knowledge and develop shared practice standards and professional norms to improve practice (M). CIMO 8. Individual skills and collective group expertise If healthcare assistants rely mainly on experience-based knowledge without adequate formal training and have variable access to learning opportunities (C), and structured peer support interventions help regular sharing of tacit knowledge through storytelling sessions, reflective practice discussions, scenario-based learning, and collaborative problem-solving activities led by trained peer facilitators (I), then experience-based knowledge transforms individual understanding into collective group expertise (O), because healthcare assistants feel safe to share their experiences to enable mutual learning in order to provide best care to patients and families and support their peers to do the same (M). CIMO 9. Risk of sharing incorrect care practices If healthcare assistants have limited formal training and rely on peer-to-peer knowledge sharing without adequate supervision or quality assurance (C), and structured peer support interventions facilitate regular sharing of experiential knowledge(I), then incorrect practices and misinformation may be reinforced and disseminated across the workforce, potentially compromising patient safety and care quality (O), because healthcare assistants may unknowingly share practices based on incomplete information or lack of relevant experience (M). CIMO 10. Organisational commitment If healthcare assistants work in organisations where leadership and management are receptive to collaborative learning and willing to commit resources to support staff development (C), and sustainable peer support structures are introduced with clear protocols, protected time, resource allocation and peer facilitator training (I), then a sense of community of practice may develop among healthcare assistants and lead to development of formal community of practice (O), because the introduced structures provide necessary infrastructure, legitimacy, and resources for peer relationships to develop and become established as ongoing professional development practice (M). CIMO 11. Forming role identity If healthcare assistants work in environments where their roles are undervalued by other healthcare professionals and broader systems, but they are motivated to provide care and support to patients and families (C), and they participate in peer facilitated sessions that position healthcare assistants as experts, enable collective reflection on value of their role and enable co-construction of role identity through storytelling and values clarification (I), then they will develop strengthened role identity and increased sense of pride in their work (O), because they can challenge negative stereotypes and form collective identity (M). CIMO 12. Sense of belonging and pride If healthcare assistants lack strong professional identity due to workplace isolation and limited peer interaction (C), and they engage in reciprocal peer relationships through multiple intervention methods (group meetings, 24/7 support, and peer mentorship) characterised by mutual respect, shared experience, confidentiality agreements, and collaborative problem-solving in safe spaces (I), then they will develop stronger sense of belonging to a community of healthcare assistants and increased pride in their role (O), because peer interactions reinforce practice values, create sense of collective effectiveness, and help develop practice standards and norms through ongoing collaborative practice (M).

Bold within CIMO table helps the reader navigate the statements, which use standard phrase of ‘If… then… because…’.

Outcome 1. Reciprocal peer emotional support may enhance wellbeing and resilience

This outcome explains how emotional support provided by peers can significantly improve the emotional wellbeing of healthcare assistants, who frequently work in isolation, manage complex needs of patients and families and form close bonds with them, especially in end-of-life care, which can lead to emotional strain, grief, and burnout.^{17,20,75,86,87}

The intervention operates mainly through regular facilitated meetings that provide structured opportunities for collective emotional processing.^{32,34,77,78,82} However, additional support may be accessed via 24/7 support that enables immediate access to peer assistance during emotionally challenging moments, and informal peer mentorship relationships that develop through ongoing peer interaction, providing sustained emotional guidance and role modelling.^11,78,80,86

The group sessions provide opportunities to facilitate safe, confidential, and non-judgemental spaces,^32,34 where peers could get to know each other, share their contact details and extend the support outside group settings.^11,32,77,78 Group sessions need to be facilitated by a trained peer facilitator to activate reciprocal peer-to-peer emotional support, including validation of feelings, empathy, venting, reassurance, mutual understanding and sharing of coping strategies.^{11,27,32,34,74,75,78,82,84,86,88} This is because healthcare assistants are more likely to open up and share their emotional burdens with peers who have shared experiences of providing care at home.^27,32,78,84 The opportunity to interact with peers helps healthcare assistants regulate their emotions and develop resilience.^11,21

The outcomes include subjective improvement in emotional wellbeing such as feeling ‘lighter’, more in control, and more willing to prioritise their own wellbeing,^34,82 behavioural changes such as increased help-seeking,^34,82,84 ultimately contributing to enhanced resilience and professional confidence in managing the emotional labour of palliative care work.

Outcome 2. Accessible peer communication systems may reduce professional isolation

This outcome addresses the persistent issue of loneliness and isolation among community healthcare assistants, who often work alone in unpredictable and emotionally demanding environments.^11,17,20,22 The nature of home care, characterised by physical separation from colleagues, limited supervision and irregular communication–can leave healthcare assistants feeling unsupported and reluctant to seek help.^{12,17,22,23,32,34,74,76,77,80,82,84,87}

This intervention component focuses on facilitating communication through practical strategies such as maintaining up-to-date contact lists, promoting norms around peer communication and encouraging a shared understanding of boundaries (i.e. who to contact, when and for what reasons). ⁸⁰ These measures are essential because many healthcare assistants hesitate to reach out for fear of being a burden or unsure whether it is appropriate to contact a colleague outside of formal channels.^11,80 However, for these measures to be successful it requires leadership and workplace culture that is supportive and facilitates such peer contact.^32,79,81,84

When these supportive measures are in place healthcare assistants are more likely to initiate contact with peers because they feel reassured that it will be welcomed and supported by both peers and management^12,80,84 and because they are motivated to provide best care by sharing tacit knowledge with their peers.^{27,76,80,84,88}

The outcome is a reduction in feelings of loneliness and workplace isolation, and an enhanced sense of peer connection. Healthcare assistants report that even knowing someone is available to contact (via text or call) can alleviate stress, especially during challenging shifts.^11,34 These informal support systems are particularly valuable during first solo shifts or emotionally intense situations, where quick access to peer reassurance and advice can make a significant difference.^11,17,76

Outcome 3. Facilitated peer meetings may influence development of a sense of community of practice and improve care quality

This section explains how healthcare assistants providing palliative and end-of-life care at home, who report working in isolation and with limited or inconsistent training and workplace support,^{11,12,22,23,87} can benefit from structured opportunities to connect with peers. These interactions can foster the development of a sense of a community of practice–a group of individuals who share a concern or passion for their work and learn how to do it better through regular interaction.^67–69

This intervention component may consist of regular facilitated peer-led meetings delivered in-person and/or online. While healthcare assistants generally demonstrate a preference for in-person interactions,^11,32,78 there is broad consensus that online platforms offer greater practical advantages in terms of accessibility and convenience.^32,77,78,84 However, online platforms may be missing the backchannel opening–opportunistic relationship building facilitated by in-person meetings.^32,34 Peer-led and peer-facilitated models are particularly effective, as they draw on shared lived experience to build credibility and engagement among healthcare assistants.^27,77 However, facilitation of such meetings needs to be supported by leadership and managers and embedded in organisational culture as without such support, barriers like staff shortages and lack of protected time can hinder participation and sustainability of the intervention.^80,84

Through these regular interactions with peers, who they can identify with due to their shared experience, they develop trust and psychological safety, sense of belonging to the team, grounded in shared motivation to provide best care to patients and their families.^27,80,88

The peer-facilitated meetings provide a space for healthcare assistants to exchange tacit knowledge^{27,32,34,77,78,80,84} and facilitate collaborative problem-solving when healthcare assistants discuss issues from practice and work through potential solutions and learn new skills to use in practice to help improve palliative and end-of-life care provided at home.^12,34,83,84 However, without adequate oversight and quality assurance mechanisms, peer knowledge sharing may inadvertently perpetuate poor practices or inaccurate information.^11,78,80,87

Due to the opportunities provided by this component of the intervention, building blocks of a community of practice are beginning to emerge.^{11,32,34,74,78,82,83} A community of practice theory ^a developed by Wenger^67–69 describes it as a group of people who share a common domain of interest, engage in ongoing interactions that build relationships and mutual learning and develop shared practical knowledge and practice through collective experiences, tools, and problem-solving approaches. The emergence of a sense of a community of practice was found to be both an outcome of the intervention opportunities, and a critical step towards the formal establishment of a sustained collaborative network. Such networks among healthcare assistants may lead to enhancing the quality of care delivered.^{11,32,74,76,78,80}

Outcome 4. Structured peer support and reflective practice may strengthen role identity

This section explains how healthcare assistants, despite working in environments where their roles are often undervalued by other healthcare professionals and broader systems,^{12,17,20,21,27,32,34,76,78} can still develop a strong role identity and sense of pride in their work through peer support and reflective practice.

Many healthcare assistants are intrinsically driven by a desire to care for patients and their families, finding meaning in emotionally demanding relationships built through their work.^{21–23,75,87} However, this intrinsic motivation alone is insufficient for developing a robust role identity, especially when healthcare assistants are isolated from peers in similar roles.^{11,12,17,22,23,32,74,77}

Structured peer support interventions delivered through both online and in-person facilitated sessions create opportunities for healthcare assistants to connect with peers who share similar experiences.^27,32,78,84 These sessions facilitate relationship-building,^11,32,77 sharing meaningful care stories and collective reflection on their roles.^32,34,77 Through this process, healthcare assistants are able to articulate the value of their work, receive affirmation and validation from peers, and co-construct a shared understanding of their role identity.^27,32,77 Reciprocity between peers and ability to share in confidential and safe space are important to enable such processes.^77,88

These mechanisms are supported by reference group theory^65,66 describing self-evaluation processes through comparison. This means that healthcare assistants assess their own attitudes, beliefs and success relative to the standards of a group they belong to by striving to follow these and setting them as a benchmark for self assessment.

Healthcare assistants reframe their work as skilled and essential, challenge negative stereotypes and assert role boundaries. ⁷⁸ This process strengthens their confidence and pride and contributes to the development of a cohesive role identity.^32,78,84

Ultimately, even in the absence of systemic recognition, peer support intervention may enable healthcare assistants to feel valued and empowered in their roles.

Initial programme theory

The initial programme theory (Table 3) developed following literature synthesis demonstrates that peer support creates a complex adaptive system where healthcare assistants develop capacity to manage the emotional and practical challenges of delivering palliative and end-of-life care in unpredictable home environments. The reciprocal nature of peer support creates self-sustaining networks that become increasingly independent of external facilitation as participants develop stronger peer relationships and enhanced confidence in supporting colleagues. The realisation of these outcomes is dependent on a set of organisational enabling conditions, including leadership receptiveness to supporting staff wellbeing, endorsement of peer support as valued professional practice, allocation of protected time for participation and resourcing of peer facilitator training. Without these conditions, the mechanisms identified in this review are unlikely to be fully activated. This theory will be further refined during realist evaluation forming the next stage of this research.

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Table 3.

Initial programme theory of workplace peer support intervention.

Workplace peer support intervention, which creates opportunities for peer interaction, is likely to influence positive outcomes for healthcare assistants providing palliative and end-of-life care at home. These positive outcomes include enhanced mental wellbeing, reduced workplace isolation, strengthened role identity, and the emergence of a sense of community of practice, through creation of psychologically safe spaces and relationships, where individuals feel validated, valued, connected with others, and through social learning among peers.
What Works	For Whom	Why	In What Context
Workplace peer support intervention consisting of regular peer facilitated group meetings, 24/7 peer support access and peer mentorship, may lead to enhanced mental wellbeing, reduced workplace isolation, strengthened role identity, and the emergence of a sense of community of practice	For healthcare assistants delivering palliative and end-of-life care at home who face workplace isolation, emotional labour, role undervaluation but who are motivated to provide good quality care	Intervention creates structured opportunities for peer interaction within psychologically safe spaces and relationships, where individuals feel validated, valued, connected with others, and involves social learning among peers.	If the intervention is facilitated by trained peers who have shared experience of providing palliative and end-of-life care at home, and exists alongside supervisory support and formal education and training within a supportive organisational context which positions peer support as valued professional practice and enables participation through protected time and appropriate resourcing.

Across the four outcomes, recurring patterns suggested that workplace peer support may operate by addressing three fundamental psychological needs of competence, autonomy and relatedness, which we interpret through self-determination theory^71,72 in the discussion below.

Enhancing competence

Ryan and Deci ⁸⁹ describe competence as feeling effective, skilled, and capable of achieving desired outcomes. Previous research demonstrates that healthcare assistants frequently experience inadequate preparation for their roles and inconsistent access to training and education opportunities,^90–92 resulting in diminished confidence regarding their competence. ¹¹ Workplace peer support interventions address healthcare assistants’ need for feeling competent through tacit knowledge exchange, reflection and collaborative problem solving, potentially fostering the development of both practical and emotional competence. Interactions between peers allow them to benchmark their practice and identify knowledge and skill gaps that can be addressed through collective expertise. However, peer knowledge sharing must be balanced with appropriate quality assurance mechanisms to prevent the inadvertent reinforcement of substandard practices or misinformation. This suggests that competence-building through peer support requires careful balance between leveraging experiential knowledge and maintaining quality assurance. Potential safeguards may include periodic oversight from registered professionals to review content shared during peer sessions, positioning peer support as complementary to rather than a substitute for formal training and education and establishing clear pathways for escalating clinical queries beyond peer expertise. However, the current evidence base offers limited guidance on specific mitigation strategies for this workforce, and further investigation is needed to determine how best to safeguard the quality of peer knowledge sharing in practice.

Beyond practical skills development, peer support interventions also facilitate the development of emotional competence – an ability to effectively manage and respond to emotions in social situations in ways that align with personal values and support healthy relationships. ⁹³ Emotional competence encompasses a set of skills that can be systematically nurtured and developed. ⁹⁴ Such skills include recognising and managing personal emotional responses to death and suffering, understanding how emotions function and are communicated interpersonally and developing empathic engagement with others’ emotional experiences. ⁹³ Each of these skills represents a vital component of healthcare assistants’ work in palliative and end-of-life care settings and can potentially be enhanced through structured workplace peer support interventions, which facilitate social learning among peers.

The parallel development of practical and emotional competence through peer support intervention is important. Inadequate competence in either domain can directly compromise the quality and safety of care provided to patients and families, underscoring the importance of well-designed peer support systems that enhance competence while maintaining appropriate safeguards.

Supporting autonomy

The psychological need for autonomy is satisfied when individuals feel they have volition and are self-directed in their actions rather than externally controlled. ⁸⁹ Healthcare assistants’ work presents a unique autonomy paradox. While working in patients’ homes provides inherent independence, healthcare assistants must simultaneously operate under the supervision of registered professionals, adhere to prescribed care plans and defined scopes of practice.^90,95,96 Evidence indicates that many individuals are drawn to this work specifically because it offers a degree of control and autonomy, ⁹⁷ highlighting the importance of understanding how workplace peer support interventions can facilitate the fulfilment of this psychological need.

Structured communication systems with clear guidelines that provide options and choice are essential for overcoming practical barriers to peer support. Such interventions should include clear protocols for peer contact and accessible communication channels, enabling healthcare assistants to maintain control over how, when and from whom they seek support. Previous research demonstrates that multiple support options are required, where peer support complements managerial supervision and reflective practice groups. ⁹⁸ Mixed delivery modes of peer support are also needed to maximise opportunities for participation. ⁹⁹

Research among home care workers indicates that experiencing autonomy in their role may contribute to higher job satisfaction and lower intention to leave.^100–102 Therefore, when implementing workplace peer support systems, careful consideration must be given to ensuring that workers experience autonomy when accessing support systems.

Fostering relatedness

Relatedness is conceptualised by Ryan and Deci ⁸⁹ as the need to feel connected to others and experience a sense of belonging and meaningful relationships. Our findings demonstrate that healthcare assistants have a fundamental need for connection with peers. However, they often experience loneliness, defined as distress from a perceived lack of quality workplace relationships, ¹⁰³ which is associated with lower job performance and reduced wellbeing across various sectors. ¹⁰⁴ Healthcare assistants face unique emotional and practical demands that are often difficult for others to fully understand, making peer connections particularly valuable.

Our review findings indicate that workplace peer support interventions address this need by creating psychologically safe spaces – environments that enhance employee performance, learning and work experience. ¹⁰⁵ These safe spaces are characterised by confidentiality, non-judgemental attitudes, mutual respect and a collective willingness to provide support to colleagues. These characteristics enable healthcare assistants to experience authentic connections necessary for satisfying their relatedness needs. Within such environments, reciprocal emotional support develops when healthcare assistants recognise that their peers genuinely understand their distinctive emotional demands.

The reciprocal nature of peer support is particularly significant for meeting relatedness needs. Healthcare assistants serve not only as passive recipients of support but as active contributors, creating relationships that enhance their sense of connection and create a sense of belonging to a community of practice. This mutuality distinguishes peer support from other forms of workplace support and strengthens the relationships between workers. Additionally, research shows that the healthcare worker groups with lower status may experience reduced psychological safety, ¹⁰⁶ potentially explaining why peer facilitation which removes hierarchical differences proves particularly favourable.

Summary

Research by Deci et al. ¹⁰⁷ demonstrates that satisfaction of competence, autonomy and relatedness needs results in higher employee wellbeing and better work performance. Building upon this theoretical foundation, our findings suggest that workplace peer support interventions may address these fundamental psychological needs among healthcare assistants, potentially contributing to improved care quality and workforce sustainability. However, the current evidence base requires strengthening to establish definitive causal relationships between peer support interventions, satisfaction of psychological needs, and broader organisational outcomes.

Implications for practice, policy and research

Workplace peer support represents a potentially sustainable intervention model that leverages existing workforce expertise while minimising reliance on external resources. The reciprocal nature of peer support may create a model for a self-sustaining intervention that becomes increasingly independent of external facilitation as healthcare assistants develop stronger peer networks and enhanced confidence in supporting colleagues.

Organisations that wish to implement workplace peer support interventions could test the initial programme theory identified in this realist review of the literature following key design principles: embed interventions within supportive organisational contexts, offer multiple modalities for diverse working environments and position peer support as valued practice.

The programme theory of what works, for whom, and in what circumstances from this realist review provides a foundation for future research to develop an evidence-informed peer support intervention. Future research should also prioritise investigating existing workplace peer mentorship models, strategies for addressing potential poor practice sharing and long-term impacts on workforce retention and care outcomes.

Strengths and limitations

The limited number of included studies may restrict programme theory development. The evidence base was predominantly dependent on self-reported outcomes with limited intervention studies and no long-term follow-up studies to evaluate sustained impacts on workforce retention or patient outcomes. Potential publication bias exists as searches were limited to English-language publications. There was insufficient data to fully understand the links with staff retention and quality of care.

This review followed established frameworks and standards for realist reviews.^42,43,52 Comprehensive search strategies accessed international evidence using a broad definition of healthcare assistants that acknowledged global variations in roles and titles. The inclusion of grey literature and stakeholder involvement throughout the review process enhanced the breadth and contextual relevance of findings. The review addresses an important evidence gap in an increasingly critical area of healthcare delivery, and provides a robust foundation for future intervention design and development. Integration with substantive theories enhanced explanatory power beyond the empirical findings alone.