At the time of this study (2009) the role of the nurse practitioner (NP) was new to the province of British Columbia (BC). The provincial government gave the responsibility for implementing the role to health authorities. Managers of health authorities, many of whom were unfamiliar with the role, were responsible for identifying the need for the NP role, determining how the NP would function, and gaining team members’ acceptance for the new role. The purpose of the study was to explain the process of NP role implementation as it was occurring and to identify factors that could enhance the implementation process. An explanatory, single case study with embedded units of analysis was used. Three primary health care (PHC) settings in one health authority in BC were purposively selected. Data sources included semi-structured interviews with participants (n=16) and key documents. Propositions and a conceptual framework developed from the review of the literature guided the study. Key components of the framework were the concepts of intention, involvement and acceptance. The results demonstrate the complexity of implementing the NP role in settings unfamiliar with it. The findings suggest that early in the implementation process and after the NP was hired, team members needed to clarify intentions for the role and they looked to senior health authority managers for assistance. Acceptance of the NP was facilitated by team members’ prior knowledge of either the role or the individual NP. Community health care providers needed to be involved in the implementation process and their acceptance developed as they gained knowledge and understanding of the role. Although relatively new in their roles, NPs were enacting, to some degree, all competencies of the role, as defined by College of Registered Nurses of BC. The findings suggest that the interconnectedness of the concepts of intention, involvement and acceptance influences the implementation process and how the NP is able to function in the setting. Without any one of the three concepts not only is implementation difficult, but it is also challenging for the NP to fulfill role expectations. Implications for research, policy, practice and education are discussed. / case study research

As mental health care increasingly embraces recovery principles, the role of peer support workers (PSWs) has gained recognition. The work that mental health PSWs do became particularly important during the COVID-19 pandemic, when increased needs for mental health care became apparent but were often unmet. This article-based doctoral thesis adopts an interdisciplinary perspective that combines research on management and organization with research on health care and systems. The thesis examines the mental health peer support role and its integration within teams, organizations and health systems. It also considers the peer support role as it was enacted in a virtual space, which became a requirement due to pandemic work-from-home mandates. Within the context of the virtual space, PSWs confronted work-life boundaries that they had to navigate as they enacted their work roles. The virtual space also presented technological and social challenges to and opportunities for peer support, which are examined in this thesis from the points of views of PSWs and peers. Overall, this thesis attends to the PSW role more generally, and to peer support work in the specific context of a virtual environment. The thesis is composed of three studies, the second and third of which had to be adapted to the unexpected challenges and opportunities posed by the COVID-19 pandemic. Study 1 (presented in Chapter 2) is a narrative review that synthesizes the literature on factors influencing formal PSW role implementation in mental health systems. The findings are synthesized in a multilevel framework consisting of macro, meso and micro level influences. The analysis reveals that macro-level influences on PSW role implementation include socio-cultural, regulatory, political and economic factors, most of which act as obstacles. At the meso level, organizational culture, leadership, and human resource management policies play a significant role. Micro-level influences center around PSWs' relationships with team members. Interlevel interactions are also discussed. This study is co-authored with Professor Samia Chreim and was published in Administration and Policy in Mental Health and Mental Health Services in February 2022. For Studies 2 and 3, qualitative data were collected from members of a peer support organization situated in Ottawa. This organization is a publicly funded, not-for-profit organization that provides services free of charge to people experiencing mental health and addictions challenges. Due to the pandemic, all services and operations of this organization transitioned to remote services involving virtual platforms. Study 2 (presented in Chapter 3) is a qualitative case study that delves into the work-life boundary challenges and management of PSWs who were providing virtual mental health support during the pandemic. The study identifies temporal, physical, and task-related boundary challenges in work-life domains. Strategies employed by PSWs to manage these boundaries include segmenting and integrating work and personal domains. The study highlights the importance of self-care and the need for training on work-life boundary management for mental health workers. This research is co-authored with Professor Samia Chreim and is published in BMC Public Health. Study 3 (presented in Chapter 4) focuses on the transition from in-person to virtual mental health peer support services. Through semi-structured interviews with PSWs and service users (or peers), the research examines how technological factors act as bridges and boundaries to mental health peer support services, and whether and how a sense of community can be built or maintained among PSWs and peers in a virtual space when connections are mediated by technology. The findings highlight the mental health peer support needs that were (un)met through virtual services, the technology-based boundaries that were manifested and the steps taken to remove some of these boundaries, and the strategies employed by the organization and its members to establish and maintain a sense of community in a virtual environment marked by physical distancing and technology-mediated interrelations. The manuscript pertaining to this study is co-authored with Professor Samia Chreim and will be submitted soon to an academic journal. Overall, this thesis presents a unique and multi-faceted exploration of the implementation of peer support worker roles in mental health systems and their adaptation to virtual environments. It makes a number of contributions. The multilevel framework developed in Study 1 not only advances knowledge in the field but also offers a structured approach for policymakers and organizations to enhance the formal incorporation of PSW roles into mental health systems. Study 2 provides valuable insights into the nature of work-life boundaries in a virtual space, an important topic at a time when peer support workers and organizations are considering whether and how to maintain some form of virtual work post-pandemic. Study 3 adds to knowledge by highlighting the significance of virtual peer support beyond pandemic conditions. It also enhances understanding of the need for technological adaptation in mental health services and for community building regardless of the model of service. Limitations and implications for research, practice and policy are addressed.