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

Background: Healthcare assistants are support workers who play a central role in delivering home-based palliative and end-of-life care across many countries, often working alone delivering care at home. Despite their essential contribution, they face complex emotional and clinical demands with limited workplace support. Peer support has been suggested as a potential solution to practice challenges, yet no reviews of such interventions exist.
Aim/Research question or hypothesis: To understand and explain how, why, for whom and in what contexts workplace peer support interventions for healthcare assistants work (or do not work) in home-based palliative and end-of-life care.
Methods: A realist review following Pawson’s five-stage framework and publication standards. Systematic searches of CINAHL, MEDLINE, AMED, Scopus and grey literature sources were conducted November-December 2024, without date restrictions. All study designs containing data relevant to programme theory development were included. Evidence was assessed for rigour, relevance and richness. Data synthesis employed context-intervention-mechanism-outcome configurations to develop initial programme theory of the workplace peer support intervention.
Results: Synthesis of 24 eligible sources from six countries generated 12 context-intervention-mechanism-outcome configurations. Initial programme theory of workplace peer support intervention has been developed (see image). Four main workforce outcomes of intervention include: enhanced wellbeing and resilience, reduced loneliness and isolation, development of the sense of community of practice and strengthened role identity. Key intervention strategies: peer-facilitated group meetings, 24/7 peer support access, and informal peer mentorship, help create psychologically safe spaces and relationships, where individuals feel validated, valued, connected with others, and support social learning among peers.
Discussion: Workplace peer support interventions may address fundamental psychological needs of competence, autonomy, and relatedness among healthcare assistants. The programme theory reveals peer support as a complex adaptive system that leverages existing workforce expertise. This synthesis advances palliative care research from describing healthcare assistant challenges toward theoretically-informed solutions, offering new research directions for workforce support interventions.