Applying Peer Counselor Concept at Workplace and Pilot Test for its Efficacy

Objective: This study aimed to develop a peer counselor training program that can apply peer counselor concept at workplaces and conduct a pilot test for verifying its effects on peer counselors in relation to perceived stress, occupational stress, coping strategy, work-life balance and work flow, and to explore the possibility for the trainees to act as peer counselors in the future. Methods: A peer counselor training program was developed based on reviewing journals related to common stressors of employees and stress management programs. Fourteen employees completed self-report questionnaires including perceived stress, occupational stress, ways of coping, work-life balance, and 3 questions regarding work flow, before and after the program. They also filled out a questionnaire which measured their satisfaction of the content and composition of the program upon completing the program. Results: Perceived stress level and occupational stress level, including job demand, insufficient job control, interpersonal conflict, organizational system, and lack of reward, significantly decreased after the program compared to the outset level (p<0.05). Work-life balance also significantly improved (p<0.05). Satisfaction level for the program scored an average of 4.2 on a 5 point Likert scale. Conclusions: Peer counselor training program can alleviate trainee’s various aspects of stress and enhance their motivation and confidence as a peer counselor. Further studies verifying the effects of this program on peer employees who receive support from peer counselors are needed.


Introduction
Modern employees are experiencing a lot of job stress due to the introduction of new working methods, need for quick decisionmaking, increased use of computers and human contact [1]. Such job stress among employees not only affect their work adaptation and psychological stress such as anxiety, aggression, depression, alienation, and nervousness [2][3][4], but also physical health such as high blood pressure, back pain, headache, muscle tension, heart disease, and increased cholesterol level [4][5][6]. Stress among employees does not stop at having effects only on an individual level but also becomes the cause of decreased productivity on a corporate level from decreased motivation and absenteeism and burden of cost due to increased accidents. In terms of its influence on a local community or a country, employee stress lead to negative consequences such as hampering the development of a local community and nation due to drop in competitiveness [7,8].
With concerns for such stress among employees, it is becoming more common to perceive job stress as a problem that requires systematic management at organizational and national level instead of treating it merely as a personal problem. The Korean government inserted a clause in the Occupational Safety and Health Act mandating business proprietors to prevent health hazards resulting from physical fatigue and mental stress and also established an article in the Enforcement Decree for Standards of Occupational Safety and Health demanding that business proprietors should evaluate job stress factors, establish improvement countermeasures for those factors, periodically assess their risks, and implement health promotion programs [9]. These measures, thus, provided a legal foundation for the management of job stress.
Various stress management programs have been developed for the mental health of employees. However, there are still some limitations to implement those programs at many businesses. First, since the existing stress management programs for employees are designed for specific occupations, there is a limit to applying them to diverse occupations. In fact, the main subjects who have been involved in Korean studies that developed and verified the effects of stress management programs were limited to elementary to middle-school students or university students [10][11][12][13], patients or medical workers [14,15], and athletes [16]. Therefore, it is necessary to make an effort to develop stress management programs that can be universally applied to a wide array of jobs. Second, while it is important to adopt a personal approach on stress management at workplaces cultivating each worker's ability to effectively manage stress, what is more desirable is to have the effectiveness of personal approach transfer horizontally and vertically and to integrate approaches that can be developed on an organizational scale [17]. However, most of the existing stress management programs focus on the psychological wellbeing of an individual and aim simply to reduce an individual's stress level. Third, most of the existing job stress management programs were implemented either in the form of outsourcing with the help of external experts or through a mental health specialist hired by the business. These methods are available only for large companies since they require high expenditure on a corporate level to cover such expense for employee benefits. Besides, these benefits may be the first in line to be cutback when there is an economic crisis or the company experience financial difficulties. Therefore, it is necessary to develop a program that can be used practically in small and medium-sized businesses and is also realizable regardless of a company's financial crisis.
To apply a peer counseling model to mental health promotion programs at workplace can be a good attempt to supplement these limitations. Peer counseling refers to supportive service provided to co-workers experiencing psychological problems and other difficulties that may occur at work and life in general by a peer, who share similar work culture and life experiences and have been trained for the role of a counseling paraprofessional [18]. Compared to professional counselors, a peer counselor, even if a paraprofessional, has advantages for s/he can identify co-workers in crisis more quickly and better understand their situation or the environmental context of the company, and form firm support network with other peer counselors [18]. From the viewpoint of a company, the activities of peer counselors themselves are expected to establish a desirable culture of communication and emotional support within the company. Also, a cost-effective mental health prevention system can be built within a company by having peer counselors since they can serve the role of a gate keeper who makes referrals to mental health specialist in early stage when mental health problems are found among co-workers [18].
The purpose of this study was to develop a peer counselor training program to educate employees for a set period of time, and conduct a pilot test for verifying the effects of this training program.

Development process of the peer counselor training program
The peer counselor training program plan 1 was composed by selecting indispensable elements for peer counselor training based on factors related with employees' stress drawn from analysis of previous studies. The goal of plan 1 was to graft counseling skills into the training program so that the trainees can naturally experience the effects of counseling from receiving the training. Hence, with a basic course that deals with the improvement of interpersonal skills and counseling skills, and optional programs that can be added according to the circumstances of respective company, the training program was composed of 6 two-hour sessions, 12 hours in total. In order to assess the suitability and feasibility of the peer counselor training program plan 1, 10 experts, including psychiatrists and counseling specialists working at employee assistance program centers in large companies, were recruited for a meeting. They expected that workplace atmosphere can be improved not only through the effects of counseling activities of peer counselors who participated in the training but also through their improved self-understanding, communication skills and interpersonal skills. They responded positively to the composition of experience-oriented training, but suggested that partial modification of the order and content of the program is necessary to properly train employees who are nonprofessionals. The research team had a meeting referring to the opinion of expert consultants and developed the modified peer counselor training program plan 2. The key goal to plan 2 was to help the trainees, who are paraprofessionals, acquire activity programs that can be easily utilized during actual peer counseling in addition to learning basic counseling skills. First six hours of the entire 12-hour program are allotted to basic elements of counseling skills including active listening, empathizing with others, importance of selfdisclosure, and questioning methods, and the latter six hours to programs that are helpful for employees in general such as decisionmaking skills, coping conflicts, and stress management [appendix].

Session Activity
Content and purpose of main activities

Participants
Through study recruitment poster in 3 hospitals, a total of 15 employees volunteered to participate in the study. Participants were 14 female and 1 male workers, and their mean age was 36.1. One of the participants had to discontinue the program for unavoidable personal circumstances. Hence, the study used the data from the 14 participants who completed the program for the final statistical analysis.

Methods and measures
Recruitment of the program participants and implementation of the program itself proceeded from August to September, 2010. The program lasted 12 hours and was implemented in two blocks for six hours and two weeks apart. This is a pre-post comparison study based on implementing the peer counselor training program. In order to measure the effectiveness of the program, participants were asked to complete identical questionnaires before and after participating in the program. They also filled out a questionnaire which measured their satisfaction of the content and composition of the program upon completing the program. All data were collected through self-reported questionnaire. All the participants completed their questionnaires at the same time and at the program site before going into the first session and immediately following the last session of the program. The scales used in the present study to measure the effectiveness of the program were as follows:

Perceived stress questionnaire
The 'Perceived Stress Questionnaire' (PSQ) is an instrument developed to measure the level of stress subjectively perceived [19]. In the present study, we used the Korean version of Perceived Stress Questionnaire, which has shown acceptable validity and internal consistency [20]. The Korean version of PSQ consists of 30 items, and each item has 5 response alternatives, ranging from 'not at all (1)' to 'always (5)'. Higher scores indicate higher level of perceived stress [20]. Cronbach's α for this questionnaire is 0.96.

Korean Scale of Occupational Stress (KSOS)
The Korean Scale of Occupational Stress (KSOS) [21] synthesizes job stress scales used in other countries such as Job Content Questionnaire [22], National Institute of Occupational Safety and Health (NIOSH) General Job Stress Questionnaire [23], Effort-Reward Imbalance [24], and Occupational Stress Index [25], and also contains questions developed from qualitative studies intended to reflect the Korean reality. As a standardized measure developed from surveying 30,146 employees in Korea and tested for reliability and suitability, KSOS is designed to be applicable to any occupations in Korea. Based on a four-point Likert scale, the KSOS measures eight key areas of job stress: 'physical environment' measuring environmental factors such as air pollution and risks of work method; 'job demand' measuring the extent of job pressure felt by the employee; 'insufficient job control' measuring the employee's right to make decisions related to work and the extent of using discretionary power involving work; 'interpersonal conflict' measuring interpersonal relationship such as help or lack of support between colleagues and supervisors at work; 'job insecurity' measuring the stability of job or work; 'organizational system' measuring the strategies, operating system, resources, internal conflict, lack of rational communication, possibility of promotion, and appropriateness of position within the organization; 'lack of reward' measuring whether the reward expected of the work is appropriate; and 'occupational climate'measuring Korean collectivism, job conflict, lack of rational communication system, and sexual discrimination. Higher scores indicate the higher stress in that occupational area. Cronbach α is 0.512~0.822 for subscales.

Korean version of the Ways of Coping Checklist
In this study, we adopted the Korean version of the ways of coping checklist [26] that is modified from the original one [27]. This scale evaluates four types of subordinate stress-coping methods including problem-focused style, emotion-relieving style, wishful thinking style, and social support seeking style. It contains 62 questions in total and is based on a four-point Likert scale ranging from 'do not use at all (0)' to 'use a lot (3)'. Higher scores indicate that the person has higher coping ability in that specific area. Cronbach α is 0.87~0.95 for subfactors.

Work-life balance scale
This scale is an instrument consisting of 29 questions measuring four main elements: 'work-family balance', 'work-leisure balance', 'work-growth balance', and 'work-life balance' [28]. Each question is based on a seven-point Likert scale ranging from 'strongly disagree(0)' to 'strongly agree (6).'Cronbach α is 0.676~0.847 for subfactors.

Work flow
Work flow was measured using 3 questions [29]; 'I am good at focusing on my work', 'I find my work interesting and enjoyable', and 'I am doing my best in my duty'. Each question was scored based on a seven-point Likert scale ranging from 'strongly disagree (0)' to 'strongly agree (6).'Cronbach α for this scale is 0.824.

Program satisfaction questionnaire
Program satisfaction questionnaire was used to evaluate the program participants' satisfaction about the content and composition of the program. This questionnaire contains 21 questions and asks the participants to evaluate on a five-point Likert scale, ranging from 'strongly disagree(1)' to 'strongly agree (5)'. In addition, as means of qualitative evaluation for the improvement of the training program, a blank space was provided at the bottom of the questionnaire allowing participants to freely describe what was most satisfying about the program and what needs to be improved.

Ethical considerations
Seoul National University Bundang Hospital Institutional Review Board reviewed and approved this study. All subjects voluntarily participated in this study. Participants were given full information about the study and informed consent was obtained. This study was conducted in accordance with the recommendations in the Declaration of Helsinki.

Statistics
We used descriptive statistical analysis on the program satisfaction questionnaire results and the non-parametric testing method of Wilcoxon signed rank test on the pre-post statistical analysis for the verification of the program effectiveness. SPSS software, version 17.0 (SPSS Inc., Chicago, IL, USA) was used for overall data analysis. (Table 1) The participants' perceived stress levels significantly decreased (Z=0.026, p<0.05). With respect to KSOS results, significant differences were found in job demand, insufficient job control, interpersonal conflict, organizational system, and lack of reward (job demand Z=0.049, p<0.05; insufficient job control Z= 0.029, p<0.05; interpersonal conflict Z= 0.002, p<0.01; organizational system Z= 0.004, p<0.01; inadequate compensation Z=0.019, p<0.05).

Pre-post comparison analysis
Results from work-life balance scale also showed significant statistical change (Z=0.013, p<0.05).

Items
Pre-test

Satisfaction for the program (Table 2)
Based on a five-point Likert scale, the overall satisfaction for the composition and process of the program showed a high score of4.2 points. In particular, high satisfaction was found in items asking whether the participant intends to participate in follow-up programs (4.6 points), intends to recommend the program to other colleagues (4.6 points), and found the program beneficial (4.6 points). With respect to the time composition of the program, however, the satisfaction level showed a low score of 2.8 points. Many participants made requests for extension of program time responding to items such as 'a four-week composition of six-hour program would be better,' 'it would be more effective to have the six-hour program every week and not two weeks apart,' and 'the twelve-hour program felt too short and lacking'.
For the participants' satisfaction rating about learning the program content, we assessed their psychological satisfaction through program participation and their perceived level of program content acquisition. Results showed that their overall satisfaction score was high at 4.1 points.

Discussion
The aim of this study was to develop a program that allows general employees who wish to act as peer counselors acquire the basic attitude and skills necessary for a counselor and to examine what effects the program has on the participants as well as the possibility of nurturing peer counselors based on such a program.
As a result of implementing the program to employees who voluntarily participated in the study, it was found that there was significant decrease in their subjective perceived stress level and their occupational stress level in sub-factors such as stress involving job pressure, extent of having authority over the job and using discretionary power, interpersonal conflict, strategies and operating system of the organization, and adequacy of compensation.
The fact that the participants showed significant changes in subareas of occupational stress such as the 'organizational system of the company' and the 'interpersonal conflict,' which measures interpersonal relationship such as support from colleagues and supervisors at work, can be interpreted as the outcome of implementing the peer counselor training program with an emphasis on communication skills and interpersonal skills beneficial for interpersonal relationship within workplace.
Interestingly, study results indicate positive changes in other occupational stress areas such as 'job demand,' 'insufficient job control' and 'adequacy of compensation' that are not relevant to interpersonal relationship or emotional aspects. Taking into account that 'job demand' deals with stress factors in workplace such as responsibility, pressure, and time constraints and 'insufficient job control' with rights to subjective decision-making and job performance, and that 'adequacy of compensation' involves selfevaluation regarding compensation provided for given work, it would be reasonable to judge these positive changes as subjective perceptional changes of the participants rather than to assume that the actual system within the organization or external environmental factors have changed during the short period time the program was implemented. Explaining these positive changes in light of the study results showing decreased perceived stress level of the participants, it suggests that the level of occupational stress that employees actually experience is more influenced by their subjective perception of stress factors than the external stress factors themselves [19].  We may expect that the interpersonal and communication skills or emotional support covered in the peer counselor training program may indirectly influence other areas of occupational stress to increase job satisfaction and relationship satisfaction in the workplace as well as personal satisfaction, ultimately bringing positive effects to the overall atmosphere of the organization.
The participants also showed significant improvement in work-life balance. This suggests that trainings covered in the program that are related to time management, balancing work and private life, and taking initiative in and managing personal life proved to be effective. before'; 'Through this program, I will be able to help my colleagues who are experiencing conflicts better than I used to before'; 'Through this program, I think I will be able to better help my colleagues who are stressed. ' This program was implemented on weekend taking into consideration the time restrictions of employees who participated in the program. Although the research team was concerned that the participation rate might drop due to the weekend schedule, the participants rather expressed their satisfaction for making a good use of a holiday. Participants also expressed their experience of immense psychological comfort and ease of relationship problems with other people from putting what they have learned in the first session into practice over the short interval of two weeks between the first and the second session of training. Such an outcome suggests that employees are not receiving sufficient training in the workplace with respect to psychological care and that even with short trainings their perceived stress level can be reduced in their daily lives. During the program wrap-up session, the participants expressed their wish to see relevant programs continue and to have peer counselor meetings even after the program.
The present study, however, has the following limitations. First, the essential goal of the peer counselor training program is to train peer counselors so as to improve the mental health of other colleagues in the same workplace through their activities. This being so, it is ultimately necessary to verify what effects the assistance of these trained peer counselors have on various mental health areas of colleagues in the workplace. Second, since the present study was conducted only with people who work in hospitals, it is difficult to make a general statement that similar level of satisfaction and effectiveness will be found among people working in other occupations.
Despite these limitations, the present study is significant in the following aspects. First, introducing the notion of peer counselor to mental health problems at workplace which relied on in-company counseling center and outsourcing in the past, the study attempted to establish a mental health promotion system for employees in a costeffective manner even in the small and medium-sized business scene where covering such expense for employees benefit can be overwhelming. Second, breaking away from the existing approach of dealing only with stress when it comes to managing occupational stress, the present study composed the program with contents allowing trainees to experience emotional self-introspection and to learn about the problems of interpersonal conflicts they experience directly at work and how to cope with them, and thus, is significant in its practicality for providing concrete methods that can be applied flexibly in various environments at work.
Third, although the study involved a small sample, the participants nonetheless confirmed the needs for stress management and mental health promotion of employees and their commitment to work as paraprofessional peer counselors. Fourth, although the integrated stress management model combining the individual approach and organizational approach have been continuously discussed as desirable, previous studies were limited in that organizational approach frequently involved challenges. The peer counseling model at workplace proposed in the present study, however, enables easy participation and support within an organization and concurrently deals with the individual stress management approach, and thus, is expected to be a practical case for an integrated stress management model.

J Psychiatry
Journal of Psychiatry, an open access Volume 18 • Issue 1 • Psychiatry-14-97 In particular, depending on the atmosphere, scale, or features of a company, needs different from those found among the participants of the present study can emerge in the course of implementing the training program. Third, in this study, the number of female participants was overwhelmingly greater than the other. Hence, the results of the present study may not be generalized when large numbers of male employees are involved. Given the theory that women are more relation-oriented compared to men [30], training results with male participants may differ. Thus, it is necessary to have follow-up studies conducted with various groups of employees. Fourth, with the small number of subjects involved in the study, quantitative statistical analysis of the results has its limits. Studies in larger scale dealing with the same occupation group are needed to confirm the efficacy of the program.
In addition, we can assume that the motivation and confidence of the participants as a peer counselor was enhanced since they gave high scores on the following items: 'My desire to serve as a peer counselor grew stronger through this program'; 'Through this program, I have become more interested in the feelings of my colleagues that I was However, statistically significant results were not found from the data measuring stress-coping methods. Because the questions involve whether the participants have any experience of changing their stresscoping methods, it is possible surmise that accurate measurement was difficult in the context of post-test taken right after the program.
The study result showing overall decrease of stress level can be attributed to the fact that the training program not only covered basic counseling skills necessary for fostering peer counselors but also the participants' individual introspection and mode of perceiving problems, emotional self-exploring and discernment. In other words, such positive changes among the participants was possible because of the program features constructed for the active learning, practice and insight of the participants based on participation and not for a lecturebased training program geared toward knowledge acquisition. Feedbacks by the participants also show such characteristic of the program, as their comments about the best part of the program included the following statements: 'When it comes to counseling, I learned that empathy is more important than solving the problems of others'; 'I realized the importance of self-insight'; 'I used to think that listening intently is about making eye contacts and verbal responses while listening, but I realized that it is important to look into the inside of that person and also to look into my mind and feelings'; 'I learned how to relieve my stress and that of others'; 'I was impressed by the ways to reject someone smoothly and gently.'