Why peer-led crisis plan practice does — and does not — transform psychiatric ward culture: a realist-informed qualitative study from Japan

Background Japan's psychiatric inpatient environment — characterized by the world's highest per-capita psychiatric bed rate, entrenched coercive care, and persistent physical restraint — has resisted policy reform. Crisis Plans (CP) are meant to be authored by the service users who may experience a crisis, but in practice, clinicians often write them instead. Peer-led CP practice has been proposed as a catalyst for recovery-oriented transformation, yet how it actually generates organizational change remains theoretically underspecified. Aim This study aimed to identify the generative mechanisms and structural conditions through which peer-led CP practice transforms psychiatric ward culture in Japan. Methods We interviewed thirteen nurses, managers, and peer support workers (PSWs) at two psychiatric hospitals. An integrated qualitative design was used: interview data were first analysed inductively using the Modified Grounded Theory Approach (M-GTA), then re-examined through Realist Evaluation (RE) to identify causal mechanisms. Archer's morphogenetic approach was applied to interpret how organizational structures change or persist. Results Broad change in ward relationships developed when three mechanisms operated together: the hospital, rather than the individual nurse, taking responsibility for clinical risk (M1); the staged introduction of PSWs' lived-experience knowledge via a bridging staff member (M2); and staff letting go of the assumption that their job is to manage the person, allowing the peer-led return of CP authorship to the service user (M3). When these operated together, roles reversed: service users came to ask for care, and professionals responded. In the negative case (a site without PSWs), CP practice produced only individual-level change that was ultimately reabsorbed into existing practice. Conclusion PSWs occupy a structurally distinctive position: standing between the ward's existing conditions and the processes that change them, they turn structural constraint into a driver of change. It appears to be the maintained tension and ongoing disagreement between professional and lived-experience perspectives that sustains this change and the self-questioning on which durable transformation depends.