Managing mental health in chronic care in general practice: a feasibility study of the Healthy Mind intervention

Abstract

Background and objective

Mental health issues are common among patients with chronic physical conditions. This study aims to evaluate the feasibility of the Healthy Mind intervention, a general practice-based programme that provides problem-solving therapy (PST) to patients with poor mental well-being and type 2 diabetes (T2D) and/or ischaemic heart disease (IHD).

Design and setting

A one-arm feasibility study was conducted in three general practices in the Central Denmark Region.

Intervention

Eight healthcare providers from the included general practices underwent a two-day course to acquire PST skills. Screening for poor mental health was carried out at the annual chronic care consultation for T2D or IHD, and PST sessions were offered to patients on indication of poor mental health. Nine patients received PST.

Methods

Semi-structured interviews with eight healthcare providers and six patients were conducted. Data were analysed deductively focusing on appropriateness, acceptability and fidelity of the intervention.

Results

The intervention was considered appropriate for the patient group and the general practice setting. The providers acknowledged PST as a valuable tool for managing psychological issues in general practice, and the patients perceived PST as an effective and tangible treatment. Since practice nurses’ schedules were generally better suited for longer consultations, they were often the preferred intervention providers. The intervention was largely delivered as intended. However, the GPs generally expected patients to prefer a more directive approach, which sometimes challenged their role as facilitator and guide.

Conclusion

The Healthy Mind intervention was found to be feasible, and the results support proceeding to a full-scale evaluation trial.

Key Points

• Patients with type 2 diabetes and/or ischaemic heart disease often experience poor mental well-being, revealing a shortage of general practice-based interventions targeting this issue.

• This study evaluates the feasibility of a problem-solving therapy intervention in general practice for patients with poor mental health and type 2 diabetes and/or chronic ischemic heart disease.

• Both patients and healthcare providers regarded problem-solving therapy as an acceptable intervention for managing psychological issues in general practice.

• Healthcare providers preferred practice nurses as the providers of problem-solving therapy since their schedules were often more suitable for longer consultations.

• In problem-solving therapy, the provider is expected to take a facilitating and guiding role, but GPs sometimes struggled remaining in this role due to a preconceived anticipation that patients expected them to take a more directive approach.

Keywords:

• Mental health
• heart diseases
• diabetes mellitus
• type 2
• problem solving
• general practice
• psychosocial intervention
• feasibility study

Introduction

Type 2 diabetes (T2D) and chronic ischaemic heart disease (IHD) are among the most prevalent chronic diseases worldwide [1–3]. In these patient groups, the prevalence of depression is almost ten times higher than in the background population [4–7]. The mechanisms mediating the association between reduced mental health and chronic somatic conditions are complex and include a number of bio-psycho-social factors, like symptom burden, adverse effects of medication, and the psychological burden of living with chronic disease. Also, chronic physical conditions can increase the risk of reduced mental health and vice versa [8]. In addition, worse somatic health outcomes and increased mortality rates are reported in patients with comorbid physical and mental conditions, partly due to reduced self-care activities and poor medication adherence [9–12]. International guidelines for T2D and IHD management emphasise the importance of attending to mental health issues in addition to somatic and biomedical aspects of the disease [13,14]. Nevertheless, the primary focus remains on the biomedical aspects [15].

General practice is responsible for providing the care for these patients in most developed countries. Typically, these patients are offered 1–2 annual chronic care consultations with the general practitioner (GP) and/or practice staff, usually a practice nurse (PN). The continuity of care facilitates a patient-centred approach and offers confidentiality and knowledge about psycho-social aspects of the individual patient’s life. Therefore, the chronic care consultations in general practice could be a highly relevant setting for facilitating early detection and treatment of mental health issues.

Previous studies have found that non-pharmacological interventions based in primary care to target mild depression are effective, acceptable and preferred over medical treatments by patients [16–18]. One such intervention is problem-solving therapy (PST), which is a well-established psychological treatment that can be tailored to a primary care setting and has proven an effective treatment for depression and other mood disorders [19,20]. In recent years, several national guidelines have recommended PST for management of depression in primary care [21–23].

PST is an easily accessible and tangible treatment for both patients and providers, and PST can be delivered by trained healthcare providers within the time constraints of general practice [24,25]. Thus, PST seems to fit within the setting of general practice and may be a valuable treatment for patients with poor mental well-being and T2D and/or IHD. However, PST is not widely applied in Danish general practice, and most healthcare providers are unfamiliar with the approach. Moreover, to the authors’ knowledge, PST has never been offered to patients with a somatic disease based on screen-detected poor mental well-being.

The Healthy Mind intervention was designed as a complex intervention in the general practice setting to offer PST to patients with poor mental well-being and T2D and/or IHD [26]. Patients are screened for poor mental well-being at the annual chronic care consultation, and PST sessions are offered to patients on indication of screen-detected poor mental well-being.

Feasibility testing of interventions is highly recommended prior to a full-scale evaluation, in order to explore whether the intervention can be delivered in the specific setting [27,28]. Important outcomes to assess include the fit of the intervention to the setting and the patient group (appropriateness), receivers’ and deliverers’ perception of the intervention (acceptability), and the degree to which the intervention is delivered as intended (fidelity) [29].

The aim of this study was to evaluate the feasibility of the Healthy Mind intervention by assessing the appropriateness, acceptability and fidelity.

Methods

Design and setting

This single-arm feasibility study was conducted in Danish general practice from March to May 2022. Danish health care is mainly tax funded, and all residents have free and equal access to general practice services. Reimbursement and services offered in general practice are dictated by the collective agreement between the Danish Organization of General Practitioners and Danish Regions. GPs are independent contractors, who are free to organise their clinics within the framework of the collective agreement. Practice nurses are often employed in general practice and conduct independent consultations, including chronic care consultations under GP supervision.

According to the collective agreement in Denmark, reimbursement can be provided for up to seven 30-minute talk therapy sessions per patient over a 12-month period [30,31].

Intervention

PST aims to enhance the patient’s problem-solving skills, coping and self-care through empowerment and behavioural activation [32,33]. According to proposed behavioural models, effective problem-solving skills are the operating principle determining whether negative life events and problems develop into reduced mental health [32,34]. In PST, training of these skills is essential, and the patient must actively engage in problem-solving, whereas the PST provider takes the role as facilitator and guide. In the Healthy Mind intervention, patients used worksheets as a central part of PST. The worksheets guided the problem-solving process through five sequential steps (one worksheet per step): (1) Identifying the problem, (2) Defining the problem, (3) Generating solutions, (4) Analysing advantages and disadvantages for each generated solution, and (5) Implementing the most appropriate solution. Additional supporting material was developed for the healthcare provider to facilitate the PST sessions. Issues addressed during the PST sessions could be related to all aspects of the patient’s life. To match the Danish general practice setting, patients were offered up to seven PST sessions (each of a duration of 30 min). This was in accordance with previous recommendations of offering up to 6–12 sessions of a duration of 30–60 min each [35]. The number of sessions offered to each individual patient was based on the patient’s preferences and the healthcare provider’s assessment of need.

PST training

The PST training course was based on insights from a previous study in which 10 Danish GPs received PST training and offered PST to patients with various emotional issues [36].

In the present study, healthcare providers participated in a two-day PST course, which was hosted by two psychologists with special PST expertise. The course consisted of 1.5 days of PST training followed by a half-day training session, which was conducted one month later. Thereby, the healthcare providers had the opportunity to share and draw on each other’s experiences between the first and second session. The training covered the theoretical basis of PST and consisted of theoretical education and practical exercises, including role play, based on the four stages of Kolb’s learning cycle: concrete experience, reflective observation, abstract conceptualisation and active experimentation [37]. Furthermore, participants discussed how the intervention could be delivered in their individual general practices, and they developed plans for introducing and implementing PST in their general practices.

Participants

Recruitment of healthcare providers

Three general practices were recruited through e-mails sent directly to the clinics. The research group recruited these particular general practices since they differed in size, staff composition and location (rural/urban), and their personnel had previously expressed interest in working with mental health to members of the research group. At least one GP and one PN from each individual practice were mandated to participate in the study, and a total of three GPs and five PNs agreed to participate. All included healthcare providers were obliged to participate in PST training, but the individual general practice could decide who was to deliver PST to their patients. Table 1 shows the affiliation of healthcare providers and location of general practices.

Table 1. Affiliations and characteristics of participating healthcare providers and general practices.

General practice ID	General practice location	Healthcare providers (sex)
General practice 1	Rural	GP1 (M)
		PN1 (F)
		PN2 (F)
General practice 2	Urban	GP2 (M)
		PN3 (F)
		PN4 (F)
General practice 3	Rural	GP3 (F)
		PN5 (F)

GP: General practitioner, PN: Practice nurse, M: male, F: female.

Recruitment of patients

Eligible patients were adults diagnosed with T2D and/or IHD who attended an annual chronic care consultation in general practice. After giving informed consent, eligible patients were screened with the World Health Organization Well-being Index (WHO-5). The WHO-5 index is a psychometrically reliable and valid questionnaire that comprises five positively phrased questions measuring the subjective mental well-being of the responder. It yields a total score ranging from 0 to 100 points, with scores below 50 points indicating reduced mental well-being [38]. Patients with a score below 50 points were offered PST sessions provided by the GP or PN. Patients were excluded if they did not speak or understand Danish, were in a psychotic or suicidal mental state, had severely impaired cognitive function or underwent other simultaneous psychological treatments.

Support to intervention practices

To support implementation and uptake of the intervention, weekly updates were provided by email to the general practices. This included information about the number of recruited patients and the number of completed PST sessions in each practice. During the study period, each practice was expected to include 2–4 patients.

Theoretical framework

Implementation issues can be explored through specific implementation outcomes that enable systematic assessment of implementation and aids the understanding of implementation processes [29]. These outcomes can be studied during active implementation phases but are also common in studies conducted during the early phases of exploration and preparation, such as feasibility studies [39]. Inspired by Proctor et al. [29,39] this study assessed three early-stage implementation outcomes regarded as key for evaluating the feasibility of the Healthy Mind intervention: appropriateness, acceptability and fidelity. The operationalisation of the implementation outcomes is described in Table 2. Further, in pilot and feasibility studies, one may assess the feasibility of the intervention and/or the evaluation design [40]. In this study, we focused on the feasibility of the intervention.

Table 2. Operationalisation of implementation outcomes.

Implementation outcome	Definition*	Operationalisation
Appropriateness	Perceived fit, relevance or compatibility of the intervention for a given practice setting, provider or consumer and/or perceived fit of the innovation to address a particular issue or problem.	Participants’ views on how PST fits to the setting and patient group
Acceptability	Perception among implementation stakeholders that a given treatment, service, practice or innovation is agreeable, palatable or satisfactory	Participants’ views on the content and structure of PST
Fidelity	Degree to which an intervention was implemented as prescribed in the original protocol or as intended by the programme developers	The degree to which the PST sessions were delivered as intended

*Definition according to Proctor et al. [28].

Data collection

During the study period, one semi-structured group interview was conducted with healthcare providers from each of the participating general practice. A focus group interview with all participating healthcare providers was conducted at the end of the study period. Two PNs were unable to participate in the focus group interview, and they participated subsequently in individual telephone interviews. Group interviews were conducted in the respective general practices and the focus group interview was conducted in general practice 2. Before the interviews, all participants gave informed consent after receiving information about the study.

Patients participated in individual telephone interviews after their final PST session. An overview of the qualitative data collection is provided in Table 3.

Table 3. Qualitative data collection.

Healthcare providers				Patients
Data source	Group interviews (N=3)	Focus group interview (N=1)	Individual interview (N=2)	Individual interview (N=6)
Duration	26–50 min	105 min	20–43 min	8–42 min
Participants	· GP1, PN1, PN2	· GP1, GP2, GP3, PN3	· PN1	· PT1
	· GP2, PN3, PN4		· PN2	· PT3
	· GP3			· PT4
				· PT5
				· PT6
				· PT7

GP: general practitioner; PN: practice nurse; PT: patient.

All interviews were completed by AM and/or AS and were audio-recorded. Interviews were based on semi-structured interview guides with open-ended questions aiming to explore the implementation of the intervention by assessing implementation outcomes, as described in Table 2. The participants were asked about their experiences with delivering (healthcare providers) or receiving (patients) the intervention, how well the intervention fitted the general practice setting and the patient group, and their general perception of PST. Overall, the interviewers encouraged the participants to freely express their thoughts and opinions. The interview guides were developed during multiple discussion rounds in the multidisciplinary research group and are available on request.

Analyses

Data were coded deductively based on operationalisations of the implementation outcomes: appropriateness, acceptability and fidelity (Table 2). As suggested by Nevedal et al. [41], the analyses were conducted directly from the audio-recordings, thereby deriving detailed notes and captured quotes. To validate the coding, this was done independently by two authors (AS and SER), and any disagreements were negotiated until agreement was reached. A third author (AM) validated the analysis, and it was condensed into one joint narrative describing both healthcare providers’ and patients’ perspectives on appropriateness, acceptability and fidelity. Inspired by the concept of information power, we continuously considered the study aim, sample specificity, use of theory, quality of dialogue, and analysis strategy to further validate the analysis [42].

Ethical considerations

The study complied with the Declaration of Helsinki, which outlines some general ethical principles for good medical research practice [43]. Patients were informed, orally and in writing, about the study. They were informed that participation was voluntary and that they could withdraw from the study at any point in time. Written consent to participate was obtained from the patients.

General practices were remunerated in accordance with their time spent on study-related activities. Data storage and access complied with the General Data Protection Regulation (GDPR) of the European Union, and the project was listed in the record of processing activities at the Research Unit for General Practice, Aarhus [44]. According to the Danish National Committee on Health Research Ethics, no ethical approval was required for this study, since it did not include any human material [45].

Results

Participants

Table 4 provides an overview of patient characteristics and healthcare provider/patient relationships. All healthcare providers completed the training programme. However, two PNs (PN4 and PN5), from two different general practices, left the workplace shortly after completing the PST course without having delivered PST to any patients.

Table 4. Overview of patient characteristics and healthcare provider/patient relationships.

Professionals	Patients
Healthcare provider	Patient	Sex	Age, years	Diagnosis	WHO-5 score	Number of PST sessions attended
GP1	PT1	M	60	T2D, IHD	44	2
PN1	PT5	M	51	T2D, IHD	32	4
	PT6	F	63	T2D	48	6
PN2	PT9	F	52	T2D	20	2
GP2	PT4	M	56	T2D	20	2
PN3	PT7	M	83	T2D	44	4
	PT8	F	45	T2D	36	5
PN4	–	–	–	–	–	–
GP3	PT2	F	90	N/A	48	2
	PT3	F	82	N/A	44	1
PN5	–	–	–	–	–	–

GP: general practitioner, PN: practice nurse, M: male, F: female, PT: patient, N/A: not available.

Of the 54 patients screened during the study, nine patients (17%) were found to have poor mental well-being (WHO-5 score < 50 points). All patients agreed to participate in PST sessions. Two patients were excluded from the study based on the healthcare providers’ assessments, and three patients declined to participate in the interviews after the PST sessions.

Three main themes were derived from the analysis: the fit of PST to setting and patient group, content and structure of PST, and delivery of PST.

Theme 1: Fit of PST to setting and patient group

Increasing the focus on mental well-being

Broadening the focus of the annual chronic care consultation to include a systematic focus on both mental and somatic aspects was positively viewed by healthcare providers and patients.

A PN explained that she considered somatic and mental health to be interconnected, but she often found herself more preoccupied with the somatic aspects of the disease during the chronic care consultations. The patient-centered approach during the study helped her balance her attention to both somatic and mental aspects.

[It is useful] to shift the focus away from all the biochemical aspects and values, and rather talk about how the patients are actually doing. Because their diabetes may be well managed… But [it is also useful] to be more interested in their mental well-being. Because sometimes we care so much about the former, right? That’s also important, but there is something else that is important, too. And it is so interconnected. (PN2)

All patients expressed positive attitudes towards the increased focus on their mental well-being in their chronic care. One patient described how the increased focus on mental health contributed positively to his chronic care:

In the past, I would get a blood test and my medication was adjusted. But this time, we also delved into the personal aspects, and it was a relief to me that I could talk to her about these things. (PT7)

All patients were prepared and willing to discuss mental and emotional issues with their healthcare provider. One patient thought that the mental issues being addressed had to be directly linked to aspects of the somatic disease, such as how to cope with having to follow a strict diet or taking medication on a daily basis, which was not the case.

One patient described that the close professional relationship with his practice nurse made him participate, even though he was generally reluctant to talk about and cope with emotional issues.

The healthcare providers often had a pre-existing professional relationship with the patients due to the continuity in chronic care. One PN explained how her pre-existing confidentiality and acquaintance with the patients made it easy for her to increase the focus on mental aspects and engage her patients in the PST sessions.

I know these patients […] very well. I already know their challenges, and they are used to talking with me. (PN1)

Based on their pre-existing knowledge of the patients and their professional relationships with them, the healthcare providers considered the intervention appropriate for most patients. However, participation was considered inappropriate for two patients, who were excluded from the study due to a fragile professional alliance between healthcare provider and patient. A PN elaborated:

I have spent three years building up a trusting relationship with one patient, who has an extremely dysregulated diabetes, and she is such a person where I would think that this [the intervention] is not appropriate. We are already working with the mental aspects – there are all sorts of things in her life. [When] you finally convince her to come for a [chronic care] consultation and – POW – she drops out again. (PN2)

Navigating time constraints

Time was described as the biggest challenge for delivering the intervention. Both GPs and PNs reflected that if the intervention was to be implemented in real life, PNs would have to be the main intervention providers. Compared to the GPs, the PNs’ schedules were generally better suited for long consultations, which made it easier for them to deliver the intervention.

In two of the general practices, a PN left the workplace during the study period, which caused the general workload to increase for the remaining healthcare providers, and time became an important barrier for offering the intervention. A GP reflected:

The biggest challenge is time […]. I think it has been exciting [to participate in the study], but I was overwhelmed by busy days and then it becomes a burden. (GP3)

The patients noticed that the healthcare providers seemed to have a busy schedule. One patient described that, even though he felt the need for additional psychological support during the days after the first PST sessions, he was reluctant to ask for more consultations when he saw how busy the GP seemed to be:

I am sure that he [the GP] would have taken me in – I do not doubt that – but I also know they have a busy schedule, and he probably does not need to spend his time on long psychological consultations. (PT1)

Theme 2: Content and structure of PST

The tangible and action-oriented nature of PST was positively viewed by both healthcare providers and patients, and PST was regarded as an easily accessible and comprehensive treatment and a valuable clinical tool for managing mental health issues in general practice. A GP elaborates:

It [the intervention] feeds into everyday life instead of dealing with a personality structure or something more complicated. (GP3)

The predetermined stepwise structure of PST was perceived as particularly helpful by healthcare providers with limited previous experience in treating mental health issues, and treatment progress was found to be facilitated by the structure of PST. One PN stated:

It is nice to have a tool that is a little stringent. You stick to what you discussed last time instead of moving on. It transforms into more action. It becomes more committing – both to the provider and to the patient. (PN1)

One healthcare provider, who was experienced in managing mental health issues, reflected that combining PST with other psychological treatment methods, such as cognitive behavioural therapy, was compelling to her. Still, she also reflected that using PST alone may be more time efficient compared to other treatments.

All patients expressed an overall positive view on the content and structure of PST. The straightforward and tangible nature of PST was comprehensible to the patients. A patient expressed that the use of worksheets facilitated the identification and in-depth analysis of her problems. Another patient reflected that the method allowed him to see things from a new perspective, which helped him find new ways to manage his problems.

Theme 3: Delivery of PST

All healthcare providers reported that they followed the stepwise methodology during PST sessions, with the worksheets as a central part of the delivery. The duration of all PST sessions was 30 min.

All GPs expressed that it was difficult to stay in the role as a guide and facilitator rather than taking an active part in the problem-solving process. A GP explained:

The method is not like when we were on the course. The patients do not behave like they are supposed to. You need to be more of an idea generator and come up with solutions to a larger extent than what the method implies. (GP2)

Another GP reflected that the patients expect the GPs to be problem fixers:

I have come up with more ideas than my patients have. But maybe that is what is expected. So, now you come to the doctor, now you need some advice and then you are not supposed to sit and…. It is probably on our shoulders as well, since we have a hard time holding our tongues and giving time. (GP3)

One patient felt that the healthcare provider dictated which problem to address during the PST sessions:

We wrote down 3-4-5 topics on the list, and he chose the one with physical activity. I had expected him to ask me what I thought was the most important – and it [physical activity] was not what I would have said. (PT4)

Due to the patient’s lack of influence on choosing which problem to work with, he perceived the problem as trivial and did not feel committed to the treatment.

All healthcare providers reported that they encouraged the patients to take home the worksheets and to continue the problem-solving process at home after each consultation. Nevertheless, none of the healthcare providers expected their patients to be able to independently complete the more analytical problem-solving steps of the process.

All patients brought home the worksheets and reported that they were encouraged to use them between the PST sessions as a guide during the problem-solving process. However, they reported to have sporadically reflected on the problem-solving process in an unstructured manner rather than using the worksheets systematically.

All patients described that the treatment helped them take action and implement the solutions that they had come up with during PST sessions. For example, one patient changed jobs, and another reorganised his everyday chores to make time for more social activities.

Discussion

Main findings

This study aimed to evaluate the feasibility of a PST intervention, the Healthy Mind intervention, offered to patients in general practice by assessing appropriateness, acceptability and fidelity.

The intervention was found to be appropriate. Increasing focus on psychological aspects during chronic care visits was viewed positively by both patients and healthcare providers. Patients were prepared and willing to engage in PST sessions. The pre-existing professional relationship between patient and healthcare provider facilitated delivery of PST and influenced the patients’ decision to participate in the treatment.

Concerns about time constraints were considerable. GPs and PNs reflected that PNs should be the main deliverers of the intervention since their schedules were generally more accommodating for longer consultations.

The intervention was found to be acceptable. Healthcare providers perceived PST as a valuable intervention for handling psychological issues in patients, and PST was considered suitable for both GPs and PNs to deliver. The patients viewed PST as a relevant and comprehensible treatment method.

The intervention was delivered with an acceptable level of fidelity. The stepwise methodology was followed in all cases. However, the GPs sometimes struggled with remaining in their roles as facilitators and guides, which was facilitated by a preconceived anticipation among GPs that the patients expected them to take a more directive approach.

Strengths and limitations

An important strength of this study was the inclusion of perspectives from both patients and healthcare providers on important aspects of implementation. This allowed the research team to obtain a broad and nuanced understanding of the perceptions of both deliverers and receivers of the intervention. Further, we interviewed all healthcare providers and most patients who tested the intervention. Moreover, the intervention was tested in three general practices that differed in size, geographical location and workflows, thereby capturing insights from various types of organisational structures. However, including more general practices, participating healthcare providers and patients could have contributed with more insights on the feasibility of the intervention. Two healthcare providers were unable to attend the focus group interview after termination of the study and subsequently gave individual interviews. Thus, the dynamic nature of focus group interviews where participants can interact in a dialogue and discuss different views and opinions could not be applied. However, the same interview guides applied for both the focus group interview and individual interviews and the perspectives that emerged during the focus group interview were introduced in the individual interviews.

Our study explored the feasibility of only the intervention, not the evaluation design. Yet, the analysis of recruitment and refusal rates, number of sessions per patient etc. is not described further, although they are relevant in the design of the subsequent larger trial. Also, we focused mainly on the early implementation of PST. Insights into sustained use of the intervention may have been obtained if the study had been conducted over a longer period, thereby allowing for other aspects of intervention feasibility to be evaluated, e.g. follow-up response rates. All included general practices had previously expressed that working with mental health issues was an area of special interest to them, which may have affected their perception of the intervention. Thus, the findings may not be generalisable to general practices with no special interest in mental health.

Findings in relation to other literature

Patient-centered care is a core value in general practice [46]. However, biomedical aspects remain the primary focus in the chronic care consultations [15]. In the present study, all participating patients were ready and willing to discuss psychological issues with their healthcare provider. Although it is not a prerequisite for the intervention, a pre-existing relationship with the healthcare provider seemed to facilitate the patients’ readiness for participation, which is also found in other studies [47,48]. One of the reasons why general practice is a relevant setting for psychological interventions is that patients here often have longitudinal and continuous relationships with healthcare providers and, consequently, a trusting relationship is established prior to the treatment. However, two patients reported uncertainty about the framework of the PST consultations; one patient expected that the issues addressed during PST should be related to the somatic disease, and another patient was reluctant to schedule more PST sessions when considering how busy the GP seemed to be. This may reflect preconceptions that physical health is the main concern in chronic care in general practice and that psychological treatment is not the GP’s main focus. Such patient expectations have also been found in other studies [49,50] and need to be addressed to facilitate successful implementation.

One of the most important barriers identified in our study was time constraints. The PNs’ schedules were generally more accommodating, and it was easier for PNs to make time for longer consultations. However, the unexpected attrition of two of the healthcare providers led to an increase in workload that burdened the remaining healthcare providers and compromised the implementation of the intervention. In healthcare interventions, it is important to acknowledge that time is a scarce resource, and interventions need to be designed to fit clinical realities and accommodate potential challenges, such as unexpected staff attrition, which could be addressed by increasing the number of intervention providers. However, if the providers’ increasing experience with delivering the intervention is expected to increase the quality of the delivery, it is necessary to balance the vulnerability of attrition (increasing the number of intervention providers) with the need for the provider to gain sufficient skills in providing the intervention (ensuring that the provider gains sufficient experience).

In this study, we found that delivery of PST was appropriate for both GPs and PNs. However, since the PNs’ schedules were more flexible, the healthcare providers reflected that delivery by PNs was most appropriate. In recent years, workforce shortage among GPs combined with an increasingly ageing population and expansion of general practice core tasks have led to a transfer of tasks to an increasingly multidisciplinary workforce in general practice. This task delegation to trained practice staff has been shown to be both safe and effective, and it is an important component in overcoming the challenges faced in general practice [51]. Trained practice staff is increasingly involved in chronic care services, which should be considered when designing interventions targeting patients with chronic diseases in general practice. Preferably, such interventions should be flexible in terms of delivery to ensure that both nurses and GPs can deliver the intervention according to the preferences of each individual general practice.

Some GPs anticipated that their patients would expect them to take the lead by generating possible solutions and giving advice on how to pursue the goals, which is not the intended approach in PST [35]. At times, it was challenging for the GPs to balance this expectation and remain in a facilitating and guiding role during PST sessions, which ultimately challenged the implementation of the intervention. Thus, it is important to consider the preconceptions of both patients and healthcare providers when introducing an intervention in general practice. To ensure that participants are aware of their own preconceptions and to facilitate consensus between healthcare providers and patients, they should be encouraged to articulate their expectations prior to commencing the intervention. Furthermore, it is crucial to teach healthcare providers how to negotiate the agenda of the consultation when the roles in and the structure of the consultation differ from an ordinary consultation. Prior to a definitive trial, the PST course is therefore recommended to increase focus on preparing healthcare providers for delivery of the intervention, including awareness of possible patient expectations and the importance of delivering the intervention with high fidelity – including remaining in a facilitating and guiding role.

Conclusion

The Healthy Mind intervention was found to fit the setting in general practice and the patient group. The content and structure of PST was positively viewed by the participants, and PST was delivered with an acceptable level of fidelity. Healthcare providers expressed concerns about time constraints and GPs sometimes struggled to remain in a guiding role. Delivery of PST was considered suitable for both GPs and PNs, however healthcare providers reflected that PNs should be the main deliverers of the intervention. In consideration of these findings, we perceive the Healthy Mind intervention to be feasible, and it is considered appropriate to proceed with a full-scale evaluation study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by TrygFonden under Grant ID: 153246 and The Danish Heart Foundation under Grant ID: 2021-9866.