Initiating and Maintaining a Lifestyle Program Directed at Persons Living with Severe Mental Illness in a Municipality Care Setting

Abstract

Lifestyle programs are effective in improving the health of persons living with severe mental illness. However, the implementation of these programs and making them a sustainable part of daily care remain challenging. This qualitative descriptive study aimed to describe how staff worked with and experienced a lifestyle program in a municipality mental health care setting over time. The program intended to support persons living with severe mental illness to overcome health challenges. Data was collected at three time points spanning 7 years. The staff motivated the participants with SMI with severe mental illness to take part in the program, prepared them, and gave them individualized lifestyle support. A key factor of the program’s implementation was the staff’s interest and engagement in lifestyle questions. According to the staff it was apparent that small efforts such as running the present program could give synergic health effects such as improved mental- and social health. This study shows that it is feasible to conduct this lifestyle program in ordinary care without considerable resources. However, support from management is crucial, as well as the development of guidelines and routines of the work with lifestyle questions.

Introduction

Growing evidence shows that lifestyle programs are effective for persons living with severe mental illness (SMI) to improve mental health, physical health, and quality of life (Deenik et al., 2017; Manger, 2019; Rosenbaum et al., 2014; Rönngren et al., 2018; Speyer et al., 2019). Treatment with drugs e.g. antipsychotics is a major risk factor for unwanted health effects including metabolic syndrome (Molina et al., 2021). Moreover, persons with SMI often have poor access to health care, poor compliance with treatments, and somatic comorbidities (Almeida et al., 2014; Łopuszańska et al., 2014). The reduced life expectancy of persons living with SMI may also be related to their higher likelihood of having unhealthy lifestyles, including poor eating and exercise habits, smoking, and the use of drugs and alcohol (Kalinowska et al., 2021; Lawrence et al., 2010; Scott & Happell, 2011). Since persons living with SMI have a reduced life expectancy compared to the general population, one important strategy is to support them in developing healthy lifestyle habits (Liu et al., 2017; Plana-Ripoll et al., 2019; Vigo et al., 2016).

Furthermore, persons with SMI may spend a lot of time alone in their apartments (Tjörnstrand et al., 2020). Loneliness is a major problem among persons with SMI and may also function as a barrier to other healthy behaviors (Fortuna et al., 2021; Łopuszańska et al., 2014; Penninx & Lange, 2018). Persons with SMI also often have low health literacy (Degan et al., 2019; Farrell et al., 2020), defined as the ability to acquire, understand, evaluate, and use the information to maintain and promote health, which is important to achieve a health status comparable to that of the general population (Berkman et al., 2011; Mantwill et al., 2015). On the other hand, much can be done to address the health challenges faced by persons with SMI. One concrete method to support persons with SMI is to continuously provide health education to increase health literacy (Brainard et al., 2016; Jager et al., 2019). Lifestyle programs that are individually adapted and involve peer and staff support appear particularly useful in changing health behaviors and improving quality of life (Richards et al., 2016; Yalçın et al., 2019).

Although lifestyle programs directed at persons living with SMI have led to improvements in health parameters, the sustainable implementation of these programs in ordinary mental health care services remains challenging (Suetani et al., 2016; Suetani et al., 2016). Even though studies emphasize the importance of implementation (Vancampfort et al., 2016; Walburg et al. 2022), research addressing the implementation process of lifestyle programs is scarce (Bartels et al., 2018; Deenik et al., 2020; Deenik et al., 2019). Therefore, this report aimed to describe how staff worked with and experienced a lifestyle program in a municipality mental health care setting over time.

Methods

Study design

In the present study, a descriptive and qualitative methodology was used that aimed to understand and describe complex issues in real-life settings from the perspectives of the persons who were directly involved (Sandelowski, 2000). To provide more detailed information about the staff´s experiences regarding the implementation process of the lifestyle program, longitudinal data collection was used (Audulv et al., 2023). The methodology was chosen because it could help to illustrate the complexity of implementing a lifestyle program in municipality care.

Most qualitative longitudinal studies follow the same individuals over the data collection period, but some studies also follow settings or interventions. The type of entity (e.g. individuals, setting, or intervention) should be chosen depending on how change is going to be studied (Audulv et al., 2023).

Context

In this study, the persons living with SMI (called participants with SMI herein) included users of municipality mental health care services who lived in residential psychiatric settings or received housing support. In Sweden, housing support is a common municipality support directed toward persons with mental illness who experience problems managing everyday life and have limited ability to take care of themselves. Housing support includes home visits from staff that may involve different supporting activities based on individual needs (e.g. supporting everyday life structure, grocery shopping, cooking, and social contacts). The psychiatric nursing staff (called staff herein) in Sweden consists of enrolled nurses with a degree in psychiatric nursing.

The development of the program

Our research group developed and conducted a lifestyle program directed at persons living with SMI. The program aimed to facilitate individual lifestyle changes and provide new strategies for physical and mental health improvement but also to function as support for social relationships and increase health literacy (Rönngren et al., 2018; Rönngren et al., 2017). The lifestyle program was developed and tested in municipality care settings in the middle of Sweden from 2013 to 2015. The program was developed in cooperation with nursing staff, managers in the municipality, and an interest organization for mental illness (Rönngren et al., 2018; Rönngren et al., 2014).

The program was delivered in a group format and was designed to address the physical, mental, and social components of individual health support. The program used three basic components, namely interpersonal relationships, health education, and individual cognitive support.

The program was led by two of the authors who are also nurses specializing in psychiatry (YR, AB). The authors led the groups, guided the groups through meetings, and provided advice for individual lifestyle changes. Importantly, staff participated in the program together with the persons with SMI and provided individually adapted support both during the group sessions and between sessions. The structure of the group sessions was as follows: 1. relaxation exercise, 2. a presentation round to see how everyone in the group was doing, 3. health education and health-related discussions, 4. individual nursing prescriptions for individual lifestyle changes, 5. practical exercises, and 6. closing procedure (Rönngren et al., 2018; Rönngren et al., 2017; Rönngren et al., 2014). Furthermore, the program also showed some quantitative improvements in health-related quality of life, cognitive performance, walking capacity, and waist circumference (Rönngren et al., 2018).

Data collection

Interviews were conducted at three-time points (see Table 1). Almost all participating staff were interviewed, which provided a unique opportunity to describe the implementation of the program.

Table 1. Overview of data material.

	Data material	Development
Timepoint 1 (2015)	3 focus group interviews, a total of 10 members of the staff, representing three different mental health care accommodations.	The program was developed and tested in three mental health care accommodations.
Timepoint 2 (2016)	6 individual interviews with staff and a manager in one mental health care accommodation.	One mental healthcare facility continued with the program integrating the program in their unit.
Timepoint 3 (2022)	2 individual interviews with the staff that were group leaders under the continuation of the program.	Both the enrolled nurses that had been leading the program had left the mental health care accommodation and the program was no longer performed.

At the end of the initial program (Time point 1, in 2015), three focus group interviews were conducted with 10 staff who had been involved in the program. These staffs were employed at three different mental health care accommodations and were between 30 and 64 years of age. Their work experience in psychiatric care ranged from 8 to 46 years (md = 15 years). Focus groups were chosen to capture the dynamics of the workplaces and staffs were interviewed together with colleagues from the same accommodation.

At timepoint 1 the following open questions were asked: Can you talk about your experiences of participating in the program? In your opinion, what was important for implementation and results? How did the organization around the program function? Subsequent clarifying and encouraging probes were asked, such as: Can you tell me more about that? Can you give an example?

After the program ended (2015), several staff wanted to continue the lifestyle program. At one mental health accommodation, the staff decided to continue the group session activities and integrate the program into ordinary care. Therefore, in 2015, three group leaders (GLs) were educated to continue the program with guidance from YR and AB, who previously led the group sessions.

At Time point 2 (in 2016), individual interviews were conducted with the GLs (n = 3), staff (n = 2), and manager (n = 1) from the accommodation that, at this point, had continued with the program for 1 year (all staff that was approached choose to take part in the interviews). Individual semi-structured interviews were here chosen to gain a more in-depth description of how the staff had worked with the program, also acknowledging their roles in the program. The respondents in this second round of interviews were between 32 and 65 years old and had worked in psychiatric care for 12–48 years (md = 17 years). The interview questions at time point 2 were like those at time point 1.

In 2022 (Time point 3), two of the GLs who had been involved in the program throughout the process from 2013 were interviewed again. These interviews focused on the following questions: What are your experiences of using the lifestyle program? Why did the program end? Do you use experiences from the program at your current place of work?

Data analysis

Transcribed interview data was structured longitudinally using a recurrent cross-sectional approach (Audulv et al., 2023; Grossoehme & Lipstein, 2016). Meaning that the data were analyzed per time point and later in chronological order. First, the transcripts from each time point were read several times to ensure that the researchers understood the content and to gain a sense of the material. In the next stage, the material was divided into sections (each section included a sentence or two) and coded to capture the content of each section. In the third stage, the codes were sorted, so codes with similar content were brought together into categories. The longitudinal aspect was in focus during the whole analysis, and the findings from different time points were compared. The analysis was mainly performed by YR with support from ÅA. The evolving analysis was discussed in team meetings with all authors on several occasions.

Ethics

Ethical considerations were by the Declaration of Helsinki (World Medical Association, 2013). Approval for the study was obtained from the Ethical Review Agency in Sweden (No. 2015-412-32Ö). Before the interviews started, the respondents received oral and written information about the study. All respondents signed a consent form before the interviews. They were guaranteed confidentiality and an anonymous presentation of the findings, and for this reason, no pseudonyms were used in the presentation of the findings. The respondents had the opportunity to withdraw at any time during the study without any explanation.

Results

Time point 1: The end of the lifestyle program led by researchers

Changing views

At time point 1, the staff’s experiences of participating in the program when the researchers were GL are described. During the program, the staff described changing views. In the beginning, they were unsure if they should participate or not in the program. Reasons for being hesitant centered around the participants with SMI and their abilities. For example, staff had been doubtful that walking 1.5 km to the location for the group sessions would be difficult for the participants with SMI. However, all staff agreed that these aspects had been negotiable. The staff also noticed a gradual change among the participants, wherein initially had difficulties focusing but became more engaged and focused with time. In the beginning, some of the participants with SMI sat apart from the other participants with SMI, but gradually, they became more involved in the group sessions. An important finding was that the participants with SMI talked about the program and socialized more when encountering each other outside the group sessions. According to the staff, the activities involving physical movement, dance, and relaxation exercises were the most appreciated parts of the program. At the end of the program the staff that in the beginning had been hesitant had changed views and were considering diverse ways of continuing to engage participants with SMI in healthy activities.

“I think that we could have activities in the basement, and we could offer dance for half an hour on Thursdays. I do not think we need to go out, but we need to be more physically active, and now we can do it together.”

Overcoming challenges

The staff described several challenges encountered while working with the program. First, the participants with SMI had special needs that needed to be accounted for. Mental health symptoms impacted participation in several ways and strategies to meet these challenges needed to be incorporated in the program. For example, participants with SMI may have problems with cognitive function (e.g. problems in organizing, planning, and implementing activities) which impacts their ability to utilize healthy behaviors. However, this could in part be overcome by support such as schedules, reminders, and performing physical activities together with others. The participants with SMI received individualized exercise schedules but needed support from the staff to adhere to them. However, according to staff, most exercise schedules were not used after a few weeks.

Another aspect was social anxiety, which for some participants with SMI made it difficult to attend the program. On the other hand, the staff conveyed that the program might be most important for persons with anxiety-related problems since many of them seldom leave their homes.

“At first, some people did not want to come to the group session, but then we prepared them for what would happen and after that, they wanted to participate.”

To feel in control, some participants with SMI needed individualized information about the group sessions or reminders the day before the meetings. Furthermore, the staff experienced that continuity in GLs and the group constitution, as well as feeling welcomed and safe had a positive effect on participation. Many of the participants with SMI struggled with their self-esteem and had previous experiences of being neglected.

The staff noticed that the participants with SMI often had little knowledge regarding physiology and body function. This increased the program’s importance but also raised the challenge of developing educational material suitable for the participants with SMI.

The staff also expressed concern regarding conflicts within the staff group. The interviewed staff reported that some of their colleagues chose not to participate in the program. This led to irritation, and the interviewed staff wondered if it was okay to skip work tasks such as supporting healthy behaviors if one did not want to do them. The interviewed staff explained these different views of the program by stating that physical health was not prioritized in the culture of psychiatric care.

“One negative aspect was the fact that some staff participated, and some did not. This might create a feeling of ‘us and them’ within the group of staff. It is very important to include the entire group of staff.”

Experiencing synergic impact

The staff described various impacts of the program. Although the staff did not believe that the program yielded any major health benefits, the program was perceived as sowing seeds for lifestyle changes in the participants with SMI. For example, discussions were raised about quitting smoking, healthier diets, physical activity, and social relationships. Staff described seeing a change in the participants with SMI wherein they transitioned from being rather passive in the beginning to gradually becoming more active regarding lifestyle questions. During the program, the staff noted that the participants with SMI developed the ability to talk about their life situations and communicate their feelings. The participants with SMI also showed more insight into how the body and mind were connected. Both the staff and the participants with SMI enjoyed the group sessions and looked forward to them. This was particularly important since a major proportion of the participants with SMI did not have any regular occupations or activities outside their homes. The program provided a meeting place for the participants with SMI, and the participants with SMI started talking about different issues including personal matters and life situations. The staff also felt that it was beneficial to do something together with the participants with SMI.

“Some of the people here…they might not see each other so much. They are mostly meeting with their contact person. So that is…they get to know each other.”

During the group sessions, the staff and the participants with SMI talked about issues different from those addressed in their everyday encounters. Therefore, the staff got to know another side of the participants with SMI. The staff also expressed that they gained energy and appreciated that something “new” happened at their workplace. The staff seldom came together as a group, and therefore, appreciated this aspect of the group sessions. The staff also described that they obtained better tools and ideas for supporting healthy behaviors in the participants with SMI by following the program’s structure.

At the end of the program, the staff expressed that they and the participants with SMI wanted to continue the program. The staff had also developed new ideas on how to work with health, for example, by taking daily walks at lunchtime, focusing more on healthy food, and introducing dance as an activity.

Time point 2: Continuing the program

Standing at a crossroads

In 2015, staff were standing at a crossroads whether they should continue with the program which included leadership of and organizing the group sessions. One accommodation decided to go ahead. This resulted in a mutual decision supported by the manager that three GLs were trained to be GLs and take responsibility for the program. Additionally, the two researchers (YR, AB) previously leading the program were available for guidance.

The program continued for 1 year (two terms) under the supervision of the three GLs. At every group session, 8–15 participants with SMI, two GLs, and 2–3 staff members were present.

The GLs reported that their work in organizing and leading the group sessions supported their personal development. Among other things, they described learning new teaching skills. The GLs also stated that leading the group sessions had gone better than they expected and that they had enjoyed the experience. A significant reason for this was that participants with SMI enjoyed the group arrangement and activities.

“Yeah, it gave me a lot. Above all, it’s fun. Yes, then you develop yourself, you do. I also think the group sessions have worked better than I had imagined them [to do].”

The GLs noted that the prerequisites to perform the group sessions included their careful planning as well as support from the researchers and the manager. The manager was positive and encouraging regarding the program and enabled the GLs to set aside time to plan and perform the group sessions. However, planning each group session took about twice as long as the group session itself, and occasionally, the GLs felt stressed regarding planning and preparation. The group sessions were planned for every third week, considered a bit too infrequent by the participants with SMI. However, the GLs perceived that they did not have time to organize more frequent sessions. No specific financial resources were allocated, but the GLs were allowed to make small purchases of fruit and exercise items. When the need for a new location for the sessions arose, the GLs had to find a meeting room that could be used with little or no associated costs, about 1 km from the accommodation, and accessible for wheelchairs. They did obtain access to a meeting room at a municipality center.

The GLs made some changes to the program. The group sessions remained the core activity, and the participants with SMI got more involved in suggesting activities for the sessions. Exercise diaries and schedules were not used, but the GLs continued to discuss personal health goals with the participants with SMI. The GLs developed several strategies to engage the participants with SMI, for example, introducing music quiz games and hosting a party at the end of the term. The GLs repeated some topics and introduced new topics, such as daylight, anxiety, stress, and managing private finances. The GLs also reflected on how to approach sensitive topics such as personal hygiene and smoking.

“Yeah, but I believe that…it is good that we talk about anxiety. We talk…even if it is difficult. I believe it is good, that well, Pelle gets to know that Lisa also feels anxiety at times. ‘I’m not alone’…and yeah, I think it has been helpful.” [Names are pseudonyms]

Overcoming challenges

The challenges described at time point 1 persisted at time point 2. For example, the GLs and staff had to consider that the participants with SMI had social anxiety, concentration difficulties, fluctuating mental health symptoms, impaired walking capacity, and difficulties in interpreting social situations. The GLs developed their strategies to overcome these challenges, by getting to know each participant’s needs, following the same structure, and managing group sessions with sensitivity.

The staff continued to motivate the participants with SMI to continue the group sessions. More individualized motivation strategies were developed, for example, talking about the next topic or previous fun activities. A few participants with SMI left the program, one because of conflicting schedules and others because of deteriorating health. The staff also encouraged others to start, often by talking about the group sessions and eventually inviting the person to a session. For people at the mental health accommodation, joining a group session was a big step to take, and being able to try without commitment made it easier. This was especially important for persons lacking family and daily activities outside the accommodation.

Staff conflicts regarding participating in the program were also described at time point 2. All staff members who took part in the interviews reported that they were interested in health and exercise, which increased their engagement. However, they also said that some staff members had a negative view of the program. The interviewed staff described that jealousy sometimes arose between the staff who were involved in the program and those who were not. The interviewed staff wondered if colleagues might feel exposed in the group sessions, especially if they had problems with overweight or health issues. On the other hand, the staff thought that colleagues could also be opposed to changing working routines. The interviewed staff described that they needed to be able to laugh at their own expense and talk about their experiences in the group sessions. Thereby, the staff became more personally acquainted with the participants with SMI. The staff described this as being important but also as a new way of being and behaving in their professional role.

Experiencing synergic impacts

At time point 2, the staff described partly similar kinds of impact as at time point 1. However, some aspects were described as more profound at time point 2, foremost on the participants with SMI and their social skills and activity levels. The staff was still unsure regarding the program’s impact on health. However, they gave examples of participants with SMI who made health-related changes (e.g. taking the stairs or eating healthier). The program increased health knowledge, and thus, generated ideas for future changes, but to make changes, the participants with SMI needed daily support from their contact person. Some staff described that they talked about healthy food while shopping with the participants with SMI.

“No, but…I support a guy that…He buys fruit almost every time we go to the grocery store. Something he didn’t, absolutely didn’t do before. Exactly, there you see a change of behavior in him.”

The staff also reported a more general improvement in the health of the participants with SMI. For example, the participants with SMI were more engaged, they walked faster, they expressed more ideas, and psychiatric symptoms were reduced. One of the staff believed that the use of on-demand medication had decreased, but this had not been measured. The staff also described that the participants with SMI were being seen and heard.

“Interviewer: Do you know…can you think of what they are appreciating with these sessions?

Staff: Well, it might be…to sit down and that there is someone that listens. You get to air your views and thoughts and…yeah, there is someone, someone that listens…in another way than if you just meet in a corridor.”

For some of the participants with SMI, the program was the only activity they performed outside the accommodation. The staff described that the participants with SMI often needed to train their social skills and the group sessions represented a safe environment for practicing. Participating in the program also led to other activities. For example, one woman shopped for new clothes with her contact person to have at the next session, and the staff started with a group exercise at the accommodation once a week.

Within the program, the participants with SMI developed their relationships with other participants with SMI and staff. They had something to talk about when meeting each other at the accommodation, and one woman started to invite the other participants with SMI for coffee on Fridays. The staff got to know the participants with SMI better and developed closer relationships with them. At times, the staff had been surprised upon learning more about the participants with SMI’s life experiences and thoughts. The staff also said that they had developed better relationships among themselves and were more caring when they knew more about each other. Some of the staff had been motivated to undertake healthy behavioral changes themselves; they also described a new outlook on their work, realizing that they could influence their work.

Time point 3: The end of the program

At time point 3 two of the GLs who had been involved in the program throughout the process were interviewed again.

In connection to the interviews at time point 2 (in 2016), the GLs and the manager talked about the possibility of scaling up the program with more groups, including participants with SMI from other mental health care accommodations. The manager emphasized the importance of supporting engagement and enthusiasm within the staff and was impressed with the program. The GLs were intrigued by the idea but also concerned about whether the program would work similarly with other participants with SMI. Although the cooperation and support in the municipality worked well, the group sessions ended in 2016 when the most enthusiastic members of the staff changed employment. When the former GLs were interviewed in 2022, they no longer worked with the lifestyle program. However, they found the experience of taking part in the program useful and important. Furthermore, they still worked in psychiatric care and emphasized the prioritization of lifestyle support.

“This knowledge is something that I will always have with me, both in meetings with people with mental illness and also in private. The importance of balance and not underestimating the importance of starting with a small format with lifestyle changes.”

In retrospect, the former GLs also felt that their work with lifestyle changes had been unappreciated by management.

“I’m very interested in lifestyle work with people with mental illness, but I think I get a lot of responsibility and extra work without being rewarded in any way. In addition, members of staff who did not do anything extra for the persons with mental illness regarding their lifestyles get the same salary and opportunities.”

The plan in 2016 was to scale up the program, but it remained unfulfilled due to organizational and financial issues. However, in 2022, discussions took place within the organization of the mental health accommodations in the municipality regarding how health could be better supported for people with SMI. Therefore, a new collaboration with managers in the county council and municipality commenced to continue the work with the lifestyle program.

Discussion

This report aimed to describe how staff worked with and experienced a lifestyle program in a municipality mental health care setting over time. Many persons with SMI are motivated to improve their lifestyle but need considerable time and support due to cognitive impairments. Therefore, lifestyle programs must be provided continuously rather than as shorter engagements. In summary, the implementation achievement of this lifestyle program seemed partly dependent on the staff’s engagement and interest in lifestyle questions. The lifestyle program also seemed to have a synergic health impact on the participants, suggesting that similar programs may be suitable for inclusion as a regular part of municipal mental health care.

According to the Consolidated Framework for Implementation Research Framework (CIFR), implementation aspects can be divided into five domains: innovation, outer setting, inner setting, individuals, and implementation process. All five domains were seen in our data, even though the focus was on the inner settings and individual domains.

Implementing new working routines in municipality care is a demanding process, requiring both individual and organizational adoption, as well as support from the manager (Mathieson et al., 2019). In this study, no extra financial resources were allocated, but the managers provided time and encouragement to the staff. Despite that, an interview at time point 3 showed that in the end the GLs might not have felt appreciated for the work they did. A consequence of this may be that the staff choose not to be engaged at all in lifestyle changes. This study shows the importance of the staff’s engagement in maintaining a program. This was apparent since the program ended when the key persons were employed elsewhere, and no one took on the responsibility to continue the program.

Minor conflicts arose between staff members who participated in the program and those who opted not to, and these issues remained unresolved. The CIFR points out shared values, beliefs, and norms to be particularly important for the implementation of a program (Damschroder et al., 2022). Managers who operate in municipality care have an important role in leading activities of health promotion toward a joint vision at all levels of nursing care (Lundström et al., 2020). Important to bring to the next program is that managers should take greater responsibility in resolving conflicts and strive to ensure that all staff work together as a team toward the same goal, namely, improving the lifestyle of persons with SMI.

At first, persons with SMI needed individual support to compensate for their functional limitations. Symptoms of SMI impacted the ability to take part in the program e.g. anxiety, and problems in organizing, planning, and implementing activities. Therefore, the staff needed to step up and tailor motivational support, and information to these participants’ needs. As previous research suggests, self-efficacy and facilitating the development of support systems among persons with SMI will be pivotal for initiating and maintaining health behavior changes (Hawes et al., 2022). However, the aspects of the program including scheduling, making plans, and integrating healthy behaviors in everyday life are the least utilized activity of the program. The most useful activities were those that the staff and individuals with SMI did together. Future programs might need to put more emphasis on cognitive support if such components are part of a program.

Important findings included the staff’s experience of synergic impacts on both physical, mental, and social health. Similar findings emerged after time point 1 and time point 2. Although the participants with SMI did not drastically change their lifestyle habits, smaller changes in everyday life, including increased motivation and knowledge, were seen. This is in line with other research on lifestyle interventions (Alexander et al., 2018; Ruser et al., 2005; Weman-Josefsson et al., 2015). However, small amounts of physical activity are still important and may have an impact, for example on cardiovascular health (Fletcher et al., 2018).

During the implementation process, other kinds of positive changes were experienced by staff e.g. psychiatric symptoms decreased and participants with SMI started participating in other activities as well. Social relationships were developed, and the participants with SMI got to know each other better and interacted more. The program may potentially reduce loneliness, which is identified as a risk factor for poor physical and mental health and increased mortality (Heinberg & Steffen, 2021). This indicates that future research on lifestyle programs might evaluate effects in more areas than traditional health outcomes.

The group format seems to facilitate meaning-making by creating a sense of belonging, mutual support, and understanding (Lund et al., 2019) but also represents a way to learn from each other and increase health literacy. In another study where a lifestyle program lasted for one year, similar findings emerged. The participants with SMI, in similarity with our study, were interested in changing their lifestyle but needed a lot of support due to cognitive impairments. The group format of the program was also positively experienced (Walburg et al. 2022). Enhancement of self-efficacy is crucial to conduct sustainable lifestyle changes. Additionally, facilitating the development of support systems among persons with SMI will be pivotal for initiating and maintaining health behavior changes (Hawes et al., 2022). Also, this program aims to improve self-efficacy through health education and health discussions and the group format may be of importance to facilitate the development of support systems.

Because of the program, the staff was given a new role at work that was challenging and may also entail them having to change their way of working. These also open opportunities to develop both on a personal and professional level. At time point 2 the staff was very engaged in the program and developed the content of the health education sections according to the needs and wishes of the group. As a result of this, more practical activities were included. In line with the work of Deenik et al. (2019), this study found that factors facilitating the implementation of the lifestyle program included a positive attitude among the staff and the participants with SMI (Deenik et al., 2019).

Managers who operate in municipality care have an important role in leading activities of health promotion toward a joint vision at all levels of nursing care (Lundström et al., 2020). Barriers to implementation included organizational factors, limited financial resources, and a lack of time (Deenik et al., 2019). It was feasible to run a lifestyle program over a considerable period with limited input from external resources. The GL got some time to plan the group activities. However, they stressed that they would have liked more time to be better prepared.

As with all research, this study has limitations. The scope of this paper was to study how staff worked with and experienced a lifestyle program in a municipality mental health care setting over time. Therefore, we did not collect any outcome measurements or interview the participants with SMI. The reason for that was partly to interfere as little as possible, and not cause stress to the participants with SMI. However, implementation is dependent on many aspects and perspectives and future research should take up perspectives omitted from this study, for example by looking at health economics and/or participants with SMI experiences. Since the program was led and facilitated by staff, we chose to focus on their perspective in this study. In qualitative research, the number of participants is of less importance in comparison to the insights and richness of the interviews (cf., Malterud et al., 2015). In this study, all staff had extensive experience working with the program and could thus generate rich data. The longitudinal data collection also allowed us to understand better how aspects of the implementation evolved, although more data collected around the time when the program ended would have been preferable.

Conclusion

However, integrating lifestyle programs into daily work requires management support and clear guidelines for the staff’s involvement.

However, this study shows the importance of lifestyle programs being developed together with staff and participants with SMI for programs to fit in the organization. Nursing staff, with existing interpersonal relationships already developed with the participants with SMI, can thus play a key role in facilitating the implementation of this kind of lifestyle program in ordinary care.

Recommendations for the future implementation of lifestyle programs

Guidelines and routines for health promotion should be developed for municipality mental health care in collaboration with managers and policymakers. This program may be one possibility for actively supporting healthy lifestyles in people with SMI in ordinary nursing care. Moreover, to make lifestyle programs part of ordinary care, managers must show support and commitment, and provide good working conditions. Engaged staff need appreciation, but competencies also need to be shared among the staff, so the organization is not too exposed if some employees resign.

Acknowledgments

We are very grateful to the municipality’s mental health care setting for their collaboration. Managers and nursing staff’s commitment to improving the health of persons living with SMI and their support for nurse-led initiatives have been crucial in the implementation of this lifestyle program.

Disclosure statement

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

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.