Study design

The study had a qualitative design, and is based on the first author’s master’s thesis (Granly, 2023). It aimed to understand the MPs’ role and how they interpret and attribute meaning to their work experiences (Merriam & Tisdell, 2015). The study followed a social constructivism paradigm, which assumes that knowledge is socially constructed between the researcher and the participants (Kvale & Brinkmann, 2015). Semi-structured interviews were used for data collection, and reflexive thematic analysis was employed for data analysis (Braun & Clarke, 2006; 2021).

Recruitment and data collection

Recruitment began in October 2022. Purposive sampling was used to recruit psychologists employed in municipalities in the greater Oslo region in Norway who had public health-related tasks and had been in their position for at least six months. We sent a standardised email to all 30 municipalities in the region, explaining the project and requesting contact information for psychologists who met the inclusion criteria. Fourteen municipalities replied, of which we recruited from eight. The snowball method was also utilised, as four participants were recruited through suggestions from previously recruited participants (Bryman, 2016); these four were contacted via email. Initially, 14 participants were recruited, but one withdrew due to sick-leave and another because they were leaving their position.

The total number of participants was 12, from 8 different municipalities (4 which had 2 participants each). There were 2 male and 10 female participants, with ages ranging from 28 to 51 (averaging 39). They had diverse backgrounds and varying levels of work experience, ranging from limited to extensive. Their work tasks also varied: Some focused mainly on public health, some on clinical work and others on both. They were situated in different units and levels within the municipalities. Table 1 provides an overview of the participants.

Interviews were conducted by the first author in December 2022 and January 2023. Nine interviews were conducted face-to-face at the participants’ workplaces, while three took place digitally. Only the first author and the participants were present during the interviews. Individual rather than focus group interviews were selected as a method, to gain insights into personal experiences and obtain a detailed picture from each participant, as each municipality and MP position is unique. An interview guide was thoroughly tested and developed in collaboration with co-authors and a former MP. A pilot interview with an MP was conducted in December 2022 and was included in the final data set due to its quality. The interview guide focused on three main topics: the MPs’ role and general experiences, enabling factors and constraining factors. It was provided in advance for those who requested it. The interviews lasted an average of one hour and were audio recorded after obtaining consent from the participants. The audios were transcribed verbatim by the first author.

The generated transcripts were not member checked; however, participants were informed that they had the right to request and review the final transcripts. Given the number of participants, the length of the interviews and the pilot testing of the interview guide, we generated sufficient and rich data that could be analysed properly and systematically; repeat interviews were thus considered unnecessary.

Data analysis

A reflexive thematic analysis approach was used to analyse the data (Braun & Clarke, 2006; 2021). Codes were generated by the first author using the computer-assisted qualitative data analysis software NVivo, version 1.7.1 (QSR International Pty Ltd., 2022). The entire data set was systematically reviewed and given equal attention in the analysis process (Braun & Clarke, 2006). Coding was performed inductively, meaning that the codes were data driven (Boyatzis, 1998).

In the process of creating themes, several versions of thematic maps were made, which helped to visualise the data. Themes and sub-themes were revisited, and the codes were reviewed to ensure that the themes emerged from the data. In this iterative analysis process, the first author took a leading role, with constant support from the co-authors. Ultimately, the analysis yielded two overarching themes and eight sub-themes, on which all authors reached consensus. Table 2 presents an example of the process.

Ethical considerations

The study was approved by the Norwegian Center for Research Data (NSD, now SIKT) in December 2022 (reference number 628 360). Participants were provided with a detailed information letter outlining the study’s aims and stating that participation was voluntary. They were also informed that they could withdraw from the study at any time. Written consent was obtained before each interview. The interviews were recorded using the Nettskjema Dictaphone app (University of Oslo, n.d.) and safely stored in accordance with data management guidelines at University of Inland Norway. During transcription, data were anonymised, and participants were given pseudonyms to protect their privacy, anonymity and confidentiality.

The challenge of developing and understanding the MP role

This overarching theme encompasses the participants’ experiences in developing and understanding their role, and how the challenges they face influence their ability to contribute to public health initiatives.

Working together for mental health – challenges, opportunities and a need for support

Here, we present the experiences and views of the participants on how aspects related to collaboration and the support they receive influence their everyday work life, especially their ability to engage in or contribute to public health work.

Lack of role clarity as a policy and management issue

Most participants described their job descriptions as vague, unclear, or not concrete enough, which left them having to develop the role themselves. This relates to the implementation challenges faced by the MPs. It also raises questions about whether municipalities value this position or consider it a priority. As outlined in the theory section, the new public management (NPM) ideology in municipalities may contribute to the perception that public health work is seen as a lower priority for psychologists, resulting in the role being underdeveloped. Without a well-defined or prioritised role, MPs struggle to shape their positions while navigating between public health work and clinical practice. Although similar findings were reported by the Norwegian Institute of Public Health (Heggland et al., 2013), our study offers a more nuanced and deeper understanding of this issue.

As the MP position is relatively new, this may explain the lack of clear guidelines, as it is common in public policy for ‘muddling through’ to be one of the implementation strategies (Howlett & Ramesh, 2003). The prevailing understanding seems to be that the MP role should encompass work at all municipal levels, meaning each MP is expected to engage in both systems/public health work and clinical practice, as well as everything in between (Schjødt, 2018; Schjødt et al., 2012). This study has shown that such expectations may be unrealistic, as many participants expressed a preference for specialised roles that account for appropriate placement within municipalities. The issue of alignment between placement and job description is also highlighted in the literature as currently inadequate concerning the MP position (Heggland et al., 2013; Sønstebø, 2015). However, the most recent Escalation Plan for Mental Health (Meld. St. 23 [2022–2023]) seems to suggest that the role of MPs may soon be more concretized.

The prioritisation of clinical work versus public health work

This study found that, for MPs, clinical work tends to be prioritised over other tasks, such as public health work. These findings are consistent with previous studies (Heggland et al., 2013; Norsk Psykologforening, 2020; Ådnanes et al., 2013). This can be explained in two ways. The first explanation is that there is a high demand for clinical services in municipalities (Norsk Psykologforening, 2020). This argument is strengthened by the fact that many MPs are situated in Health Centres or similar places, where it is easier for them to undertake immediate clinical tasks. In light of NPM, performance management is a key component. Among the two competing roles of MPs, public health work and clinical work, the latter is easier to concretise, measure and quantify. Thus, clinical work aligns better with the current influential management system (i.e., NPM).

The second argument is that MPs themselves prefer to engage in clinical work, perceiving it as more meaningful or achievable given their competencies (Deci et al., 2017). While this could be influenced by individual preference, we argue that this stems from their training. We note some recent changes in the training of psychologists towards a greater focus on health promotion and preventive work in some regions through the new national guidelines for health and social studies education (RETHOS) process (Viddal et al., 2022). However, professional education in psychology still predominantly emphasises clinical work and training students to become therapists (Sønstebø, 2015). Many MPs specialise in community and general psychology, which provides them with training in holistic perspectives such as the biopsychosocial model (BPS). However, their primary education remains in clinical psychology (Norsk Psykologforening, n.d.). Consequently, in line with a biomedical perspective, MPs may feel like they have more competency in undertaking clinical work at the individual level than public health work at the group and population levels.

Another interesting dimension that may explain participants’ preferences regarding work tasks could be how MPs are perceived and judged by co-workers and their supervisors in relation to their competencies. As many MPs now specialise in community psychology (Sønstebø, 2015), the assumption is that they should have the competencies to work with public health at the group and population levels. However, if the general perception is that they are viewed primarily as therapists, they will continue to be allocated mainly clinical work. This necessitates an attitude change within municipalities, including among MPs’ immediate supervisors. Our findings indicate that leaders in municipalities still regard MPs as professionals who focus on clinical work. Consequently, the MPs’ competencies are being underutilised by municipalities, as these range from community psychology to health and mental health promotion (Sønstebø, 2015; Barry et al., 2012; Tamminen et al., 2019). This calls for general shift in attitudes towards MPs, their competencies and the conceptualisation of mental health, as it is currently narrow and predominantly biomedical in focus (Espnes & Smedslund, 2018).

Challenges and opportunities of intersectoral collaboration

By conceptualising mental health as a product of biopsychosocial factors, one recognises that actions on all determinants of mental health, including social aspects, are necessary. Actions on these social and structural factors require intersectoral collaboration (Barry et al., 2015; Hinrichsen et al., 2022). However, this study found that collaborating across municipal departments, units, services and sectors, or even attempting to establish such collaborations, was often experienced as challenging and even frustrating by the participants. They described how the silo mentality that exists in different parts of the municipalities creates boundaries that are difficult to cross.

This lack of collaboration might impact the MPs’ need for relatedness (Deci et al., 2017), which fosters a sense of enjoyment of their work tasks and environment. Our study findings suggest a high turnover of MPs, which may further indicate that they are placed in work environments where they feel lonely. This also relates to the relationships they have established with their immediate supervisors; those participants who reported good relationships felt that they were thriving. Collaborating with others, both internally and externally, was noted by our participants as one of the most important elements for public health work and as a means to carry out this work successfully (Corbin et al., 2018). In this regard, the need to belong to a team and the need for relatedness appear to be crucial for MPs to thrive in their work environments. The public health team working to advance the legislated systematic public health work in the municipalities is an example of an existing formal collaborative space in which the MPs could participate and contribute a mental health perspective (Sønstebø, 2015).

Recommendations for policy and practice

Based on both the results from this study and relevant literature, we recommend the following:

The Norwegian Directorate of Health should prioritise creating and distributing official general guidelines for municipalities on what the MP role(s) should entail. These should be adaptable to each municipality.

Requirements for community psychological expertise should be anchored in the Public Health Act (2012, §27) (which is currently being revised) in the same way community medical expertise is, to ensure that municipalities must employ at least one psychologist positioned on the same level and with similar responsibilities as the chief medical officer.

Municipalities should prioritise creating stability in MP positions, including efforts to prevent loneliness in these roles. Co-location with, as well as support from, relevant co-workers and leaders seem to be important in this regard.

A formal position should be created for MPs in the intersectoral public health teams in the municipalities.

Study limitations

In this section, we will present some potential limitations of the methodological choices we made during the research process. It is important for the credibility of the study to acknowledge such limitations, as they may have affected our findings. Firstly, the study used purposive sampling. While this is a strength in that it ensured that participants had the relevant information and knowledge we sought, we may have excluded other categories of participants that could have enriched the study. In this regard, using other sampling procedures might have yielded different or more nuanced results, potentially leading to other conclusions. Secondly, there was a gender imbalance in our sample, as only 2 out of the 12 participants were male. Experiences and worldviews are gendered, and therefore a skewed gender distribution may have affected our findings. Thirdly, interviews were conducted in Norwegian and translated into English; during this process, we might have lost some valuable information.

Fourthly, there was no direct member checking of the results, although participants were informed of this right. Member checking could have strengthened the study’s credibility. However, we took steps to ensure that the MPs had some input regarding our findings. For example, we presented our results at the Psychology Congress in Oslo in 2023, and the MPs who were present provided feedback indicating that the experiences reported were similar to their own. Additionally, throughout the project, our contact with the Norwegian Psychological Association revealed that their members were encountering largely similar issues as those reported in our study.

The final issue we need to highlight in this section is that, as our study was conducted within the greater Oslo region, our findings may not be transferable to more rural parts of the country or other urban settings. Each municipality should therefore assess its own situation and make an informed decision on whether these findings are relevant to them. In qualitative research, generalisability is not the goal; hence, our findings should be interpreted within the context of the greater Oslo region. For future research, we recommend addressing some of these limitations through a robust study design with a broader scope than that of our study, which was primarily anchored in a master’s thesis.

Conclusion

The study findings show that participants experienced challenges related to role unclarity, which hindered their ability to balance clinical and public health work. The findings further indicate implementation and management challenges regarding the MP position, both at the municipal level and with the immediate supervisor, as well as challenges related to intersectoral collaboration. To contribute more effectively to local public health work, MPs need a clearer role in this work. This could be achieved by establishing official guidelines for the role and making the MPs formal members of the public health teams in municipalities. Legislation recognising psychological expertise in the Public Health Act could also help create a clearer mandate for MPs and provide them with greater authority. The study enhances the understanding of the role of MPs in public health work in Norwegian municipalities, which may be valuable for policymakers, municipalities, MPs and other professionals seeking to innovate within the municipalities. However, further research is needed to explore the MP role and to complement and expand on the MP’s perspectives on the situation. This can be accomplished by investigating the views and experiences of other relevant municipal employees, such as public health coordinators and municipal leaders.