Experiences of specially trained personnel of group education for patients with type 2 diabetes—A lifeworld approach

Abstract Aim To describe how the group education process for people with type 2 diabetes is experienced by diabetes nurses and dietitians who support the patients’ learning, in a primary care setting. Design The project took place at two primary care settings in the south of Sweden. Methods Data collected from focus‐group interviews and reflection notes were subjected to phenomenological analysis. Results The specially trained personnel experienced that group education made it possible for the patients to learn through reflection concerning their own and others’ experiences. Furthermore, group education entailed increased knowledge for the trained personnel. When the patients were challenged to make changes in their lives with the illness, the personnel experienced that both patients and personnel supported each other. The study concludes that the trained personnel person‐centred approach, with help of the didactic model, get tools to support patients learning.

it consists of structured programmes which assume active participation. The programmes are usually based on educational theories, models or knowledge of adult learning, as in this study the didactic model, "To take charge in life with long-term illness" ( Table 1). The model used is based on the patient's understanding and challenges it on both a cognitive and an existential level as described in previous research (Andersson et al., 2015). The groups can be led by various health professionals who have subject and educational skills, in this study diabetes nurses and dieticians (SBU, 2009). The National Board of Health and Welfare (2018) recommends that a structured group-based patient education for people with T2D is offered.
Group-based patient education given with the above conditions gives a significant reduction of Hba1c (Scain, Friedman, & Gross, 2009).
Health professionals in primary care prioritize and take responsibility for the patient's learning in their daily work and have a higher degree of pedagogy at university level, compared with nurses in other care-related environments (Bergh, Persson, Karlsson, & Friberg, 2014). The specially trained diabetes nurse in primary care may experience ambivalence about the ability to practise patientcentred care, concerning the professional role and a position of withdrawn expertise as a nurse. Instead of providing information, the alternative role was to listen, discuss and interact with the patient (Boström, Isaksson, Lundman, Lehuluante, & Hörnsten, 2014).
To integrate a long-term illness, such as T2D, into a life context requires considerable efforts (Whittemore & Dixon, 2008), and the integration is one important task for the specially trained diabetes nurse to support. Illness integration and self-management can be a parallel process that ends up in a turning point (Hörnsten, Jutterström, Audulv, & Lundman, 2011). The turning point occurs when the illness is experienced as more severe and may affect the self-management and make the patient more engaged in the learning process (Jutterström, Isaksson, Sandström, & Hörnsten, 2012).
The duration of illness is not of importance for the patient's learning process, which emphasizes a person-centred care to meet the different and changing needs when living with lifelong illness such as T2D (Kneck, Fagerberg, Eriksson, & Lundman, 2014).
Learning as a concept is double-sided, either teaching by showing or practicing on someone else, or learning something by the person himself being active in acquiring knowledge through experience and insight (Berglund & Källerwald, 2012). A way of reflective learning as a person is transforming experiences to new knowledge and skills by thinking, doing and feeling (Jarvis, 2006). Genuine learning should be supported at an existential level and involves the patients' thoughts, feelings, actions and reflections of their experiences (Berglund, 2014;Johansson, Almerud Österberg, Leksell, & Berglund, 2015), which requires openness and support from the health professionals (Friberg et al., 2015). The support provided challenges and encourages the patients to reflect about their own goals, expectations and needs (Johansson, Almerud Österberg, Leksell, & Berglund, 2018) and leads to a greater understanding of the patients' life situation with the illness (Andersson et al., 2015). The patient needs to be confronted with their life situation and challenges for changes to realize that the patient is the one who takes charge, instead of the disease controlling the patient (Berglund, 2011). Subsequently, learning can be defined as the person with T2D accepting the illness, with a new understanding of themselves as a person (Johansson et al., 2018).
Supporting patients' learning processes increases the patient degree of self-management and involvement in their own care, on good terms, which is essential for a person-centred care. T2D is a major, increasing health problem in Sweden, which makes caring for patients with T2D in a primary healthcare setting a great burden.
Persons with T2D need the health professionals' support. Individual counselling is the most common form of education in diabetes care, although group education is highly recommended. In the literature, there is little describing how group education of persons with T2D is experienced by diabetes nurses and dietitians, particularly in terms of supporting learning based on a didactic model, in a primary care setting.

| Setting and project
The project "To take charge in life with T2D-a model for group education in primary care" took place in two primary care settings in the south of Sweden and involved two registered nurses and three dietitians who had special education and long experience (3-17 years) of counselling and diabetes care. The health professionals who facilitate the education sessions had graduated from a university course about the didactic model based on a lifeworld approach: The challenge-to take charge in life with long-term illness. The model aims to support patients' learning on an existential level (Andersson et al., 2015). Learning from a lifeworld perspective can be understood as an altered understanding that requires and is created through reflection and dialogues. Creating a reflective dialogue with patients is central to this model. A dialogue to challenge the person with T2D into reconciliation with the actual situation is therefore TA B L E 1 The thesis in the didactic model "The challenge-to take charge in life with long-term illness." A tactful, challenging approach is profound in the model Confronting one's life situation and challenging oneself to make changes Positioning oneself at a distance when creating a new whole Developing self-consciousness and taking responsibility from "one" to "I" Making learning visible with the aim of achieving development and balance in life recommended. The health professionals learn to apply a tactful and challenging approach based on the patient's life situation (Berglund, 2011(Berglund, , 2014. The participants, who were recruited from two primary care units, participated in five group meetings lasting 2 hr every other week based on various themes (Table 2).

| Data collection
Three focus-group interviews with the nurses and dietitians were conducted before, during and after the group-based education programme, in a separate room at the University by two researchers (SA, MB). The focus-group interviews were carried out as a dialogue, to enable the participant to reflect together about the phenomenon of interest (Kvale, 2009). At the first group interview, two nurses and three dietitians participated. After the first interview, one dietitian chose to leave the study due to a lack of diabetes nurses who could participate in group education. In the second and third interviews, four informants participated. Each interview lasted be- in a reflection book included in the educational material (Dahlberg, Dahlberg, & Nyström, 2008). All the participants spoke Swedish.

| Analysis
The phenomenon of this study is diabetes nurses' and dietitians' ex- Overall, all text is seen as data, as one whole piece of text. In the first phase of the analysis, the text was read in an open manner to get acquainted with the data. All data were then divided into meaning units, a sequence of the text that has a meaning of its own.
Each meaning is reflected against the background of the whole. The next phase involves building groups of meanings, as clusters. Finally, the essence is formed, which is described by Dahlberg (2006) as an abstraction and synthesis of a phenomenon's unique structure of meanings. The essence with structure and nuances of the phenomenon can be understood as a new whole.
In this paper, the essence is presented in the results. The phenomenon under study is further enlightened by the five constituents: Creating prerequisites for safety within the group, learning through reflection, taking a listening and leading role, challenges versus confidence and using tools to stimulate reflection. The results are illustrated with quotations from the interviews.

| Ethics
A written informed consent was obtained from all those involved, the participants, course participants and responsible manager, and the study confirms the principles outlined in the Declaration

| Creating prerequisites for safety within the group
The health professional experiences of group education in T2D indicate the importance of creating conditions within the group so that the participants feel safe and free to share their experiences. The health professionals believe that the rounds can convey safety but may also be perceived as pressing in those cases where the patient has not made any major changes since the last group meeting. The participants have signed a contract of confidentiality in the group. The contract is a prerequisite for sharing experiences and contributes to the security of the group.

| Learning through reflection
The participants learn about their illness and how to live life with T2D by reflecting about their own and others' experiences. The health professionals are concerned that medical evidence will not be affected. Consequently, a lot of questions are raised and discussed. The health professionals feel confident in answering the participants' questions and that they have the knowledge required: It is nice to have done this in a different way compared to before. We have the material, we can talk about it. Eh, so it's nothing to worry about During the group-based education, the health professional experiences that the participants discuss and reflect over raised questions in a deeper manner, compared with their earlier experiences. They often find the answer together within the group. The group requests facts and discusses issues such as food, blood sugar levels and diabetes in relation to their habits and lifestyle. Through self-control of blood glucose levels, discussions and reflections are created at the group meetings: It will be something completely different. And especially when they share it. Then the whole group has made that experience in some way The group discussions clarify the participants' views on what illness means to them as a person. They all have T2D, but they are still unique as a person. The group education raises insight and awareness which improves the preparedness and ability to take responsibility for the outcome: Then there are actually several participants who draw pictures of themselves with a fat stomach before dia-

betes. Flat stomach after diabetes
The health professional notes that the adjustments in lifestyle lead to improved blood glucose levels and improved weight reduction, achieved during the ongoing group education.

| Taking a listening and leading role
The health professional creates the conditions for all participants to share their experiences by the rounds. It is crucial to be prepared, to listen to the reflections in the group and to take notes to support learning. One way to stimulate the group conversation is to

| Challenges versus confidence
The health professionals express an uncertainty about how participants will experience group education. They describe how the health professionals feel safe about having a theoretical basis in the model.
However, they also argue that the participants will experience the model as unclear and therefore feel insecure. Consequently, they see it as a challenge to venture out onto a new and uncertain path.
On the other hand, they feel a degree of security since they have previously completed group tuition, which contributes to the calm they feel about the task: It will be ok, as it has every time so far Instead, the group contributes to the health professionals'

| Using tools to stimulate reflection
Various tools are used in addition to blood glucose measurement to stimulate reflection. The participants are asked to draw something, based on a specific thought. It makes it easier for those who find it hard to express their thoughts and feelings on their minds. Drawing and writing are used as a tool that stimulates reflections. The health professionals can see a difficulty for the participants who do not feel comfortable with drawing or writing. Pictures are another tool that worked well which was used to start reflections in the group. Each participant selects a picture to reflect around: And they chose (the picture) with care. So it was more of a concrete thing that gave us some fun The supervision material helps the health professionals to reflect on what has happened between the meetings. It seems to be a challenge using the tools at the right time. The participants have voluntarily chosen to write and draw their reflections in the supervision material.
The health professionals believe that it is enough to handle one question per meeting and then let the participants control the content with their questions and thoughts. As a health professional, you have support in the material and use it based on what participants ask for. This means that the health professional does not have to prepare for the group education. It turns out that the method of conducting group discussions makes the participants aware that they can do things differently. There is nothing right or wrong. Preparations for the meetings require less preparation for the health professional since they do not lecture. The group meetings do, however, take some time.

| D ISCUSS I ON
The following results are discussed in relation to the didactic model's four principles (Table 1). The study shows that a relationship built on trust and safety between health professionals and participants develops during the group education based on the didactic model, with a lifeworld perspective, compared with earlier experience of more traditional education, based on a medical approach. One of the theses in the didactic model: "confronting one's life situation and challenging oneself to make changes" requires a tactful, open, listening and challenging approach (Berglund, 2011). This approach entails that when the health professionals meet the patient, the health professionals must have a genuine will to understand the patient from the patient perspective (Dahlberg, 2006). Therefore, the health professionals' approach must be person-centred, which may be experienced as an altered professional role (Boström, Isaksson, Lundman, Graneheim et al., 2014) as well as a challenge to translate into practice (Zoffmann et al., 2016) The approach requires the courage to address questions on an existential level, to stay and listen to the answer (Andersson et al., 2015).
The health professionals received supervision before, during and after group meetings. Supervision is helpful to their own learning process to distance themselves and visualize their use of the model (Andersson et al., 2015). There is a need to be supported and mentored in this role to be able to support the patients to self-reflection and be responsible for their diabetes (Johansson et al., 2018).
As a health professional, it is crucial to see to it that everyone in the group feels secure and free to reflect, exchange reflections and express feelings related to the diabetes; this is supported by Boström, Isaksson, Lundman, Graneheim et al. (2014). The model supports the reflective process amongst the group participants. This study shows that health professionals learn to ask questions that give the participants the possibility to review their life and experiences with the illness. It is necessary to adopt a distant position using a reflective process by: 'positioning oneself at a distance when creating a new whole' which contributes to the health professionals' own learning.
Therefore, the group discussions increase insight within the group, despite their suffering from the same illness, they are still unique as a person, seen as a person and not as an illness or disease.
The tools used in this model, such as drawing, writing, drawing pictures and seeing other pictures and home assignments, allow participants to reflect together. The participants in this study received home assignments in the form of measuring blood sugar values related to eating and exercising. They reflected on the outcome within the group, and this provided meaningful discussions.
The participants "develop self-consciousness and taking responsibility from "one" to "I" by reflecting about the actual situation in the group, related to the illness and by using "I" instead of "one" during the conversation (Berglund, 2011). The conversation is conducted in the form of rounds and the health professionals must keep still and quiet, which can be perceived as difficult. Deep dialogues with patients, move care to a higher level (Andersson et al., 2015) to support learning instead of providing information. The results of the study support the fact that health professionals should pay attention to how the patient is talking about himself, the disease and if any resistance exists. This is done to support the patient to move on to taking responsibility from "one" to "I." The health professionals feel that the model creates a deeper learning in comparison with previous group education. The supportive and permissive climate gives a knowledge exchange controlled by the participants and was supported by the different professional competences. It is important to achieve a interaction between the professionals and patients during the group meetings that are patient-centred (Boström, Isaksson, Lundman, Graneheim et al., 2014).
Being two health professionals was experienced as strengthening their professional roles. Andersson et al. (2015) claim that the aim of the model is to give patients the ability to be in charge of their lives and their treatment, which allows them to show the direction of the care that the health professionals can follow. By putting the patient's choice first, before the counsellor's advice, there is a new way for the health professionals to think (Andersson et al., 2015).
The model guides the health professionals to not always answer the patient's questions, but instead, patients are challenged to find the answers themselves. According to Berglund (2011), questions and not answers can support the participant to visualize his learning to reach the feeling of being in progress in life with a long-term illness.
The health professionals note that patients make improvements in their living habits, with reduced blood glucose levels and weight loss.
Nurse-led self-management in groups improves HbA1c as shown in earlier research (Jutterström et al., 2016). The health professionals experience that patients who choose to participate in group education are more motivated to change lifestyle habits. To "Make the learning visible with the aim of achieving development and balance in life" requires motivation to make lifestyle changes. The integration of a lifelong illness such as T2D is an important task for the nurses and can be seen as a parallel process with self-management (Hörnsten et al., 2011). Learning involves new knowledge and skills and leads to a change of thinking, acting and feeling (Jarvis, 2006) which is supported by the result of this study. The learning patterns differ between persons, and the strategies differ over a time span (Kneck et al., 2014) and can last for several years, but there is a need for support from health professionals. Prerequisites for the healthcare personnel to take responsibility for the patient's learning are, on the one hand, to have a degree of pedagogy at university level (Bergh et al., 2014) and, on the other, to receive continuous education.

| Methodological discussion
The interviewees had many years of experience of conducting interviews in research. The researchers were also trained in the supervision of health professionals in caring and nursing. The group of health professionals may be considered small, but the data contained rich and detailed information. The researchers reflected on their pre-understanding throughout the study and tried to maintain an open attitude (Dahlberg et al., 2008). Further studies are needed.

| CON CLUS I ON AND PR AC TI C AL IMPLIC ATIONS
The primary application of this approach is to support the learning process for those living with a lifelong illness as diabetes. The result of the study shows that health professionals with help of the didactic model and a lifeworld perspective support patients learning. The health professionals' learning is facilitated through reflection about patients own and other group members' experiences. This contributes to the group as well as to the health professionals' own learning. Consequently, the approach demands the health professional's courage to address questions on an existential level and to have the courage to stay and listen to the answer and is a prerequisite to give a person-centred care.

ACK N OWLED G EM ENTS
Our sincere thanks are due to the diabetes nurses and dietitians who took part in this study. Thanks are also due to the patients that participated in the group education.

E TH I C A L A PPROVA L
This study was approved by the Central Ethical Review Board, University of Gothenburg. (Dnr: 442-15).

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to declare.