The ten informants had worked between one and 35 years in a dietetic role and time spent in the diabetes field ranged from six months to 35 years with a median of 14.5 years. All the informants were involved in group-based patient education to adults with T1DM, but with varied frequency from one to 22 sessions per year. Four of the informants described that their group-based education was delivered in a multidisciplinary setting while six suggested they had sessions without any other health care professional attending. For two of the informants, the multidisciplinary setting meant they had a diabetes specialist nurse attending for some or in all the education sessions, while two informants had different professional categories attending during the sessions. The ones (n = 4) who took part in multidisciplinary patient education rather than working alone experienced a more structured and goal-oriented education plans and routines for follow-up. Five of the informants had undertaken continuous professional development in pedagogic methods or had previous teaching experience.
From the content analyses, four categories were identified with three to six subcategories each (Table 3).
Categories and sub-categories from content analysis of dietitian’s experiences regarding group-based education.
The dietitian’s role and experience of group-based patient education
The role of the patient and its experience of group-based education
Structure, goals, and participation in group-based patient education;
The dietitian’s perspective of group-based patient education and its prospects.
The dietitian’s role
The patient’s role
Participation and knowledge acquisition
Structure and organization
Patient centred care
Strengths with group-based education
Weaknesses with group-based education
The results are presented in the following order: 1) The dietitian’s role and experience of group-based patient education; 2) The role of the patient and its experience of group-based education; 3) Structure, goals, and participation in group-based patient education; and 4) The dietitian’s perspective of group-based patient education and its prospects.
The dietitian’s role and experience of group-based patient education
The informants were all appreciative of supervising group-based patient education and how it benefits the patients but did suggest there were challenges regarding supervising a group as well as for their own personal and professional role. As one informant stated,” It is a super wonderful opportunity. Patients can meet and exchange experiences. You start with the information but then they usually run the group themselves” (Dietitian 2).
Seven informants particularly mentioned that their main challenge was to adjust the level of depth and complexity to the information provided. As one informant described, “One of the hardest things is to adjust when they are at different levels” (Dietitian 4). However, one informant mentioned the complexity with different level of knowledge between participants but described using it as an opportunity for patients to teach each other as the informant found it beneficial when they received information from peers. Most of the informants also raised that this category of patients is a heterogenic group, and it is challenging when they are brought together as one. With regards to supervising a group, the informants described several situations where they were required to draw on their pedagogical skills such as patients taking over the discussion or non-participating group members. One informant also reported on being questioned on the information provided and described,” I was very questioned there, sometimes it was tough, mentally stressful to deliver those education sessions” (Dietitian 5).
The methods used to effectively gather the groups’ focus was asking questions, practical examples, or workshops, or confronting any patients who were dominant in group discussions. Five of the informants had some form of continuous professional pedagogic education such as MI, CBT, or teaching experience, but all of them described that work experience had developed their role in supervising groups. One informant described a previously feeling of fear during public speaking, but with time had developed necessary skills to cope.
The role of the patient and its experience of group-based patient education
The informants illustrated how patient education and the group processes that occur enhanced the solidarity and cooperation between patients in the shape of sharing experiences, sharing knowledge, peer support and a sense of belonging. As one informant stated,” It is also that the patients can meet each other. It is a big difference when I tell them -” you are not alone, others feel like this too” compared to when someone with diabetes tell them that” (Dietitian 4).
All the informants mentioned the need for adults with T1DM to meet peers in the same situation, and the strengthening impact it can have on self-management of the condition. However, they also reported that they experienced that the group’s composition was decisive for the group dynamic and peer support. The informants shared examples to illustrate the outcome depending on a group’s composition with regards to age, pre-understanding, treatment, stage, or type of diabetes condition. As one dietitian described, “I have felt that it is difficult to get homogeneous groups, so that the groups are beneficial because they [the participants] have been on such different levels it has not been good” (Dietitian 7). Having a randomly composed group was described as less beneficial, and in worst case a risk of a negative experience. As stated by one informant,” If there is someone with lots of long-term complications who gets caught up in that, it can have a discouraging effect instead” (Dietitian 8).
Structure, goals, and participation in group-based patient education
Six informants described having group-based patient education on their own while two had a diabetes nurse present and two were part of a multi-professional team providing education. In the case where the education was a multidisciplinary session the informants described a clearer goal setting with regards to the service mission such as learning to count carbohydrates or lower Hba1c. The six informants who were working independently with their group education did not describe having developed goals to achieve to the same extent. However, none of the informants reported having a clear discussion about goals with the patients in relation to the group education. One informant described that the lack of discussion on goals was due to the assumption that the patients knew why they attended the group education, or as another informant reported, “We haven’t discussed goals with regards to what this should lead to, it’s more a feeling of what they might need so it’s not as structured as it should be, it really isn’t” (Dietitian 8).
None of the informants reported that they worked actively with patients’ individual goal settings and action planning either before, during or after their sessions. One informant described,” Goal setting, it is really only for us that the patient has participated in the education session. We don’t follow up with any personal goals. I can feel it is quite deficient and one must ask what it gives” (Dietitian 3). None of the informants reported any follow-up on their goals or audits.
The informants described that most patients were referred to the education sessions by a nurse or the physician, this was most likely after a discussion, but one informant described patients experiencing being told that education is something they must attend. As stated by the informant, “It can be the nurse or doctor who says you will attend this. So, they can be forced to go even though they themselves don’t want to” (Dietitian 3). Another informant also described the referral process as problematic since there were no assessment or criteria for who was referred which led to non-attendance or low motivation to participate in the group. As the informant described, “I haven’t met the patients before, so I don’t know about their motivation. They are referred to me and I have then thought they are motivated and want this. And maybe they even said that at previous appointment. But then they don’t really want this or at least they´re not ready to spend time or energy on it” (Dietitian 10).
The routine of having a follow-up session for the attending group within six months of the education was reported by two dietitians while other informants mentioned that patients always have the possibility to request an individual appointment. One informant described that the patients are encouraged to phone the clinic two weeks after the education session for an individual follow-up. One informant, who previously had not worked with a structured follow-up, concluded that this was something that would be important to develop. Furthermore, one informant mentioned the difficulty to provide equal care when there are no regional structures or pathways regarding what type and form of care people with T1DM are offered. None of the informants reported conducting any auditing on the outcomes of the education sessions. But several informants did mention that they believed that having a structured group education is conditionally, particularly to provide equal care. As one informant stated,” I think you owe it to the patients to have a structure and goal setting, the structure is what gives an equal care” (Dietitian 2).
The dietitian’s perspective on group-based patient education and its prospects
Seven informants highlighted time savings as an advantage of holding patient education in groups, but only if the participants in the group have a high attendance level. One informant described the administrative work around the group education as too time consuming and therefore time gain never was achieved.
The main benefit as mentioned by all informants was the positive impact for the patients as they get more time with the dietitians, to hear the same information several times in different forms and participation in practical examples and listen to each other's questions and answers. All informants also highlighted the support between patients as a positive key factor to reaching out with self-care messages. The informants described how the ongoing Covid-19 pandemic (2020-2022) had accelerated a digital development in healthcare, and three informants described that patient education in groups was about to be offered digitally while one was already running groups solely on digital platforms. One informant emphasized that with digital channels the entire care team can meet the patient without having to be in the same place, or there could be an opportunity to share videos or other digital content. As an informant described,” The development will be digital, it is coming to us in spring . Digital channels will be a real challenge and great fun. I never think we will go back to people coming in person, especially not type ones or people of working age” (Dietitian 2).
While the digital development was recognised as a positive prospect for patient education, one informant who was already actively involved in digital patient education did highlight that it was challenging to achieve the same level of discussions and interactions online. Three of the informants described that they would like to return to a so-called day-care week where patient education and workshops are provided in groups for several days in a row for one week. As described by one informant,” If you can really dream, I would like to have the day care week back, where the patients come and participate in lectures, cooking sessions, carbohydrate counting and such in a group with other people. It is an invaluable way to learn self-management” (Dietitian 1).
Four informants described that they would like to individualize group-based patient education by developing new education sessions and material for groups in different topics such as pregnancy, exercise, and patients that have been newly diagnosed with T1DM. Among other things, it was emphasized that time is what limits the development of new subject areas, partly to create educations and partly to gather feedback from patients to match the demand for groups. One informant emphasized that dietitians could benefit from sharing education materials with each other, ”It would be great if us dietitians could look at joint material, I am sure there are lots of us who have the same type of groups, but everyone creates their own [education material].” (Dietitian 3).