From fixer to facilitator: an interpretative phenomenological study of diabetes person-centred counselling and empowerment-based education

Background The purpose of this study is to explore the professional and personal experiences of multidisciplinary healthcare professionals during and following diabetes counselling and empowerment-based education. Methods Everyone who had participated in a diabetes counselling and empowerment course between 2008-2016 was invited to respond to an online survey and follow-up telephone interview if willing. Interviews were recorded and transcribed verbatim. The research team used interpretative phenomenology to identify core themes from both the survey and telephone interviews and which captured the impact of empowerment-based education. Results 22 doctors, nurses, dieticians, and psychologists completed an online questionnaire. 10 subsequently took part in telephone interviews. Empowerment-based education changed them from fixers to facilitators. Their transformation included a sense of becoming authentic, ‘being the way I want to be’ in clinical practice and becoming more self-reflective. This affected them personally as well as reinvigorating them professionally. Conclusions The participants described a personal and professional journey of transformation that included discovering their person-centred philosophy. They adopted a consultation structure that empowered people with diabetes to care for themselves. It can be speculated that participants’ experience of transformation may also guard against professional burnout.


Introduction
Diabetes care focuses on blood glucose management to prevent micro and macro vascular complications.This depends mainly on individual self-management, including dietary behaviours, medication/insulin management, and monitoring.The ability to self-manage is influenced by psychosocial aspects, which present wide-ranging and individual barriers.Living with diabetes can impose a psychological burden, including a higher prevalence of distress and depression, which predict poor physical outcomes. 1,2People with diabetes have asked professionals to pay attention to their psychological health. 3,4This requires professionals, many of whom were trained in the traditional medical paradigm, to provide care that supports self-management. 5The remit of the professional is to support behaviour change, but this can only be effective when framed in the context of the person's life. 6ny educators have developed courses to teach psychosocial care, but evidence of effectiveness is limited.Courses most often concentrate on communication skills, for which there is some evidence of effectiveness, mainly in cancer care and primary care.'High-intensity' courses (lasting days rather than hours) delivered by clinicians or researchers with curricula that include cognitive, behavioural, and affective skills development, filmed role play, and individualised feedback have helped clinicians elicit people's' concerns. 7These have also helped clinicians exhibit a personcentred consultation style including expressing empathy. 8,9Transfer of these skills into everyday practice cannot be assumed. 10,11There is a dearth of well-evaluated interventions that more directly target behaviour change, extend beyond communication skills, and examine longer-term impact.
The diabetes five-step empowerment model was first introduced in 1991 and subsequently refined by incorporating strategies are based on self-determination theory and self-discovery educational methods. 12Patients identify their issues/ problems, explore their thoughts and feelings in relation to these, consider options, make a plan for change and finally how to evaluate the plan.
Successful empowerment-based education requires a person-centred collaborative relationship between clinician and the person with diabetes.This can be achieved when the clinician is able to let go of the traditional medical model of socialisation towards themself as expert and the person with diabetes as passive, which is also reinforced by workplace hierarchies. 13This paradigm shift 14 requires skills and a consultation structure (the empowerment model) that enables the clinician to help people to reflect on their lives with diabetes and decide what is important to them and what they wish to change.
The empowerment approach focuses on the experience of life with diabetes including eliciting barriers to diabetes selfmanagement, exploring the burden of living with diabetes, and facilitating patient identified goals and planning for change. 12e way the empowerment approach has been put into practice in the UK is through a three-day course in which participants develop a philosophy based on the Person-Centred Approach to counselling created by Carl Rogers. 15In 2008, Professor Bob Anderson from the University of Michigan met with the faculty of an existing UK counselling course to help redesign it to include the empowerment model of education.This has enabled participants to combine the personcentred approach with the five-step empowerment model within a consultation structure. 16e present research results from over a decade's experience of using this approach to train healthcare professionals to help people with diabetes optimise their diabetes self-management.
Course participants said that attending the course not only enhanced their care for people with diabetes but had a 'transformative' effect on their clinical practice and their personal lives.This study focuses on the experience of the participants during and following training in person-centred empowerment-based education.Reasoning that a clearer REVISED Amendments from Version 1 We have responded to reviewers' points regarding some of the language used e.g., 'empowerment education' versus 'empowerment-based education' and also the term 'self-empowerment' and made the recommended changes.
We have added clarity throughout as requested by both reviewers in the areas of Methods, including the response rate, and regarding source data availability.We have added clarifying and more concise sentences to questions that arose from the reviewer in Methods, Data Collection, Results and Discussion.
Any further responses from the reviewers can be found at the end of the article understanding of participants' experiences might provide much-needed insight into the education of healthcare professionals for psychosocial care, the authors set out to explore the phenomenon.

Ethics approval
Ethical approval was obtained from the School of Medicine, Dentistry and Biomedical Sciences Research Ethics Committee, Queen's University, Belfast.Although this was not stipulated as a condition of approval, we decided against putting the data into an open access repository because of the high risk that individuals could be identified ('deductive disclosure').

Study design
This was an in-depth, exploratory qualitative analysis of the experiences of an opportunity sample of health professionals.It was designed to clarify professionals' lived experiences of participating in an educational intervention grounded in person-centred philosophy and the diabetes empowerment approach.

Conceptual orientation
Qualitative research is constructivist in the sense that researchers engage subjectively with what participants say, and 'construct' interpretation.Whilst this does not 'prove' that relationships exist, it does provide rich descriptions of social phenomena, which can be transferred to other people in other places.Rigour is enhanced by giving qualitative research projects an explicit theoretical orientation, linking the findings to a wider body of knowledge, rather than researchers' whim.The methodology of this project was interpretative phenomenology, which interprets people's accounts of their life experiences.The researcher makes sense of, or interprets, participants' experiences within the context of the study. 17,18e intervention This research treats the empowerment course as a 'complex intervention', whose impact can be explored by examining participants' subjective experiences.The curriculum is designed to enable delegates to reflect on what personcentred care means to them.The course is held over three days, twice a year, in England and Ireland.The venues are residential and relatively remote, which helps participants reflect without outside distractions.Each course is made up of 18 participants and six trained multidisciplinary healthcare facilitators.These include psychologists, a humanistic personcentred therapist, diabetes specialist dietitian and nurses, and consultant diabetologists.
Participants are introduced to person-centred theory including understanding the core conditions of person-centred practice. 19They practise a range of skills that communicate person-centred care using video real play in small groups made up of three participants and one facilitator.Within the groups, each participant takes their turn to experience the roles of counsellor, client, and observer.When taking the client role, participants are asked to bring an issue that is real to them (rather than roleplay) as this enhances learning through self-awareness and reflection.Feedback sessions within the small groups are led by the counsellor, using interpersonal process recall. 20This allows learning through reflection in a confidential, unthreatening environment.At the end of the course, trained actors role-play people with diabetes enabling delegates to practice what they have learned in a work-related context.Table 1 shows a course programme outlining the components and structure of the course.Research team and their reflexive involvement Five of the authors who are also course facilitators (FF-W, AK, AA, CF, and MD) wrote autoethnographies of 200-400 words reflecting on their own experiences of the course, and their views on the topics of empowerment and diabetes counselling.This step helped them be reflexive; in other words, participate in the research, whilst remaining conscious of their own subjective positions. 21FFW, a female researcher and diabetes specialist nurse who has an MPhil in phenomenological research led the study and interviewed participants.She was well known to participants as a course facilitator and, more widely, a national leader in person-centred diabetes care.The other five authors supported her role in the research by helping her be aware of her presuppositions about the topic, conduct interviews impartially, and interpret participants' responses with very well-informed and yet detached curiosity about what they said.Technically, this is known as adopting 'the phenomenological attitude'.
Recruitment and participants 125 multidisciplinary healthcare professional who attended courses between 2008-2016 and whose email addresses were available were informed about the project and invited to complete an online survey (Letter to Participants in Extended data).
The online survey comprised four demographic questions and four open-ended questions about their experiences during and after the course (Online Survey Questions in Extended data).Some contact details held for participants who had attended the course in earlier years were likely to be no longer in use, so our sampling strategy was opportunistic which is in keeping with the relativist (all views are equally valid) framework of the research.
Response to the questionnaire was taken as informed consent to take part in the study.Attendance at the course was the only inclusion criterion.Unwillingness to participate was the only exclusion.
Participants willing to take part in telephone interviews gave contact details at the end of the questionnaire.They were all sent a separate invitational email for a telephone interview and informed consent was agreed by response to email.

Data collection
The online questionnaire started with closed, factual questions.In accordance with phenomenological methodology, it also included open and minimally-structured questions to elicit the unique experience of each participant, inviting them to write reflections on their experiences of the course.It invited them also to reflect back on their relationships with patients, clinical practice, and the systems of care looking back on their experiences at the time they attended the course and subsequently, recounting any specific instances.Finally it asked them to reflect on the personal as well as the professional impact of participating in the course.
Telephone interviews were, likewise open-ended and minimally structured to elicit the unique experiences of each participant (Interview Guide in Extended data).Interviews were carried out during 2017.Interviews lasted up to 1 hour, their exact length being determined by the depth in which a participant was willing or able to discuss the topic.Each interview was recorded and transcribed verbatim.

Analytical procedures
The dataset comprised written responses to the online survey and transcripts of telephone interviews which were transcribed by a commercial bureau.To preserve confidentiality and avoid bias, the lead researcher (FFW) withheld the names of interviewees and pseudonymized the transcripts.All researchers listened to the audio-recordings as well as reading the transcripts.FFW used the Template Analysis method developed specifically to manage phenomenological research data.She started by systematically populating the Template with a priori themes drawn from researchers' autoethnographies. 22She then used participants' responses to the open-ended questions in the online survey to expand those themes.Next, she read individual telephone interviews closely, creating a progressively more sophisticated set of codes and organising these into higher-level interpretative themes, which informed the final written report of findings.Throughout this, she explored how participants experienced person-centred empowerment-based education, consciously doing so from a phenomenological stance.Co-researchers helped her do this by discussing her interpretation and how preconceptions and biases might have influenced this.We draw heavily on the participants' own words to report the findings using pseudonyms to disguise the identities of participants.

Demographic results
37 participants (27%) responded to the online survey of which 22 were fully completed (Table 2).16 (73%) of the 22 responders to the online survey were women, reflecting the gender ratio of the course participants.Most were nurses or doctors with at least 11 years of professional experience.15 (68%) participated in the 2015 and 2016 courses.10 responders (5 nurses, 3 doctors, 1 dietitian and 1 psychologist) took part in telephone interviews.Interviews lasted between 20 and 55 minutes.

Themes
The final Template (Table 3) has four high-level themes.These and their sub-themes illustrated with quotes from the online survey and the interviews are described below.There was a high level of consistency between participants in their experiences; verbatim quotations, below, illustrate some personal variations.Participants described a journey of change from a 'fixing' style of consultation, where they used their expertise to dictate solutions to people with diabetes, to a more facilitative style of consultation, where they engaged with the person with diabetes and focused on what was important for them.
James reflects on his experience of the pressures to be a fixer and then the change in his consultations since becoming more facilitative: I do think GPs often feel under pressure to come up with answers … Because we can refer as well, we've got the whole range of opportunities potentially, to fix things.But, in every sense, I think things (consultations) have improved overall.People have got a lot of things off their chest which were not on the initial agenda in the consultation.I think people are setting the agenda a lot more.We end up talking a lot more about their chosen subjects, rather than mine and they're happy with that.James, general practitioner Pauline describes her experience of managing a consultation and feeling an urge to fix but then realising the effectiveness of taking a step back and facilitating: I think the one thing that I learnt more than anything was to accept that I cannot always "fix things" and that I should stop trying.It is easy to give someone the answer.It is however much better to help them come up with the answer themselves.Pauline, diabetes specialist nurse Overcoming a fear of silence A feature of 'fixing' was a fear of silence and the strong desire to fill that space within a consultation.Several participants talked of coming to understand that silences gave a person with diabetes time to process and reflect.
What did I take away?I think it was … not having to fear the silence quite so much, I talk a lot, I just do, I talk a lot and sometimes it is, I just cackle along, to fill the gaps, I think it's a fairly common trait but I do think within a consultation process what I've taken away is not being afraid to sit and listen, to paraphrase what they're saying so that we both understand and not being afraid to let them provide their own answers.Jenny, paediatric diabetes specialist nurse

Becoming unburdened
Providing solutions for people with diabetes and finding that they returned with the issues unresolved had been stressful for 'fixers'.Participants described how they had experienced a weight of responsibility for glycaemic control and diabetes outcomes in individuals with diabetes.'Fixers' tended to blame themselves using words including 'ineffective', 'hopeless', 'a failure' when people under their care did not do well.
I have often felt that what I was offering as a professional was not eliciting the desired effect.Merely giving information on management and pointing out the obvious like 'you need to take care of your diabetes' or 'take insulin regularly' was utterly ineffective.Did this mean I was a poor physician?I have always aspired and endeavoured to be a good doctor.A personal sense of failure was prominent.Nadia, consultant physician Becky describes this solution-focussed way of working as a 'burden' and that working in a person-centred way felt 'like a weight lifted off my shoulders': The burden was kind of like that need to solve, obviously in a caring profession, that kind of need to find the answer and solve it for someone … it just felt really freeing, like literally being able to facilitate rather than to actually teach or educate, just kind of letting someone see and explore things which they clearly hadn't explored.Becky, diabetes specialist nurse The experience of changing from fixer to facilitator deepened most participants' understandings of person-centred philosophy.Participants reflected on how this philosophy fitted with their beliefs about practice not only in terms of communication but within the environments and systems of care participants work in.
Theme 2 Being how I want to be Participants found that working with a person-centred approach allowed them to feel true to themselves and their personal values.
I've given myself permission to step out and not be the consultant that everybody expects me to be but be the physician that my patients need me to be … as stupid as it sounds, it actually has allowed me to be happier with who I am now.Nadia, consultant physician Becky describes a sense of relief at how finding the tools helped her to become person-centred.To be able to function as a congruent clinician had a profoundly positive effect on her: It's probably the approach I've always wanted to take but this gave me structure … it sort of felt life changing for me.I think I'm more confident because I feel I can genuinely be myself and it feels authentic for me.Becky, diabetes specialist nurse Nadia realised she was applying her own values to people with diabetes.As she was able to let go of her own drive to be perfect, she was able to let go of expecting perfection in people with diabetes.
I sort of realised as … as human beings, as people, it's okay for us not to be at our absolute best all the time.I gave myself permission to be okay at most things and I did not need to be perfect … that's been huge … but then the penny dropped … that's exactly what I'm expecting patients to do every time they walk in, expecting them to be perfect, so unconsciously I'm expecting them to do everything right Nadia, consultant physician Both Nadia and Naveed described letting go of judgemental attitudes towards people with diabetes and towards themselves.

Theme 4 Changing personally and professionally
Naveed described change in the way he would respectfully listen, not only to people with diabetes and work colleagues, but to his family: The only person that changed in that one year is me, none of my patients have changed, they haven't been on any courses, but I am seeing such differences in the clinic.The clinic feels good.Nadia, consultant physician Jenny described a change that spoke of increased confidence, role satisfaction and self-esteem: I came away with a greater sense of value for the work that I do … I came away feeling more effective.Jenny, paediatric diabetes specialist nurse James spoke of long-term professional change because of the personal reward he experiences from seeing the improved responsiveness in his patients as a result of working in this way: The extent to which I have adopted the learning I think has actually lasted, because I found it very satisfying.It works for me, it's as good as having a really good new drug.The satisfaction I get from seeing people feeling a little bit better is continuing the motivation for me.It's not costing me a lot in terms of time.You get snappier at it.There is no reason for it to decline, in my mind.It's an important part of the way I operate now James, general practitioner Josh, like other participants, reflected that change became well established over time underpinned by a person-centred approach.
The course has transformed how I talk to patients.The principles of being equal partners, (and the concept of) selfempowerment are well grounded in the course which has continued to form my practice till now.The skills I picked up were invaluable, and over time, continue to develop and strengthen.Josh, consultant physician

Discussion
The aim of empowerment-based education is to facilitate empowerment in people with diabetes.Our research shows that there are also positive outcomes for clinicians who move from fixer to facilitator.This is attributed to the experiential nature of the course, through which participants grow relationships based on the philosophy of Rogers' Person-Centred Approach. 15Participants demonstrated this philosophy using communication skills and a five-step empowerment consultation structure that facilitates reflection and increases self-autonomy in people with diabetes. 12The changes took place deep within the being of the participants who came to know that not only do patients have the capacity to grow and fulfil their potential but so too, do they.Rogers described this active, more congruent state as encompassing the ideal of the 'fully functioning person'. 23rticipants made references to the day-to-day heavy burden of being a 'fixer' and needing to find solutions.This is pathognomonic of the Rescuer role on the Drama Triangle described by Karpman. 24The Triangle describes inauthentic relationships in which personal responsibility is lacking.The antithesis to Karpman's triangle is the Winning Triangle described by Choy 25 where authenticity and personal responsibility are key to successful collaborative relationships.
Studies have demonstrated clinicians' solutions alone may be at variance with peoples' needs [26][27][28] which can further increase clinicians' burden.Viewing this vicious circle through the lens of the Drama Triangle it is conjectured that clinicians engaging with patients through the Rescuer role could increase risk of burnout, characterised by emotional exhaustion, depersonalisation, and a sense of failure. 29In contrast, participants described how engaging more congruently, and respectfully responding in the Caring role on the Winning Triangle, changed them from a disease-centred approach (fixer) to a person-centred approach (facilitator).This reduced their sense of personal responsibility for the outcomes of self-management as they learned to respect and accept the ownership of diabetes self-management in the world of their patients.
A recent study observed the responses from clinicians who had self-reported empathic concern and perspective taking traits. 30The authors found clinicians when faced with emotional content during a consultation tended to respond with advice and information rather than with empathic emotional communication.One possible explanation may be the ethos that pervades medicine and associated professions of the traditional medical model of fixing, or, as the authors discuss, empathic clinicians may internalise the patient's distress and seek to fix it rather than engage with it.Rogerian personcentred theory would hypothesise that such clinicians are not demonstrating empathic understanding of their patients' emotions but are in an acute state of incongruent awareness, engaging through a Rescuer role on the Drama Triangle.Such a response also has the hallmark of clinician countertransference 31 which would explain why they 'received fewer patient expressions of emotions'.
Becoming a facilitator, reorientated participants from 'value incongruence' towards 'value congruence'.This was defined in earlier research as alignment between individuals' values and the values held by the organisations they worked within. 32In the present case, this means participants being able to work within their own philosophy rather than the philosophy of traditional training and/or the environment they work in.This is represented by the theme 'Being how I want to be', a key characteristic of Rogers' notion of the 'fully functioning person'. 23The authors speculate that this, in the long-term, may reduce the risk of stress and burnout.
A strength of this study was the diversity of experienced clinicians who reported personal and professional benefit from the course.Not all clinicians who had participated on the course were contactable partly because details had become out of date over time.As a result, two thirds of participants had undertaken the course in the previous two years.This may be a limitation because non-responders may have felt unchanged by the course, although this is not borne out by the positive evaluations received from clinicians who did not agree to participate.This potential limitation is mitigated by the qualitative nature of the study, which makes no claims to generalisability and is thus less prone to sampling bias.
Future research is required in three areas.First, to investigate which aspects of empowerment-based education within relationships grounded in person-centred philosophy might mitigate clinician burnout.Secondly, to assess how personcentred philosophy, skills and five-step empowerment model could be introduced more widely into clinical practice.Thirdly to evaluate the impact of this step-change in clinician practice on people with diabetes.

Conclusion
This study demonstrates how a philosophy of person-centredness and an empowerment consultation structure that recognises barriers to diabetes self-management can transform the facilitation of self-management and behaviour change.
The change in perspective towards people with diabetes that results can reduce the personal burden of responsibility for patient self-management outcomes.
Whilst we demonstrated psychological benefit to clinicians of making this change the question of whether this protects against burnout needs to be addressed in future research.

Introduction:
Is it possible to define a person-centred consultation?

Methods:
It would be interesting to specify the strategy used to optimize the response rate to the survey.Had reminders been sent?How much and how often?Have you tried to contact non-respondents in an attempt to understand the reasons for their nonparticipation (or partial participation in the survey)?It is possible that people who had a more positive experience with the training responded more to the survey than people who had a more negative experience.

Intervention:
It would have been interesting to schematize the training (table 1) in order to quickly identify the content, format and sequence over the 3 days.

Data collection:
Are the telephone interviews fully transcribed (word for word)?It would be interesting to add 1 or 2 example(s) of questions from the telephone interview guide directly in the article (in order to avoid the reader having to consult the extended data)

Results:
Did the interviews make it possible to determine whether one of the training activities proved, according to the participants, to be more "effective" in leading to a change in their vision (from fixer to facilitator) and their practice?
Have divergent results been obtained?(e.g.challenges regarding the application of a personcentered approach) Congratulations on your paper and I look forward to reading your future work.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
No source data required

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Qualitative research, diabetes, person-centred approach I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Martha Mitchell Funnell
Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA Thank you for your thoughtful comments and responsiveness to the suggestions.

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Empowerment-based education and training for health professionals and people with diabetes.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Version 1
Reviewer Report 12 June 2023 https://doi.org/10.5256/f1000research.77257.r175121 © 2023 Halliday J.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Jennifer Halliday
Deakin University, Geelong, Australia Thankyou to the authors for the opportunity to read and review this interesting paper.It is clear from the quotes that the participants gained benefits from taking part in the course, and that they perceived empowerment education/practice to enhance their consultations.
I enjoyed reading the quotes and felt the tables were well presented.I thought the authors did a very good job of describing the approach to analysis and reflexivity of the researchers.I felt some other areas of the methods could use some additional detail -for example, Who transcribed the interviews?Could you add a brief description of the questions/topics of the survey and interview (as not all readers will take the time to refer to the extended data documents)?There are useful checklists available via the Equator Network website, such as the COREQ or SRQR which would help the authors to easily identify and address such gaps in the reporting.Many journals now require submission of such checklists along with the manuscript.
A few minor comments relevant to specific sections: Introduction "Success depends mainly on individual self-management, including dietary behaviours, medication/insulin management, and monitoring."-Suggest revising this sentence, as stating that some people with diabetes have 'success' with managing diabetes implies that others 'fail' (potential judgemental undertone, which I'm sure is not the intention of the authors).Perhaps see Speight, J. et al. 2021.Our language matters: Improving communication with and about people with diabetes.A position statement by Diabetes Australia.Diabetes Research and Clinical Practice, 173, p.108655.
○ "Course participants said that attending the course not only enhanced their care for people with diabetes but had a 'transformative' effect on their clinical practice and their personal lives" -this reads like a result, suggest delete from introduction.
○ Methods "The online survey comprised four demographic questions and four open-ended questions about their experiences during and after the course" -I feel this would fit better in the section about data collection as it describes the survey.Also could you clarify the types of experiences the questions explored?
○ "Length of interview was determined by the depth in which a participant was willing or able to discuss the topic."-I noted the interview schedule stated they would be a maximum of 60 minutes -suggest to add to the main manuscript that you aimed to keep interview under 1 hour.
○ "The dataset comprised written responses to the online survey and telephone interviews."-The transcripts and audio recordings of the telephone interviews are the data (the telephone interview itself is the method) -I suggest amending the sentence.

○
Results/discussion I am curious whether there was any diversity in people's views or experiences?This has not been explored/reported.
○ "In conclusion this study demonstrates that empowerment education has the potential to affect a change in perspective in participants' approach to people with diabetes.Becoming a facilitator may reduce the personal burden of responsibility for patient self management outcomes."-is this supposed to be the first sentence of the conclusion?It seems odd that there are two conclusions.

Conclusion
"It may also benefit professionals in a way which protects against burnout."-I suggest deleting this from the conclusion.As you say, it would be an interesting area for future research, but your study did not investigate it.I suggest instead to add a sentence around the benefits the participants reported experiencing as a result of taking part in the empowerment education course (e.g.lifting the burden of needing to fix things and affirming person-centred approaches to diabetes care) or similar to what you wrote in the first two sentences of the Abstract conclusion.Thank you again for inviting me to review this paper, I genuinely enjoyed reading it.Reviewer Expertise: Psychological aspects of diabetes I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.R1: Self-empowerment is redundant.We cannot empower our patients.By definition, empowerment is inherent in a self-managed illness -We agree -One occurrence was a verbatim quote, which should not be changed.We have deleted the word 'self-' in the second occurrence (Discussion, first line) R1: the phase "empowerment education" is not clear.We can provide empowerment-based education to patients and teach empowerment-based strategies to both other health professionals and patients.
-We agree and have used the term empowerment-based throughout.Also, only MDs get "medical" training or education.Professional would be the more accurate description.
-We used the term 'medical' accurately because each occurrence criticises the type of education epitomised by the profession of medicine.R2: "Success depends mainly on individual self-management, including dietary behaviours, medication/insulin management, and monitoring."-Suggest revising this sentence, as stating that some people with diabetes have 'success' with managing diabetes implies that others 'fail' (potential judgemental undertone, which I'm sure is not the intention of the authors).Perhaps see Speight, J. et al. 2021.Our language matters: Improving communication with and about people with diabetes.A position statement by Diabetes Australia.Diabetes Research and Clinical Practice, 173, p.108655.-Point taken.We don't think it is necessary to cite the position statement because the point is so self-evidently important.
-We have replaced the word 'success' with the word 'this'.R2: "Course participants said that attending the course not only enhanced their care for people with diabetes but had a 'transformative' effect on their clinical practice and their personal lives" -this reads like a result, suggest delete from introduction.
-We agree that this phrase in Introduction foreshadows the results, but we don't adhere to rigid application of IMRAD.Making the proposed change would impact the logic of the research because, without giving that important piece of background, there would have been no logic behind researching the phenomenon of 'transformation'.Data collection R2. "The online survey comprised four demographic questions and four open-ended questions about their experiences during and after the course" -I feel this would fit better in the section about data collection as it describes the survey.Also could you clarify the types of experiences the questions explored?-Our response to R2's first point is the same as our response, above, to her critique of the final paragraph of Introduction.In reality, research is an iterative process.We could not have described recruitment to the Telephone interviews without describing the content of the survey instrument so taking up this suggestion would replace one problem with another problem.-We have not made the suggested change for the sake of readability and coherence.
-Please see response immediately above referring R2 to the place in the revised manuscript where we clarified the survey procedure.R2: "Length of interview was determined by the depth in which a participant was willing or able to discuss the topic."-I noted the interview schedule stated they would be a maximum of 60 minutes -suggest to add to the main manuscript that you aimed to keep interview under 1 hour.-We take this point.
-The relevant sentence in 'data collection' now reads: 'Interviews lasted up to 1 hour, their exact length being determined …..' R2: "The dataset comprised written responses to the online survey and telephone interviews."-The transcripts and audio recordings of the telephone interviews are the data (the telephone interview itself is the method) -I suggest amending the sentence.
-We have amended the first sentence of Analytical procedures to: ' …. and transcripts of telephone interviews.' Analytical procedures R2: Who transcribed the interviews?-We have added the phrase: '…which were transcribed by a commercial bureau.'R2: I thought the authors did a very good job of describing the approach to analysis and reflexivity of the researchers.
-We appreciate this positive comment.

Results
R2: I am curious whether there was any diversity in people's views or experiences?This has not been explored/reported.
-We have added the sentence: 'There was a high level of consistency between participants in their experiences; verbatim quotations, below, illustrate some personal variations.'

Discussion
Are the conclusions drawn adequately supported by the results?R1: Yes R2: Partly Please see the response below, in which we have revised the conclusions into a single, more concise statement.R2: "In conclusion this study demonstrates that empowerment education has the potential to affect a change in perspective in participants' approach to people with diabetes.Becoming a facilitator may reduce the personal burden of responsibility for patient self management outcomes."-is this supposed to be the first sentence of the conclusion?It seems odd that there are two conclusions.R2: "It may also benefit professionals in a way which protects against burnout."-I suggest deleting this from the conclusion.As you say, it would be an interesting area for future research, but your study did not investigate it.I suggest instead to add a sentence around the benefits the participants reported experiencing as a result of taking part in the empowerment education course (e.g.lifting the burden of needing to fix things and affirming person-centred approaches to diabetes care) or similar to what you wrote in the first two sentences of the Abstract conclusion.
-Point well taken.
-We have condensed those two paragraphs into a single conclusions section, containing the best of both the previous ones.

Minor comments:
It was not clear how the telephone interview participants were chosen, which would be helpful.
○ Language: Self-empowerment is redundant.We cannot empower our patients.By definition, empowerment is inherent in a self-managed illness.In the same token, the phase "empowerment education" is not clear.-Point taken.We don't think it is necessary to cite the position statement because the point is so self-evidently important.
-We have replaced the word 'success' with the word 'this'.
R2: "Course participants said that attending the course not only enhanced their care for people with diabetes but had a 'transformative' effect on their clinical practice and their personal lives" -this reads like a result, suggest delete from introduction.
-We agree that this phrase in Introduction foreshadows the results, but we don't adhere to rigid application of IMRAD.Making the proposed change would impact the logic of the research because, without giving that important piece of background, there would have been no logic behind researching the phenomenon of 'transformation'.

Methods
Are sufficient details of methods and analysis provided to allow replication by others?R1: Partly R2: Partly: I felt some areas of the methods could use some additional detail -We note the agreement between the two reviewers and have listed their specific requests below.
-See below Are all the source data underlying the results available to ensure full reproducibility?R1: Partly R2: No source data required -We note the difference of opinion between the two reviewers.
-Since some readers might share R1's concern, we have added a sentence in the ethical approval section reporting our ethical concerns about making source data openly available.We point out that the article contains a very comprehensive statement of data availability, including the option to ask us for the source data.
Recruitment R1: the response rate was disappointing -R1 touches here on an important methodological point.The adjective 'disappointing' suggests that the response rate compromised the quality of the research, which assumes that recruitment should be representative of the denominator population.We would have agreed with R1's epistemological position if this were quantitative research, but this is qualitative research.Opinion is shifting amongst progressive qualitative researchers towards the validity of informative responses as opposed to representative ones.
-We have commented on this in order to defend the validity of our methods in the context of open publishing, but do not think it would strengthen the article to argue it out in the text.We draw R1's attention to the sections headed 'contextual orientation', 'reflexive involvement', and 'recruitment', which position the research epistemologically within the relativist/constructivist paradigm.
R1: It was not clear how the telephone interview participants were chosen, which would be helpful -We agree that this was unclear.
-We have added the word 'all' to the final sentence of the final paragraph of 'Recruitment'.
R2. Could you add a brief description of the questions/topics of the survey and interview (as not all readers will take the time to refer to the extended data documents)?There are useful checklists available via the Equator Network website, such as the COREQ or SRQR which would help the authors to easily identify and address such gaps in the reporting.Many journals now require submission of such checklists along with the manuscript.
-We do not share R2's enthusiasm for checklists, which tend to have an inherently strong positivist bias, and are therefore at odds with our constructivist position.
-We have included brief precis of the survey and interview in the text, as R2 requested.
Data collection R2. "The online survey comprised four demographic questions and four open-ended questions about their experiences during and after the course" -I feel this would fit better in the section about data collection as it describes the survey.Also could you clarify the types of experiences the questions explored?-Our response to R2's first point is the same as our response, above, to her critique of the final paragraph of Introduction.In reality, research is an iterative process.We could not have described recruitment to the Telephone interviews without describing the content of the survey instrument so taking up this suggestion would replace one problem with another problem.
-We have not made the suggested change for the sake of readability and coherence.
-Please see response immediately above referring R2 to the place in the revised manuscript where we clarified the survey procedure.
R2: "Length of interview was determined by the depth in which a participant was willing or able to discuss the topic."-I noted the interview schedule stated they would be a maximum of 60 minutes -suggest to add to the main manuscript that you aimed to keep interview under 1 hour.
-We take this point.
-The relevant sentence in 'data collection' now reads: 'Interviews lasted up to 1 hour, their exact length being determined …..' R2: "The dataset comprised written responses to the online survey and telephone interviews."-The transcripts and audio recordings of the telephone interviews are the data (the telephone interview itself is the method) -I suggest amending the sentence.
-We have amended the first sentence of Analytical procedures to: ' …. and transcripts of telephone interviews.' Analytical procedures R2: Who transcribed the interviews?
-We have added the phrase: '…which were transcribed by a commercial bureau.'R2: I thought the authors did a very good job of describing the approach to analysis and reflexivity of the researchers.
-We appreciate this positive comment.

Results
R2: I am curious whether there was any diversity in people's views or experiences?This has not been explored/reported.
-We have added the sentence: 'There was a high level of consistency between participants in their experiences; verbatim quotations, below, illustrate some personal variations.'

Discussion
Are the conclusions drawn adequately supported by the results?R1: Yes R2: Partly Please see the response below, in which we have revised the conclusions into a single, more concise statement.
R2: "In conclusion this study demonstrates that empowerment education has the potential to affect a change in perspective in participants' approach to people with diabetes.Becoming a facilitator may reduce the personal burden of responsibility for patient self management outcomes."-is this supposed to be the first sentence of the conclusion?It seems odd that there are two conclusions.R2: "It may also benefit professionals in a way which protects against burnout."-I suggest deleting this from the conclusion.As you say, it would be an interesting area for future research, but your study did not investigate it.I suggest instead to add a sentence around the benefits the participants reported experiencing as a result of taking part in the empowerment education course (e.g.lifting the burden of needing to fix things and affirming person-centred approaches to diabetes care) or similar to what you wrote in the first two sentences of the Abstract conclusion.
-Point well taken.
-We have condensed those two paragraphs into a single conclusions section, containing the best of both the previous ones.

Competing Interests: None
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Reviewer Report 20
November 2023 https://doi.org/10.5256/f1000research.157703.r221799© 2023 Funnell M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

References 1 .
J S, T C S, T D, T B, et al.: Our language matters: Improving communication with and about people with diabetes.A position statement by Diabetes Australia.Diabetes Res Clin Pract.2021; 173: 108655 PubMed Abstract | Publisher Full Text Is the work clearly and accurately presented and does it cite the current literature?Yes Is the study design appropriate and is the work technically sound?Yes Are sufficient details of methods and analysis provided to allow replication by others?Partly If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?No source data required Are the conclusions drawn adequately supported by the results?Partly Competing Interests: No competing interests were disclosed.

IntroductionR1:
While empowerment (especially in the early work) were based on Frier and Rogers, the 5-step model and other strategies are based on self-determination theory and selfdiscovery educational methods.This should be included for accuracy and to take a more current view of this work.(See: Funnell MM. (2016).-We thank R1 for this important point.-We have updated our citation of her work to the 2016 article she cites (Reference 12) and cited her point verbatim in the revised manuscript.
1. From fixer to facilitator 1.1 The drive to fix I always felt like I had to fix things Pauline 1.1.2The burden of fixing The burden was like that kind of need to solve Becky 1.1.3Letting go of fixing Moving from trying to fix things Leanne 1.1.4Don't Need to fix I now believe and understand that it is not important or necessary for me to have the solutions Iris

Table 3 .
Continued 1.1.5Beinga rescuer It's hard not being a hero Naveed 1.1.6Steppingback from fixingThe biggest impact was to be once again reminded about the power of stepping back and moving away from the desire to fix.Without periodic or even constant reflection I think for many of us that go into healthcare -including me -I find I am pulled into that dynamic.
Communicating core conditions rather than just feeling them Nadia 1.2.6 Skills & reflection The course not only taught me the counselling techniques, but also made me reflect on my practice as a doctor and the impact of my verbal and non-verbal communication Patsy 1.2.7 Facilitation-letting go of fixing It just felt really freeing, like literally being able to facilitate rather than to actually teach or educate.Becky 1.2.8A framework It gave me a framework for which I could approach the issues that I was dealing with Nadia 1.2.9 Facilitated consultations The course has transformed how I talk to patients Josh 1.2.10 Clarity of philosophy Knuston certainly gave me the structure but it also sort of made it okay, acceptable, permission that it's okay to work this way.Nadia 2. Being the way I want to be 2.1 Person centred values I now wear them (core conditions) on my sleeve and I'm quite proud of them … Nadia 2.2 Accepting of self It has allowed me to be happier with who I am now Nadia 2.3 Trying to do this for years This is probably what I've been trying to do for years in my practice … for years.Nadia 2.7.3With colleagues It has helped me in relationships with other team members that I work with and the fact that I'm more able to listen to their feedback and not be thinking about what I'm going to do next, trying to solve a problem in my head before I've even listened to what the problem is.Becky

Table 3 .
Continued2.7.4With familyIn order to listen to them, you need to give them your full attention.I think that's changed my relationship with my wife especially.I'm listening better than I was before.
It helped me to see patients in a different light, as individuals, as you and me.Naveed 3.4.1With oneself I'm better at reflecting on my natural ability/downfall, to know what's wrong (with patients) and that I have the solutions … Fran 3.4.2With others personally Even on a personal level with my wife and my kids I'm probably more accepting than before.
Theme 3 Reflecting on self Applying person-centred values to people with diabetes also led participants to apply those values to themselves: I think the course helps you reflect on yourself and your behaviour … by the fact that you accept the patient as they are, you try to accept yourself as you are.You have more acceptance of who you are and what you do.I think it has made me more content with myself.Naveed, middle grade doctor

work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
We can provide empowerment-based education to patients and teach empowerment-based strategies to both other health professionals and patients.Also, only MDs get "medical" training or education.Professional would be the more accurate description.While empowerment (especially in the early work) were based on Frier and Rogers, the 5step model and other strategies are based on self-determination theory and self-discovery educational methods.This should be included for accuracy and to take a more current view of this work.(See:FunnellMM. (2016).1Nocompeting interests were disclosed.
○○Is the I confirm that I

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Introduction R1
: While empowerment (especially in the early work) were based on Frier and Rogers, the 5-step model and other strategies are based on self-determination theory and selfdiscovery educational methods.This should be included for accuracy and to take a more current view of this work.(See:FunnellMM. (2016).-WethankR1 for this important point.-Wehave updated our citation of her work to the 2016 article she cites (Reference 12) and cited her point verbatim in the revised manuscript.R2: "Success depends mainly on individual self-management, including dietary behaviours, medication/insulin management, and monitoring."-Suggest revising this sentence, as stating that some people with diabetes have 'success' with managing diabetes implies that others 'fail' (potential judgemental undertone, which I'm sure is not the intention of the authors).Perhaps see Speight, J. et al. 2021.Our language matters: Improving communication with and about people with diabetes.A position statement by Diabetes Australia.Diabetes Research and Clinical Practice, 173, p.108655.