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

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.^17,18

The 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 person-centred 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 person-centred 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.¹⁹ They 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.²⁰ This 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.²¹ FFW, 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.²² She 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.

Theme 1 From fixer to facilitator

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:

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:

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.

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.

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 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.

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:

Theme 3 Reflecting on self

Applying person-centred values to people with diabetes also led participants to apply those values to themselves:

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.

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:

Nadia reflected how the change in her had affected others:

Jenny described a change that spoke of increased confidence, role satisfaction and self-esteem:

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:

Josh, like other participants, reflected that change became well established over time underpinned by a person-centred approach.