Reflection tools – support for patient learning in group education

This qualitative study describes how reflection can be supported by using reflective tools in group education in type 2 diabetes. The changed conditions for living with a long-term illness may lead to increased anxiety and new demands that affect one’s current life situation. The didactic model, ‘The challenge – to take charge of one’s life with long-term illness’, has been developed into ‘Taking responsibility in life with type 2 diabetes – a model for group education in primary care’. Specialized diabetes nurses and dieti-cians received training, a manual and continuous guidance in applying the model. Reflection diaries, notes and interviews both from the patients and the caregivers were analyzed using a phenomenological hermeneutic method. The results show that using images as reflective tools engages thoughts and feelings in a way that appears to be important for one’s learning in life with a chronic illness. The images contribute to allowing a distance from one’s situation, actions, thoughts and feelings, which seems fruitful for investigating and discovering new ‘things’ about oneself. With the support of reflective tools and guiding questions, reflection is led to a deeper existential level where both caregivers and patients contribute by asking questions that support the reflection process.


Introduction
Diagnosis of a long-term illness, such as type 2 diabetes (T2D), can have a detrimental impact on someone's life.The changed health situation demands a life with new routines such as specific diet, increased physical activity and adherence to medical treatment.The number of people with diabetes is increasing, and in 2030, 643 million adults aged 20-79 years worldwide are expected to be living with diabetes (International Diabetes Federation IDF, 2021).In Sweden, approximately 500 000 (5%) have diagnosed T2D (NDR, 2022).The increasing number of elderly people means that the need for diabetes care, and care for other long-term illnesses increases, faces major challenges.

Learning to live with long-term illness
The changed conditions in living with long-term illness may lead to increased anxiety and a lack of access to the former way of living one's life.When facing new demands due to longterm illnesses, managing them effectively is crucial as it impacts current living conditions and can have long-term health consequences.The integration of illness and treatment in life (Hörnsten et al., 2011) can be understood as learning (Berglund, 2011;Johansson et al., 2016;Kneck et al., 2011).This learning is grounded in the actual situation and requires more conscious decisions: decisions that affect one's health situation both short and long term (Berglund, 2014).The concept of learning from a lifeworld approach encompasses the whole person with illness.The learning process includes reflecting on thoughts and feelings, theoretical and practical experiences and reflection on the embodied knowledge in relation to the illness.The learning can be understood as a changed understanding of oneself with the possibility to act on conscious choices (Johansson et al., 2016).
Learning to live with long-term illness is complex, but those affected by illness and health problems manage it over time.It can be described as a process with turning points including existential and emotional aspects which can increase the motivation and willpower for changed behaviour (Jutterström et al., 2012).Despite that, it turns out that some with a longterm illness consider themselves to have 'understood too late', which leads to the illness worsening with complications.In those cases, except personal suffering, family and work situations may also be affected in negative ways and healthcare costs may increase (Ogugua et al., 2024).

Patient education
Most patients with long-term illnesses receive primary care through counselling, support, treatment, and education to increase self-care management, which includes daily activities and making decisions related to their illness (Lorig & Holman, 2003).Specialist trained nurses in primary care are often responsible for medical follow-up, care, and education to increase the patient's self-care management (Bergh et al., 2014).An individual counselling session is the most common form of follow-up.According to national guidelines for diabetes care, patient education, individually and in groups, strengthens the patient's self-care management, which is a prerequisite for good control of the disease and its treatment (National Board of Health and Welfare, 2018).
Patient education is a planned educational activity where the goal is to improve the patient's health and self-care management.Only 40% of primary care units in Sweden offer group education to people with T2D, despite recommendations.Furthermore, only 20% of these units had subject and pedagogical competence (National Board of Health and Welfare, 2015).Research shows that patient education and information provision often take place at a superficial level where the patient is expected to comply with the treatment advice.This may be one reason why the positive results that are usually achieved by group education in T2D tend to diminish over time.Although group education has been shown to be effective, specialist diabetes nurses experience that many patients decline offered group education.Innovative projects that put the patient's learning in focus and where the pedagogical idea is clear and evaluated in a systematic way are in demand.To cope with the great challenge that lies ahead, alternative solutions are required that can replace or supplement physical meetings.

The didactic model and didactic tools
The research-based didactic model in this study, 'The challenge -to take charge of one's life with long-term illness' (Berglund, 2011) is based on a lifeworld approach with the aim to meet, confront and tactfully challenge the patient to reflect on their beliefs, thoughts, actions and feelings in life with the illness.This model is based on results from studies on patients learning to live with long-term illnesses and has previously been studied in dialysis care.The studies showed that an increased focus on genuine dialogue encouraged patients to take responsibility, to act based on conscious choices, for their health process (Andersson et al., 2015;Svanström et al., 2016).The model was adapted to a concept called 'taking charge in life with T2D -a model for group education in primary care'.The project involved specialist diabetes nurses and dietitians who led the group education having learned about the didactic model in a university-level course.The group education, based on the didactic model, consisted of five sessions.These included a reflective diary with reflective tools such as selecting a photo, drawing and writing, and sharing experiences about their life related to 'the Past -Present -Future, Obstacles -Opportunities, Strengths -Weaknesses, Goals and Learning'.Each session had a different theme aimed at supporting patient learning at an existential level.The sessions included taking turns to speak at the beginning and end, encouraging everyone to be active and share experiences.The results showed that a reflective dialogue based on the patient's life situation was created and that the help to articulate feelings during turn-taking was supportive (Andersson et al., 2019;Kjellsdotter et al., 2020).
Based on the experiences gained, new research questions were raised to further understand the problem area.In this study, various didactic tools used in teaching intended to support reflection are described.The goal is to continue developing methods that have the potential to support existential learning with the possibility to take charge and personal responsibility in one´s life with a long-term illness, in this study T2D.

Aim
The study aimed to describe how reflection can be supported by using reflective tools in group education in T2D.

Research questions
-What meaning have the tools for patient learning?
○ How do they support patient reflection on the health situation?○ How do they support reflection on the patient's own responsibility?-How is learning supported based on reflection tools and the didactic model?

Method
This qualitative study is grounded in a didactic model with a life world perspective.The data is analysed with a phenomenological hermeneutic approach described by Lindseth and Norberg (2004).Ricoeur (1976) maintains the movement from the manifest content to the latent meaning of the text.He further argues that understanding and explanation should not be placed in a dichotomy, but rather as being dialectically related to each other to overlap and interact in the interpretation process.

Participants and sampling
The project took place at three primary care centres in southwest Sweden on four occasions.The registered nurses and dietitians facilitating the project had long experience in T2D care and counselling (3-17 years).They had also completed a university course on a lifeworld approach including the model 'The challenge -to take charge in life with long-term illness'.Patients with T2D, 16 males and 7 females aged 45-78, who participated in the group education were included in the study.
The education included a reflection diary with various reflection tools for the patients.The specialist diabetes nurses and dietitians who facilitated the meetings had a manual and received continuous supervision in applying the model.Reflection diaries, notes and interviews were used as data for this study.Nurses and dietitians had undergone pedagogical training in diabetes care and completed group education within the framework of their employment.The diagnosis of T2D should not be older than three years and not newer than three months.No selection was made regarding age or gender.
Interviews were conducted after group education (n = 12), transcribed verbatim and included as data.The interviews were done individually by phone and had an initial openended question about the patients' experiences participating in the group education.The open-ended question was followed up with prompts such as 'for example', 'please, can you tell me more' and 'can you give examples'.Three focus-group interviews (n = 4) were conducted face to face with the nurses and dietitians before, during and after the group-based education programme.The focus-group interviews were carried out as a dialogue to enable the participants to reflect together about the phenomenon of interest.
Reflection diaries (n = 23), with reflective tools, were filled in by patients who participated in the group education and included as data.All patients gave consent for the reflection diaries to be used in research.The diary entries were written before, during and after each group meeting.Each reflection diary consists of 30 pages with different amounts of text and drawn pictures with explanatory text.
The data also consisted of notes made by the specialist diabetes nurses and dietitians after each completed group meeting (n = 15).These notes contain the caregivers' preparations, description of how the meeting went, topics that were focused on during the session and what was said during the closing round.

Data analysis
All experiences of the phenomenon were transferred into text and analysed as a whole.The interpretation of the text included the parts that were read, explained and interpreted in relation to the whole text.The process of interpretation consisted of dialectical movements between understanding and explanation (Ricoeur, 1976), and the meaning of the phenomenon emerged during the analysis.To clarify the phenomenon, each reflection tool was analysed and presented separately.
The data analysis was carried out by all the authors.In line with the phenomenological hermeneutic approach, the analysis included three phases: the naïve reading, the structural analysis, and the comprehensive interpretation.I: During the initial reading, all data was read several times with a natural approach of openness, flexibility and a reflective manner to gain a sense of the whole, and a naïve understanding was formulated.The result of the naïve understanding was discussed between all co-authors to form a first understanding of the phenomenon.II: At the next stage, a structural analysis was carried out highlighting the patient-and caregiver perspectives.Meaning units, a part of the text that has a meaning of its own, were identified and reflected over in the light of the naïve understanding.Each unit of meaning was condensed, after which the meanings were sorted into groups.These groups were then compared for similarities and differences, which gradually led to formulation of a text illustrated with quotations.III: The text was then reflected on, in relation to the naïve understanding, to validate and adjust the interpretation.In the final phase, the structural analysis was interpreted together with the naïve reading, and a comprehensive understanding was formulated as an interpretation of the whole.

Ethics
The Regional ethical review board approved the study (Dnr: 442-15).Informed written consent was obtained from all participants in the study.Principles according to the Helsinki Declaration were followed (WMA 2013).

Naive understanding
The reflection tools contribute to initiating reflections on my own situation.The reflections clarify personal responsibility and strengthen confidence in my ability (self-efficacy) to bring about change and the importance of making conscious choices.The images reinforce and guide the reflections towards a deeper selfunderstanding, who I am, and how I can influence my life in relation to the illness.Sharing experiences also contributes to reflections on others' stories, reflections that are related to my own situation.
The caregivers are given the opportunity to gain insight into the patients' mindset, which creates openness and possibilities of sharing thoughts and feelings in the patient -provider encounter.The reflection tools require a different approach to education; it is no longer the caregivers who prepare and determine the content of the sessions.Using reflection tools demands that caregivers adopt a reflective approach to patients' experiences and to their role in supporting learning instead of merely imparting knowledge.
The results are presented as follows: the reflection tool is presented separately, followed by the patients' reflections on the tool and the caregivers' reflections.

Patient reflections on the tool and its importance
The picture of the boat (Figure 1) was used at the beginning of the group meetings, which generated multiple and deep reflections among the patients, and was described as remaining over time.The boat was described as a metaphor for the situation they found themselves in.'Well, when you've got a disease on board, you must row it ashore.That's just the way it is'.The picture created associations of being alone in the situation of illness (boat) and the notion that they have the ability and knowledge to take charge and steer their own lives.'Hmm, there is no one else rowing for you.You have to row by yourself'.Sitting alone in a boat without the knowledge and ability to steer the boat manifests a feeling of 'rowing without oars', which serves as motivation to acquire more knowledge about one's situation.
The picture of the boat contributed to reflections on the possibility of influencing one's own situation, i.e. taking charge and steering towards what is important in one's own situation.'To decide for oneself where to go.Not letting anyone else decide'.Furthermore, it increased awareness of what happens if the person does not take charge: 'If you don't do it, the illness takes over'.Here, the benefits of taking charge are weighed against the risks of not taking control of the situation: 'It prolongs life and reduces the risk of future complications.If you don't do it, you crash and sink'.The patients´ statements are strong, as the insights touch upon the possibilities for continued life.The boat as a reflection tool evoked existential reflections on one's own situation, personal responsibility and the importance of the choices made for the rest of one's life.

Caregiver reflections
With the picture of the boat, the caregivers experienced that it was easy to start reflecting.'I remember that there were a lot of good reflections.Several things that I hadn't thought of myself'.Additionally, the caregivers described how the picture generated reflections on the possibility of being able to control and influence the illness.The reflections also evolved around the importance of setting personal goals and the direction for the journey of life with diabetes, as well as the risks if one doesn't do so.
•A picture of a boat is shown to paƟents, who are encouraged to reflect on the following quesƟons: -What does it mean to steer a boat?-What happens if you don't?

Patient reflections on the tool and its importance
The photos (Figure 2) were described as pleasant and disarming in group conversation.The associations evoked by the photos in relation to a specific question were described as contributing to a sense of community and sharing of thoughts and feelings that had not been expressed before.One person described it: I chose the photo because one must keep struggling on, kind of like pushing a big elephant.Sometimes it's hard, sometimes it's easy.You must think about making the right decisions a lot.Sometimes I get tired, sometimes I'm in a good mood, sometimes I'm in a bad mood.

Another patient:
I chose the narrow wharf with the diffuse ending.It is a lifelong road with an uncertain ending.Difficult to take the disease seriously.Thus far it means taking pills and checking my blood sugar now and then.It doesn't affect me too much.It's a tricky disease that one must keep an eye on.
The patients described how the photos were enjoyable to use, as they offered pleasurable associations that also reduced tension when talking and sharing experiences in the group.It was described as easier to talk about thoughts and feelings that are not usually shared with others when they had a photo in hand.

Caregiver reflections
The caregivers described the reflection tool as a way to start up, i.e. to begin reflecting and deepen conversations.They believed that the reflection tool de-dramatised the educational situation and invited creative associations, which in turn contributed to deepening the narrative.
PHOTOLANGAGE ® is a collection of black-and-white photos used to stimulate and deepen reflection.The photos are intended to create a distance that sometimes makes it easier to put feelings and experiences into words.The patients can choose photos for different questions, for example, my picture of the disease of diabetes.They chose a photo with care and felt that they shared something relevant about their photos, something that suited them.This became something more concrete that also became something fun.A photo is somewhat more tangible in a way.
The caregivers shared that they have started using photos in contexts other than group education, such as when they meet patients who have recently been diagnosed with diabetes.One caregiver stated that she now always begins individual counselling by asking patients about their perception of the illness.They said that this approach provides a different understanding of where the patient is in terms of their thoughts and feelings, and it forms the foundation for further dialogue.

Draw a picture: who am I, who am I with illness?
The patients in the group education drew many inspiring pictures, some wrote short stories or keywords supporting the pictures (Figure 3).The images described how they see themselves today.Examples of these pictures include persons who are overweight, people eating cookies and candy, persons sitting still or who choose a car as their means of transport.These pictures also described emotions such as sadness, tiredness, happiness and overall satisfaction with life.The pictures representing 'who I am with diabetes today' described persons leading healthier lifestyles, choosing fruit instead of candy, walking, cycling, being happier and weighing less.

Patient reflections on the tool and its importance
Some patients found drawing a challenge, where they described themselves as having different prerequisites.pictures, it appears that they still felt as before, 'I am me, no one else', but there is also a pride in the changes they have made in their lives.Despite that, they still feel like the same person they were before the diagnosis.'The same as before, but I think more about what I eat'.

Caregiver reflections
A challenge described by the caregivers is that not all patients want to draw.Initially, they experienced resistance from some, with 'one person firmly refusing . . .one person who just sat with folded arms, saying, "I can't draw, and I won't draw.And you can't force me to".' Reflecting and drawing takes time.The caregivers found it difficult to know when to interrupt the task since the intention not to interrupt must be balanced with the readiness of others in the group.
You don't want to stress them if . . .Well, it is actually a bit difficult knowing how much time to give them.There is always someone writing until the end.But maybe they're just doing that while waiting for us to end the exercise.
The caregivers described how several patients, through drawing and storytelling, depicted the changes they have made in their lives since being diagnosed as having diabetes.The changes they have made, according to the caregivers, contributed to a 'changed self-image', something that they believed this reflective tool contributed to.

Patient reflections on the tool and its importance
The reflection tool Past -Present -Future (Figure 4) was used in a creative way by the patients.Drawings and words symbolised the patients' core emotions in different time frames, such as 'energetic and happy' or 'tired and out of sorts'.This is related to the past, referring to the time before the diagnosis of the disease, as well as present and future thoughts.The reflection tool highlights how persons have lived in relation to influencing factors for diabetes, such as diet, exercise, and stress.It also reveals the changes that awareness of the disease had generated and the patients' hopes for the future.As one patient expressed it: I found it, experienced it as fun//I had to think a little . . .how I had it back then//I built selfesteem in this.I got self-esteem from this//we drew how my life had been and where I am today.It was very useful/beneficial to think about . . .how it is . . .and so forth . . .

Who have you been, what has been important to you in life?
I was more social.Baked delicious cookies, cakes, and invited friends over to enjoy the home-baked.
Good food, often served in generous portions (picture of a large woman), is important to me.

Who you are today, what is important to you in life?
Avoiding all that is forbidden = BORING.
Healthy food in normal portions.

Future:
How do you see the future, what is important to you in life?
I think that I will get better, or that they will invent a cure.
Feeling good and exercising (picture of a thin woman).

Figure 4.
When using this reflection tool, the patients were asked to describe with words or draw three pictures.
Reflecting on one's situation based on the past, present and future provides insights into what may have influenced the current situation and the risks of continuing to live the same way: To enable to keep the course, you must have it fairly mapped out.To try and live in a healthy way.Exercise and eat fairly healthy.Which one ought to have thought about earlier, otherwise the diabetes gets the upper hand of my life with secondary diseases among other things.
With these insights came hope and motivation to make changes.

Caregiver reflections
Motivating and encouraging patients to reflect on their situation based on the past, present and future in relation to who they are and what is important in life was perceived by caregivers as a challenge.It required more time than could be allocated during group sessions.However, during subsequent group meetings, caregivers noticed that patients had written and drawn at home between sessions, despite the initial resistance: '. ..but then there were several persons who actually drew themselves with a thick belly before diabetes.And a flat belly after making lifestyle changes, yes, that was positive'.Caregivers felt that patients had become more aware of their lives in relation to their current situation.

Patient reflections on the tool and its importance
The reflective tools Obstacles -opportunities, strengths -weaknesses (Figure 5), obstacles were described as more or less tangible, ranging from the constant presence of the illness in one's thoughts and limiting life to the absence of any obstacles.Being challenged to reflect on what opportunities the illness provides was described as giving insights that the changes the person has made had led to healthier lifestyle habits that can result in better long-term health despite the illness.At the same time, reflecting on one's strengths and weaknesses in living with the disease reveals the resources and challenges one has.Sharing one's reflections in a group was described as a feeling of not being alone and provided the realisation that others •Restricting what and how I eat (creates some concern about long-term health consequences/sequelae).
•One has to decline coffee breaks, evenings with friends and birthday parties.How will it be at Christmas?•That I can never eat normally without checking my blood glucose.
What obstacles does the illness create in life?
•A motivational factor for better health.
•To lose weight.Reduce the risk of cardiovascular disease.
Do you see any opportunities with the illness?
•My determination and adaptability to a new aituation in life.Obstacles are meant to be overcome.
•That I have taken control/hold of my lifestyle.
•It is always possible to do something better.
My strength in living with the illness?
•It's hard to keep a diet sometimes.
•To always say no, which I rarely do.
•Maybe I don't have the character to always take care of myself.
My weaknesses in living with the illness?are also struggling or may not take it as seriously as oneself.'No one is flawless, there are more people with problems, we all share them . . .' Sharing provides relief in knowing how others think and feel, while also creating curiosity that leads patients to ask each other questions -questions that support reflection and lead to various insights.

Caregiver reflections
The caregivers described the reflection tool as easy for the patients to fill in at home.They could then discuss and reflect on it in the group.The caregivers felt that the patients had become more accustomed to the methods when this was used on the fifth occasion.This became evident when patients started asking each other questions.They discovered that their 'obstacles and weaknesses are more or less the same'.In the reflections on the opportunities presented by the disease, there was room to reflect on the patient's own short-and long-term goals, which could be challenged in the group based on whether they were realistic goals or not, considering the person's strengths.

Goals and my learning
To write, draw or choose a photo that describes what is important for the person to achieve (Figure 6).The goals should be possible and realistic to attain, but dreaming and wishing are allowed.

Patient reflections on the tool and its importance
Some criticism was expressed regarding the difficulty of answering these questions (Figure 6) as they provoked deeper thoughts.'Well, of course, it made me reflect a bit'.It was also important to be forced to read rather than just listen.'And it wasn't easy to answer them, that's • By accepting the illness, acknowledging to myself that I am "sick."• Not making a big deal out of it.
• Taking time for myself.
How do you create space for yourself with the illness?
• From within myself, my wife and son.To be able to be there for my son, now and in the future.Not to miss out on him growing up, and so on.• The fact that I can feel so good, that I have the freedom to go on a trip.
• To look at life positively.
Where do I get the strength and support to endure/to keep going?
• Try to make some changes in my daily routine.
• Not falling for any sugar traps.
My goals for the treatment of my diabetes -in the short term.
• Having my sugar cravings disappear completely.
• To lose weight, maintain stable blood sugar levels and improve my fitness.
• To prevent diabetes from causing major complications.
My goals for the treatment of my diabetes -in the long term.
• When I see that my blood sugar levels are well adjusted, it serves as confirmation that I am exercising well and maintaining a healthy diet.• I can never know that for sure; I could be dead tomorrow, but trying is at least enough.
My goals for the treatment of my diabetes -How do I know if I'm achieving them?for sure, but . . .when you read something, it tends to stick a bit more than if you just hear it'.It was considered important to have time in peace and quiet in one's own home to be able to answer these questions.
The patients expressed the importance of the meetings being structured in 'rounds' so that everyone had a chance to speak and learn a lot from each other.'I thought the setup was great.Overall, it was great that everyone got to talk and express themselves, and you learn from each other when you listen'.Furthermore, the collective reflections within the group were seen as contributing to one's own learning: '. ..yeah, it can definitely help with being more open to oneself.If you're pondering something and you don't express it. . .then it doesn't work well.You don't get any answers'.

Caregiver reflections
Formulating goals was experienced as a help in directing focus towards the future.In relation to these goals, patients reflected on obstacles and opportunities and on strengths and weaknesses in achieving them.In a series of group meetings, this tool was described as functioning as a connection with an increased focus on the future.The caregivers also described the importance of the structure of the meetings.It was considered a good practice to start by discussing 'what has happened since the last time' and to summarise the key points before ending the meeting.It was acknowledged that it takes time to apply new routines and change the way of working, which is expressed in the following: 'They managed to establish a routine of "now we have learned.Now it's my turn to talk".A typical diabetes education might involve more lectures'.The caregivers expressed positivity towards patients being able to discuss their illness in a deeper way, where emotions were allowed to be present.They believed that the reflection tools contributed to delving deeper in conversations.

Comprehensive understanding and discussion
The results show that using images as reflective tools engages thoughts and emotions in a way that appears to be significant for a person's learning in life with a long-term illness.The images contribute to a distance from one's own situation, actions, thoughts and emotions, allowing them to be explored in a curious, playful and uninhibited manner.This seems fruitful for investigating and discovering new 'things' about oneself.
When participants, based on a question, choose and reflect on what an image describes and what it means in relation to their own situation, a movement between distance and closeness occurs in a way that can be interpreted as integrating new understanding of their situation with the illness in their lives.According to Berglund (2014), this constitutes learning at an existential level where the person understands oneself, in relation to the new situation, with long-term illnesses and the ability to act based on conscious choices.
Reflection and learning can be understood, according to Ekebergh (2009), as a pendulous movement between integration and disintegration.Through reflection, persons can reach deeper insights and understanding.When the movement leans towards integration, meaning and comprehensibility are created, and a sense of wholeness emerges.Disintegration occurs in complex learning situations, such as the chaos experienced by a person when they are affected by a serious illness, resulting in a fragmented sense of wholeness.The learning process, as a movement, does not follow predetermined patterns.Instead, disintegration and integration alternate, and it requires the learner to tolerate the chaos for a new understanding to occur.
Integration is the result of a new understanding taking place and a new comprehensible wholeness being reached.The person develops a new horizon of understanding.This movement between integration and disintegration is described in Berglund's (2011) as a part of the learning process in living with long-term diseases.
The reflective tools used to reflect upon in this study seem to act as resistance, something that challenges understanding.The result indicates that the picture of the boat effectively highlights the person's responsibility to take the helm and steer their own life.The finitude of existence appears to be the ultimate resistance to reflect upon, which can be well understood considering Heidegger's (1998) reasoning on being and time.He means that it is the finitude of life that gives it meaning.Gadamer's (1996) discussions on how illness can force persons to take responsibility are also evident in the results.
Furthermore, the results show that both patients and caregivers found the use of reflective tools exciting and enjoyable.With the support of guiding questions, reflection was taken to a deeper existential level, where both caregivers and other group participants contributed by asking curious questions that supported the reflection process.Ekebergh (2009) and Berglund (2011Berglund ( , 2014) ) describe a responsive, tactful manner with the support of questions to guide the learner towards more profound reflections.With the support of the described reflective tools, reflecting upon and describing one's life, habits and consequence for health become enjoyable and less threatening.We argue that patients' learning is supported, and persons with the illness gain a better foundation for decision-making and a greater understanding of the consequences of their choices.
From distancing to integrating the illness into one's own life and personal identity, the tools of drawing and writing based on the questions 'Who am I? Who am I with the illness?' as well as the tool of past/present/future significance proved effective alongside the images.
By starting with the patient's perception of the illness, the caregiver gains insights into the patient's mindset and adapts the conversation accordingly.This approach helps create a more patient-centred and personalised interaction (Palmér et al., 2022).The results indicate that participants reflected on the changes in their life situations, their way of living and the positive health measures they have taken or aim to achieve.The reflective tools clearly bring forth these aspects, which can potentially enhance the learning process.
The reflective tools as support contribute to giving conversation a direction and a goal that involves exploring the unknown or giving voice to thoughts and emotions that have not been expressed before, such as fear, guilt and shame.The combination of verbalising one's innermost thoughts and feelings with having a picture to associate to strengthens the memory of the conversation and its meaning.Additionally, the results demonstrate the importance of sharing these experiences with others in similar situations.Hearing others' stories, associations and reflections contributes to a sense of not being alone but also an understanding that everyone has their own circumstances and concerns.
The results also indicate that the reflective tools support the underlying principles of the original didactic model (Berglund, 2011).The lifeworld approach and the explicit approach are promoted by the reflective tools, allowing for the patient to meet, confront and tactfully challenge their own beliefs, thoughts, actions and feelings in relation to life with the illness.The five thematic areas for group education, where reflective tools and didactic strategies with rounds were utilised, proved to be significant in providing everyone with the time to articulate their thoughts and emotions.Here, the individual reflection supported by the reflective tools, where participants have had time to write and draw, appears to play a crucial role.
We believe that the results demonstrate that learning to live with T2D can be supported through using the reflection tools.The findings, supported by a previous study, highlight that caregivers are acquiring a new, more reflective approach to teaching and to understanding the patient's situation.This learning becomes significant in future patient encounters as it enhances the quality of care provided.
The question is how support for learning at the described existential level can be applied and developed in support of persons with diabetes or other long-term disease.Can support for the caregivers' reflective approach be sustained through digital mentoring groups involving other diabetes nurses?
Trustworthiness is about credibility, transferability, confirmability and dependability.We have tried to consider this.The interviews, reflection diaries and notes as a method for collecting data gave the participants the ability to reflect individually and together, which enabled a deeper understanding of the phenomenon.According to the method, which was informed by the phenomenological hermeneutic approach (Lindseth & Norberg, 2004), the themes were reflected on in relation to the naïve understanding to validate and adjust the interpretation.In the comprehensive understanding, the themes were summarised and reflected on in relation to theories with the aim of expanding and broadening our understanding, which we think gives a deeper understanding of the phenomenon.

Expected significance
The model, with its reflection tools, may be considered in recommendations for how group education should be conducted with the aims of achieving learning at an existential level in T2D and strengthening the patient's self-care management.Knowledge of how the reflection tools is used can contribute to the development of digital tools supporting patient learning.Furthermore, the model may be transferred to patient education for other long-term disease states.

Notes on contributors
Mia Berglund Professor in nursing, School of Health Sciences, University of Skövde Skövde, Sweden.Her research interest focuses mainly on patients experiences of learning to live with long-term illness, she has developed the didactic model; The challenge -to taking charge in life with long-term illness and the method; Reflective Strength-given dialogues both with aim to support learning to live with long term health problem and to focus on what is important in life.Her research interest also includes students, teachers and nurses learning and the transition into nursing profession for newly graduated nurses.Susanne Andersson specially trained nurse in diabetes, PhD, associate professor and working as a Research-and innovation manager at Research and Development Centre, Skaraborg, Primary Health Care, Region Västra Götaland, Sweden.She is also as a lecturer and maintains affiliations with the University of West, Trollhättan, Sweden.Her research interest focuses on both patients' and professionals' experiences of long-term illness.Patients with long-term illnesses often receive their care through primary care.Living with illness and diseases such as diabetes, asthma/COPD and high blood pressure affect you as a person and need to be supported by healthcare professionals.Developing nursing sciences is therefore an important part of her work.
Anna Kjellsdotter associate professor and working as a Research-and innovation manager at Research and Development Centre, Skaraborg hospital located in Skövde, Sweden.In addition to her role as a research manager, she is actively engaged as a lecturer and maintains affiliations with the School of Health Sciences at University of Skövde, Sweden.Her primary area of research expertise centres on various dimensions within the field of Caring Science, particularly in the context of patients experiences of living with long-term illness and how it can be supported by healthcare.She also demonstrates a significant research interest in the nursing profession, with a particular focus on the transition into nursing profession for newly graduated nurses.

Figure 3 .
Figure 3. Draw a picture.In this reflective tool, patients can draw and share.

Figure 5 .
Figure5.Instead of writing, the patient can draw or use photos in response to these questions.

Figure 6 .
Figure 6.Questions to reflect on, and examples of patient responses.