There has been a lot of interest in the model of district nursing provided by the Buurtzorg social enterprise organisation in the Netherlands. While there have been external evaluations of pilot projects of adapted Buurtzorg models in the UK (Drennan et al, 2018; Lahni et al, 2019; Leask, 2020), we would like to share our experiences as nursing staff who have worked in this model. The Buurtzorg organisation principles for district nursing teams are outlined in Box 1.
Box 1.Principles of the Dutch Buurtzorg organisationThe Buurtzorg organisation uses a two-pronged approach to improve patient and staff experience. The first principle is a patient-centred model of care, described as the onion model with the patient at the heart, which delivers health and social care services by the same community nursing team. Core elements of this model include ensuring continuity with a named nurse (or two at most), giving patients and families the skills to be self-managing, providing health and social care, and drawing on community resources to support patient self-management. The second principle is self-managing teams of nurses and assistants of equal status in the flat, non-hierarchical team, supported by coaches, who are not managers. A central tenet is ‘humanity over bureaucracy’, that is, giving authority and responsibility to the frontline nurses supported by small functional back-office without creating tiers of management and associated expensive overheads (Kreitzer et al, 2015).
From November 2016 to June 2017, we first worked in a single ‘test and learn’ pilot team of an adapted Buurtzorg model, known as Neighbourhood Nursing using the neighbourhood care principles. This pilot was extended in one of two teams until June 2019. In this article we reflect on our experiences over this period by responding to questions, which were typically asked when we held open sessions for community nurses and managers to learn more about our experiences.
How did we provide care and self-manage ourselves?
The early test and learn pilot team was set up as a result of leaders of the community nursing service looking for a new model that would address both the patient and carer experience and also help attract and retain community nurses in an inner-city area. The success of the early test and learn team led to the expansion to two pilot teams in two neighbourhoods. The early team started with three nurses, supported by a coach (a senior community nurse) and an administrator (who dealt with back-office issues); a base office in a health centre with a patient catchment area that the team could walk to the edges within 20 minutes; and which was limited to patients of two large general practices. The two pilot teams had eight members each and worked with patients of more general practices. We used the trust's clinical policies and electronic patient record system so that data could be reported for trust governance requirements.
How did we learn to work in the Buurtzorg way?
The first nurses and coach visited a Dutch Buurtzorg team and coach to see the model in action. In the UK, there was ongoing support from a Dutch Buurtzorg coach (for the test and learn period) and from a trust organisational development advisor with knowledge of self-managing teams. Our coach was invaluable in helping us reflect and iteratively learn to build our skills in realising our patients’ objectives and also to work as a non-hierarchical team with shared responsibility for our care and ourselves. We had to ‘unlearn’ many aspects of our previous NHS work lives such as: expecting a more senior person to decide or to solve a problem, or only doing the task we had been asked to do. We regularly reminded ourselves that it was our collective responsibility to find the best solutions for our patients and our team as it was easy to slip back into learnt behaviours.
How did we work as a self-managing team?
We followed the self-managing team principles set out in the Buurtzorg handbook (Vermeer and Wenting, 2018). Every team member has equal status and takes turns in holding specific roles such as planner, reporter, developer. Decisions on how the team worked were made together in regular solution-focused meetings, ie proposals were made to then be voted on, or others had to make counter proposals. We agreed on rules as to the way we worked. As a team we agreed to our rotas, shifts, weekend cover and annual leave.
How did we provide an ‘onion model ‘of care?
We all started our first meetings with patients and their carers by listening and finding out what they wanted to achieve or improve. We then planned together how to achieve that. To ensure that someone from the team was reachable at all times, we took turns in being the duty nurse who was to be contactable by mobile phone to take all referrals. The person taking the referral became that patient's named nurse to ensure continuity in relationship, planning, supporting, delivering and mobilising care. The named nurse provided the patient with their mobile phone number to make contact if issues arose or plans had to change. We used the phone a lot to follow up with patients, help give them encouragement and confidence, as well as keep them informed about actions and care planning. In the team discussions of patients’ care, we drew on each other's knowledge and expertise to develop approaches and plans for complex patients. We met with GPs and other professionals involved in a patient's care to gather feedback on our involvement and obtain help/advice on problem solving. We identified if we weren't accomplished in certain clinical skills and organised training.
How did we provide health and social care?
While the aspiration was to work towards greater health and social care integration, our pilot teams were not funded to provide social care in the way the Dutch Buurtzorg organisation was. We did, however, provide very short-term neighbourhood nursing without boundaries, such as meal preparation while a social care package was being set up if it enabled earlier discharge from hospital or helped someone stay at home rather than be admitted.
Why did we apply to join the team and how did we recruit others?
We (YK, CR, NM) applied to be in the Neighbourhood Nurse team for a variety of reasons. The concept of working in an independent team and releasing the time to care captured the interest of YK. In addition, working as a Neighbourhood Nurse offering holistic care to patients in their own homes, promoting patients’ ‘independence, preventative care and reducing hospitalisation’. For CR, it was, and is, an opportunity to develop as a person, where skills and knowledge will not only be limited to clinical duties, but also to management. It has encouraged them to bring innovative ideas into the team for the benefit of their patients and the team. For NM, delivering holistic care and building rapport with patients was something they missed in nursing and they were interested in a self-managing team. This concept is the one that made NM join the Neighbourhood Nursing team. With the Neighbourhood Nursing model the patients had complete continuity of care, which NM's patients did not have in the past.
As a team, all authors undertook the recruitment of new team members based on a values-led process.
What positives did we experience and what gave us satisfaction in our work?
We found great satisfaction in the type of patient care we could offer and in being a team with members of equal status.
By knowing that we had worked with patients, their families and carers, taking in the wider picture, to provide holistic care on the objectives that mattered to them gave us fulfillment. Seeing someone meet their first objective was a wonderful experience. However small that first objective was to us, it was often an enormous step for them. We were often able to work with people who had quite complex problems, including mental health issues, and make a difference, for example, by helping them control their diabetes.
We received so much positive feedback from patients, their family members, GPs, allied health professionals and specialist teams. They told us we were doing a good job and were often able to tell us that while a previous experience of the district nursing service was good or OK, this was better. We knew what we were doing was different as we had previously worked in district nursing services where the focus was so often a single clinical task to the detriment of seeing the bigger picture for that person. The named nurse concept made it so that you could follow your patient's journey, and ensure that they were signposted to the right teams at the right time.
What was positive about our experience of being a self-managing team?
Working as a team and sharing the burden and responsibilities between us made many difficult situations more manageable. Many of our patients and their families were in difficult circumstances and had multiple problems. We were working in an area of significant deprivation and challenged communities. We found that ‘many heads made better working’. Collective discussion of nursing practice was a real strength; we drew on everyone's experience, knowledge, training and cultural backgrounds irrespective of their pay grade. We were able to share the work fairly and jointly. This contrasted with our experience in traditionally organised district nursing teams where each staff member had their list of patients for the shift and the responsibility was theirs alone. In those teams there was no sense of collective problem solving or helping each other to complete the necessary work in that shift.
This new way of working developed each of us clinically and professionally. As a self-managing team we saw that we had the responsibility to ensure every team member had a work-life balance and continued professional development opportunities. We know this is not the experience we have had in other district nursing services. Being a self-managing team gave us opportunities that are usually reserved for those on the highest paygrades in the NHS, such as representing the team at multidisciplinary clinical meetings or trust project planning meetings. This way of working creates a conducive working environment, a happy team, effective communication, transparency within the team members, and adherence to protocols.
What was challenging in this new way of working?
Alongside all these positives there were also challenges: some linked to being in a large trust, some to the limitations of the and some linked to the recognition that being in a self-managing team was not for everyone.
It was hard to be a self-managing team in a large trust where everything needed a manager's signoff (for annual leave, payment for out-of-hours working and ordering equipment). Some of this was resolved when we had a team member who was a non-clinical back-office support and was able to navigate the trust systems, but other aspects remained frustrating. As with the traditional district nursing teams, we were never given a budget for nursing equipment so these requests had to go for managerial authorisation — this felt like a contradiction in that we were self-managing, but could not respond in a timely way to patients’ needs.
At the same time, many managers and others did not truly understand the concept of a self-managing team. We often found ourselves having to politely re-establish that we, as a team, had decided how to respond to a manager's request and could not be instructed otherwise.
While our trust was working on improving mobile working, those of us who had seen the Dutch Buurtzorg system, found our IT cumbersome. The Buurtzorg nurses used iPads which had electronic software for patient records that were designed from the OMAHA system (Martin et al, 2011) for capturing community nursing assessments of patient needs, plans and reviews. From their electronic clinical records, the Buurtzorg back office could capture all the data required for governance and billing. It seemed to us that their system aided nursing whereas ours seemed time-consuming with limited use to our nursing care. We spent time as a team trying to make our ways of working as efficient and productive as possible.
We, as a team, made decisions in weekly meetings with the coach in attendance. We had to learn how to make and accept decisions as a team. This included learning how to manage differing opinions in a group and commit to the decisions of the team. This way of working is not for everyone and we had team members who left as they preferred to work in traditional ways. We often had to revisit our ethos and principles to ensure we were enacting them.
Our advice for others setting up such adapted Buurtzorg teams
The parent organisation has to have firm objectives for such teams, and to be committed to the principles of an ‘onion model of care’ and self-managing teams and to be clear about the boundaries of each of those to avoid confusion. There has to be real organisational ‘buy-in’ to the model to avoid points of frustration for the teams. The framework and infrastructure, including IT, has to be in place from the start.
For the nursing practice, it is important to:
- Hold the ‘onion model’ at the centre of the nursing practice
- Have a clear model of patient-led objectives but also one that is focused on self-care with a time limited end point (rather than a long-term relationship model)
- Invest time getting to know the neighbourhood and its resources and making relationships with others. GPs, pharmacists, social services, other services
- Ensure that there is agreement and clarity on the referral criteria to the teams that is made explicit to potential referrers to avoid confusion
- Use a values-led approach to recruitment. Team members have to have a passion for all of these three elements:
- Patient-focused care and building relationships in care
- Self-management by the team
- Care in the community and people's homes.
- Make sure potential new members think through whether a self-managing team, with all members having an equal voice, is really for them
- Keep questioning why you are doing something in a particular way and be prepared to be questioned by your colleagues
- Recognise the strengths and weaknesses of each other, keep the values and passion in mind when there are differences of opinion and conflict
- Recognise that this is a process of individual and collective learning
- Encourage new team members in learning the principles of self-managing teams at the same time as recognising their contribution of new ideas and experience
- Pay attention to the well-being of the team as an entity, ie ‘care for the team’
- The coach role is important and having someone with the right approach and belief in the model is important. It is a tough role and they are likely to be a buffer between the team and the organisation.
Conclusions
This article has described our experiences in working in an adapted model of Buurtzorg district nursing. The model has much to offer with its attention to the patient at the centre and concern for giving control to the nursing staff in finding the best ways of working for them and their patients. As we continue to live with a pandemic, there are important lessons from our experiences for others as they grapple with the growing challenges of nursing people in their own homes while attracting, retaining and maintaining the well-being of the staff to provide it.
Key points
- Many district nursing services are interested in addressing difficulties of providing patient focused care that supports them to stay in their own and attracting and retaining staff and are considering adapted Dutch Buurtzorg models of district nursing
- As NHS district nursing staff who have been in pilot projects of an adapted Buurtzorg model we offer reflections on our experience
- We describe our nursing practice in both holding to an ‘onion model’ of providing patient and carer centred care and the practical details of being a non-hierarchical, self- managing team
- We offer advice to others from our experience of the positives and the challenges of working in this different way from the traditional organisation of UK district nursing.
CPD reflective questions
- How does an adapted Buurtzorg model differ from more traditionally organised district nursing in the UK?
- What are some of the positives experienced by nurses working in this new way?
- What are some of the challenges of experienced by nurses working in this new way?
- What are likely to be the facilitators and barriers to implementing this new model in district nursing services?