For the last 30 years, successive government policy in the UK has advocated the expansion of primary care and community services. Paradoxically, over this same period, there has been a decline in one of the cornerstones of home-based care, and that is district nursing services (Drennan, 2019), to the extent that it is variously described as ‘in crisis’ and ‘endangered’ (Queen's Nursing Institute (QNI), 2018) and criticised for failures in quality and reach (Maybin et al, 2016). In many parts of the country, recruitment and retention of nurses is a major problem. A Dutch model provided by the social enterprise, Buurtzorg, offers solutions for addressing these problems (de Blok, 2015) through re-assertion of a patient-centred relationship-based nursing model combined with self-managing nursing teams.
Buurtzorg
The Dutch Buurtzorg organisation is a social enterprise that uses a patient-centred model of care combined with self-managing teams of visiting nurses. The central principles in the patient-centred model of care are ‘self-management, continuity, building trusting relationships and building networks in the neighbourhood’ (Buurtzorg International, 2019). The self-managing teams of about 12 have ‘professional freedom with responsibility’ in deciding together how they work, provide care to their patients and share responsibilities. A new team will set up its own office in the neighbourhood and introduce themselves to the GPs and other services in the neighbourhood. The teams are supported by coaches, not managers, and back-office teams, which deal with financial and administrative matters.
A key element of the Buurtzorg model is the use of mobile computing devices with an electronic patient record system, designed around the Omaha community nurse classification system (Martin, 2005). This system allows administrative data (such as for billing) to be captured by the back-office team without further recourse to the district nurses to provide more information (de Blok, 2015; Buurtzorg International, 2019).
Applying the Buurtzorg model in the NHS
As senior nurse leaders in a central London NHS trust who launched a ‘test and learn’ pilot of an adapted Buurtzorg model in November 2016, and are continuing to develop this model, the authors are only too aware that precious learning and insights from leading change in nursing are often hidden from view or become lost. In the present article, the authors reflect on their experience with what went well and what was, and continues to be, a challenge, sharing personal insights that might help others. Box 1 depicts the development of this adapted Buurtzorg model, known as Neighbourhood Nursing.
Team members evaluated the early pilot and their opinions are presented here. Care has been taken not to identify individuals or particular events, but instead, an attempt has been made to draw out the meaning, the learning and the authors’ understanding of the triggers and setbacks that are inevitable in such a complex change. There have certainly been some important issues that have come up over the past 3 years and have been learning points. These are:
Developing and sustaining self-managed teams in a complex organisation
Given the challenges in district nursing nationally and locally, the authors wanted to develop a sustainable model that would enable their patients and staff members to have the best possible experience of care and care provision, respectively. They persuaded their organisation to invest in the adapted Buurtzorg pilot. They were, in turn, challenged to come up with a solution—a model that works. The district nurses with whom they worked were telling the authors that they felt undervalued and that their care was undermined as there was not enough time to provide this care. The Buurtzorg model offered what the authors saw as a ‘back to the future’ vision of holistic, person-centred care (that is, a return to the way it used to be provided), ensuring continuity and giving patients and families the skills to be self-managing (Vermeer and Wenting, 2018). There were many issues the authors had to deal with as senior nurse leaders trying to implement a radical new model in a large and complex organisation.
The first early pilot team was created, supported by a coach, within what was called ‘a bubble’—a group that is protected to some extent from the wider organisation. Despite the enthusiasm and commitment for the model, the authors had to tackle challenges arising from the lack of system readiness for change. Examples of this were difficulties in finding a suitable office in the heart of the neighbourhood and trying to find solutions to support interdependencies between different parts of the system, for example, ordering supplies in the rest of the organisation requires a manager's signature. How can this be dealt with if there is no manager in a flat, self-managing team with no hierarchy?
The devolution of responsibility to the nursing team of organising rotas, shifts, weekend cover and annual leave has worked well, despite initial reservations from many in the organisation.
Engaging stakeholders at all levels
At the highest level in the authors’ trust, there was and is enthusiasm, support and recognition for the success of the Neighbourhood Nursing model. The Chief Nurse and the Director of Operations have provided leadership throughout this period, and the chair of the trust board, lead public governor, and chief executive are on board since their recent visit with the neighbourhood nurses, as published in a public newsletter sent to all foundation trust members. As this project moves into a new phase and the model is being rolled out beyond the two initial pilots, the challenges of scalability and sustainability have raised new dilemmas. This is evident as the authors move from what was their personal vision and leadership journey to one that will have to operate at scale, involve a wider group of senior managers and colleagues with their own ideas and leadership styles that will influence the future direction of the project.
From the start, the authors have had open sessions with other staff members, where they share their experiences and learning, including local newsletters, professional nursing meetings and focus groups.
Governance and assurance
The first question the authors considered and that was raised by others in the organisation was, ‘how do you address governance and assurance issues?’ The authors were clear from the outset that the clinical policies of the trust were those that the team would use. Just as in the Netherlands, where the nursing teams provide information to be reported to the purchasers of their services, so the neighbourhood nurses provide information through electronic patient records, so that the quality and volume of care can be fed back to the organisation and the commissioners of the services.
Developing the workforce
At the beginning, the authors recognised that the workforce that had been recruited needed support to transform its way of working from a hierarchical managed approach to one of authentic self-management. They were dealing with a young and transient workforce in London, typical of the inner city, which was very different to the mature profile of nurses in the Netherlands. Working closely with the trust human resources and organisational development advisor, we used a strength-based and values-focused approach to recruitment. Selection was centred on staff who could think outside the box, who were innovators, and not just leaders, but also followers. The strength-based approach to recruitment was found to be very successful. The coach's role, especially at the beginning, was viewed as one of helping staff find their feet and supporting them to think through how they define solutions and make decisions. In other words, it involved helping them to unlearn the NHS mind-set. Initially, there were skills deficits in some areas, which the nurses addressed themselves, and they organised and accessed their own training.
Developing a workforce to have confidence in itself is reflected in attitudes to career development. There is a discernible new attitude expressed by the neighbourhood nurses in seeking promotion, which is noticeably proactive. In response to this, a new career framework has been developed for neighbourhood nursing, linked to clinical skills and experience, and it has been tested and well received by the nurses and their coaches.
Turning points, changing direction and starting again
While the authors are very pleased and proud about what has been achieved so far and are appreciative of the organisational ownership, they also recognise some sense of loss over things changing and anxiety that the original purpose and clarity of the vision are under threat, because the new group of innovators are less familiar with the original vision (Paina and Peters, 2011). At this point, they believe it is important for them to re-establish their influence on the original vision. It is a challenge familiar to innovators working on the adoption and spread of their innovation. As it scales up, there is always a risk that the model will be diluted and that in itself will diminish the potential benefits. Although it took a long time (3 years) for the Neighbourhood Nursing model to be where it is now, the need to be resilient and courageous has never been more important. The setbacks and warnings from others that it is not going to work, that there are staff inadequacies, that there are risks to patient safety and a lack of assurance persist, and need to be continuously worked through. The foundation work on establishing a framework that sets out policies and where they can be adapted and tailored for local teams overseen by coaches has been successful, but it will need to be tested afresh and monitored regularly. An example of how this is implemented is the development of a new quality score card for district nursing and the neighbourhood nursing teams.
Overall, the biggest learning point is to be pragmatic. For example, the Buurtzorg model has been adapted to the particular context of an inner city NHS trust. The role of the coach has been established to handle some of the management issues. This arguably is seen as challenging for some of the existing cohort of line managers—they will become the coaches as the model is scaled up, and their role will be very different from what it is now. However, it should be acknowledged that great care has been taken not to destabilise the workforce, as this is seen as a major change in roles and responsibilities across the nursing teams. The authors are aware that this significant structural change can bring about a deep sense of personal loss due to many factors, including a change in role, job titles and reporting structure.
Continuing professional development and learning about the self-management model is important for all levels of the organisation. Reading and re-reading evidence on change management and innovation in the health services (Hayes, 2018) has been important to help shape the authors’ thinking and planning on this journey.
Conclusions
This article described the experiences of moving from piloting innovation, to starting, to scaling up an innovation. A new model for district nursing is being implemented and evaluated to create a more patient-focused service, where more time is available for care and which addresses issues of staff retention. The ongoing help and support received from colleagues, including those from programme management, organisational development, human resources and the trade union, have been invaluable in this journey. Any change is unsettling, so continuous communication and coaching are required to emphasise the goal of the change—in this case, creating more time to care. The authors often recall their original objective, which is to develop a sustainable model that would enable their patients and staff to have the best possible experience of care and caring, respectively. It is hoped that this reflection offers some insights and learning for other nurse leaders in a similar position of implementing new ways of working, which address the many challenges that district nursing services face.