The Defining Characteristics of the Buurtzorg Nederland Model of Home Care from the Perspective of Buurtzorg Nurses
The Defining Characteristics of the Buurtzorg Nederland Model of Home Care from the Perspective of Buurtzorg Nurses
My grandmother had home care, but I did not know much about what that involved. As a senior honors nursing student at the University of New Hampshire (UNH), my favorite part of nursing is getting to know the patients. Hearing stories from the elderly, joking with patients, being a shoulder to lean on and a resource for information and collaboration all resonate with my nursing philosophy. Therefore, when my faculty mentor Dr. Gene Harkless, associate professor and Chair of the Department of Nursing, suggested I apply to go to the Netherlands to learn about Buurtzorg nurses, I jumped at the chance. I successfully applied for a Summer Undergraduate Research Fellowship (SURF), and spent nine weeks in the Netherlands during the summer of 2015. The UNH Nursing Program does not have a homecare or visiting nurse community clinical, so this experience was very rewarding.
A map of the Netherlands highlighting major cities (https://stefaniebridger.wordpress.com/2014/05/12/map-of-the-netherlands-3/).
The Netherlands, also known as Holland, is a very small country on the west coast of Europe; it is a member of the European Union and has universal health care. Buurtzorg Nederland is an award-winning home healthcare organization, whose name translates to “neighborhood care.” I interviewed many of the nurses, both male and female, accompanied them on their home visits, and attended team meetings to learn the defining characteristics of the organization from the nurses’ perspectives. During my stay in the Netherlands, I interviewed Buurtzorg Nederland's visionary Jos de Blok, and got to know many of the nurses personally.
When planning my qualitative research project, I had five research questions in mind:
- What are the demographics of Buurtzorg nurses?
- What are the defining characteristics of the Buurtzorg model as described by Buurtzorg nurses?
- What is the work of the Buurtzorg nurses as described by Buurtzorg nurses?
- What are the Buurtzorg nurses’ views of the Buurtzorg model from a community and healthcare perspective?
- What professional relationships do Buurtzorg nurses have with other informal and formal care providers within the community?
The question that drove most of my research became the second one: “What are the defining characteristics of the Buurtzorg model as described by Buurtzorg nurses?”
Buurtzorg Background and Structure
In 2006, Dutch community nurses found themselves in an increasingly bureaucratic, “product-oriented” approach to delivering care (Eisler & Potter, 2014). It was that year that Jos de Blok, a district nurse, created a new team model of community nursing care based on the traditional partnership model of district nurses. His solution to the expensive business approach was to build small teams (up to twelve nurses) into neighborhood care providers. Jos envisioned Buurtzorg as, “A more humane, efficient, and effective way for nurses to work together” (Monsen & de Blok, 2013).
The author riding a bike, a main method of transport in the Netherlands, through the city of Rotterdam.
During an interview with de Blok, I learned that Buurtzorg employs some 9,100 nurses throughout the Netherlands. The more than seven hundred teams are self-managed and require fewer than fifty personnel for administrative support (Gray, Sarnak, & Burgers, 2015). Buurtzorg’s small headquarters are in Almelo, a rural town. In this model, the nursing teams have regained their position as neighborhood care providers. In doing so, they have increased staff and patient satisfaction and substantially reduced community care costs (Eisler & Potter, 2014). The Buurtzorg nurses provide comprehensive care to their patients, taking into account physical, emotional, and psychosocial needs to develop effective solutions. Care is arranged around a patient’s daily life, and the nurses work closely with the individual and family in determining needs based on the patient’s wishes. These specific, custom-made plans prevent unnecessary and inappropriate care measures that burden patients and care providers, and cost organizations money.
De Blok believes that nurses are professionals who don't need management; if they are entrusted with the responsibility of their patients, they will do what is best. The structure of self-management and holistic care is combined with an innovative technology infrastructure that results in higher productivity, employee and patient satisfaction, and lower costs than other home healthcare organizations (Monsen & de Blok, 2013). Buurtzorg has its own web server and intranet healthcare platform called the Buurtzorg Web. This online network was developed specifically for the Buurtzorg nurses. All of their resources are readily available and conveniently accessible.
50% of Buurtzorg nurses have achieved an education equivalent to bachelor-prepared nurses in the U.S., while only 10% of the nurses in other homecare organizations have this education. This means that within the small Buurtzorg teams, all nurses work at their full scope of practice from planning care with patients and indicating care hours, to scheduling and delivering care. All the nurses value each other as equals, and they all have equal say in the team decisions.
Meeting and Interviewing Buurtzorg Nurses throughout the Netherlands
Rotterdam, a major port city in the Netherlands, became my home base during my nine-week stay. From Rotterdam, I traveled to numerous cities and towns to visit with Buurtzorg nurses in order to observe the model and conduct interviews. Before beginning my research, I attended a course for the nurse practitioner program given by my foreign mentor, Lillian Maas, at the Rotterdam University of Applied Science. Following this introduction to the Netherland’s healthcare system, I met Buurtzorg teams in an area of Rotterdam called Schiedam. While there, I worked shifts with four nurses, whom I actively interviewed by listening and writing notes. The Buurtzorg International Coordinator and former team coach, Gertje van Roessel, was my main contact and made all of this possible. I travelled to Utrecht to attend a team meeting, spent a six-hour long shift with one of the nurses, and interviewed more nurses from the team.
The author at Buurtzorg headquarters with Jos de Blok.
Even though the first language of the Netherlands is Dutch, 78% of the population speaks English, making it easy for me to conduct interviews and hear directly from the nurses. While I conducted a literature review of the organization prior to my trip, I learned a great deal from the nurses, mainly in team meetings I was privy to. When travelling among the different sites, I used the metro, tram, and train, but my primary vehicle was my bicycle. It is safe to say that there are more bikes than people in the Netherlands! I fit right in with the Buurtzorg nurses, as most ride their bikes to and from work and on visits to patients.
Gertje, my “Dutch mother,” invited me to stay with her family while I visited a team in the small rural town of Cothen. There, I worked with two nurses and interviewed four. I then traveled to Buurtzorg headquarters in Almelo with Gertje, and from there, on to another small rural town, Wijk bij Duurstede, where three Buurtzorg teams provide all the town’s healthcare needs.
At the Almelo headquarters, after an informal tour, I had the opportunity to sit down with Jos de Blok and discuss Buurtzorg. During our talk, I realized that the relationships of patient and caregiver that drew me into nursing are taught in U.S. nursing programs, but are not actively practiced in the nursing profession. He suggested that, when presenting my findings upon my return to New Hampshire, I lead with nursing: what it is, what we [Buurtzorg nurses] do, and the need for this nursing care. This was a rewarding talk, as I learned a lot about the values of Buurtzorg that I will incorporate into my personal nursing philosophy.
Four Themes as a Result of Interviewing and Observing Buurtzorg Nurses
The interviews I conducted during my nine weeks were not formal or timed, but were guided by questions I had formulated. I asked the Buurtzorg nurses questions for hours as we rode in the car or bicycled to visit and care for patients. Some examples of the questions:
“What is it about Buurtzorg that you believe makes it effective?”
“How does your work as a Buurtzorg nurse differ from nursing within other organizations?”
“What does the Buurtzorg model provide to the profession of nursing?”
Both the patients and nurses were very open and welcoming, and Buurtzorg nurses of all different backgrounds were eager to talk to me about their work. When I analyzed my data from the seventeen nurse interviews, field notes, observations, and four team meetings, I found four common themes:
1. Small teams and decisional autonomy generate creative space.
2. “Time with” is an essential therapeutic intervention.
3. Buurtzorg nurses cultivate empowerment and self-trust.
4. Nimble, empowered teams promote work-life balance.
The first theme, “Small teams and decisional autonomy generate creative space,” comes from the self-managed organization of the nursing teams. Many nurses stated that the team feels like their own business within the organization, as they are self-managed and almost entirely self-sufficient. The flat organizational structure has low overhead, which translates to less money in the hierarchy of the organization and more funds to hire better educated nurses. In an interview, a nurse commented, “You have to trust the people working for you. We should always be in relation [communication] to one another.” She went on to ask “How can a manager be responsible for the things I do?” These nurses are capable of critical thinking if the organization and team members trust them. With this trust, the nurses are empowered and trust in their own abilities.
The author by one of the vehicles the nurses use to visit their patients.
The second theme, “‘Time with’ is an essential therapeutic intervention,” is reflective of the incredible nursing care these men and women provide for their patients. Buurtzorg teams schedule and plan their own patient visits, which means the nurses can take the time required to assess patients holistically and build good relationships. Nursing has always been revered as a profession of trust and care, but when the nurses have an unreasonable schedule, they are unable to provide the psychosocial support to build relationships with patients. Buurtzorg allows the space and time for nurses to be professional caregivers. As one nurse stated, “Nursing care is not based on minutes.”
The third theme, “Buurtzorg nurses cultivate empowerment and self-trust,” is based on the nurses’ empowerment of patients by focusing on their abilities and promoting strength building. Nurses are always teaching. They build trusting, professional relationships with patients, which allow them to tread where the patient’s family may not be able to go. A few nurses mentioned the following topics they had discussed with patients and their families: regaining strength to shower oneself, moving a patient to a nursing home, performing and teaching how to do a wound dressing change, and communicating with the patient about the option to die at home. The Buurtzorg teams collaborate with many resources in different levels of the patient network to allow patients to remain at home, remain independent, and eventually to die at home. The immediate network of family, friends, and neighbors is integral in the patient’s care plan to maintain independence and receive as minimal outside professional care as possible. Close contact via direct lines to patients’ primary care providers allow for personalized and appropriate care. Many patients prefer to die in the comfort of their home. Palliative and end-of-life care are major areas for collaboration among the nurses, the patients, and families. Buurtzorg has the highest rate of end-of-life patients dying at home among homecare organizations in the Netherlands. Buurtzorg nurses’ capability to manage end-of-life care at home results from the nurses’ higher education and skill level, their resourcefulness and critical thinking, and the independence to work as professionals to deliver this very intimate care.
The fourth theme, “Nimble, empowered teams promote work-life balance,” is from the capability of the self-managed Buurtzorg teams of nurses to help each other and to rely on their colleagues to maintain their own quality of life. I saw many instances of the nurses covering patient care for each other to allow room in personal lives to handle family matters and their own health. The Buurtzorg nurses also spoke of increased self-esteem related to working in teams; they empower each other, and the organization provides space for them to critically think and act autonomously. The nurses indicate, plan, and document care on the Buurtzorg Web, which allows them to look at patient notes from previous shifts before visiting homes as well as document on iPads in real time throughout the day. The platform has many other resources, such as policies and procedures for technical tasks, pharmacology information, and the team’s budgeting and production performance. This provides the teams with direct feedback, allowing them to adjust their scheduling and meet the team goal of production as it works best for the nurses and patients. Not only did I notice how important nurse-patient and nurse-patient-family relationships are, but also how nurse-nurse relationships are highly valued in Buurtzorg.
Incorporating Buurtzorg Values into My Work in the United States
The current U.S. system of home care is similar to the Dutch system that provoked Jos de Blok to form the homecare model Buurtzorg Nederland in 2006. The organizational structure and role of the nurses in Buurtzorg provide models for future improvements of our system. Buurtzorg nurses have more autonomy in determining with the patient and family how their healthcare needs will be addressed. This creates a better working environment for both the nurses and their patients. The self-managed teams require fewer administrative personnel, which means valuable resources are not spent on a complex bureaucracy.
Looking at my research broadly, the U.S. may be able to learn valuable lessons from this model. My time with Buurtzorg renewed my love of the tacit knowledge, intuition, and experiences nursing holds. I will incorporate the Buurtzorg values into my own practice as an empowered professional nurse.
My incredible research and travel opportunity to the Netherlands was made possible by a Summer Undergraduate Research Fellowship (SURF) Abroad from the Hamel Center for Undergraduate Research, and the donors Mr. Dana Hamel, alumna Ms. Allison Ginwala, and the Patricia M. Flowers ’45 Scholarship Fund. It was also made possible by my foreign mentor, Lillian G. Maas, and foremost by my University of New Hampshire mentor, Dr. Gene Harkless. I will forever be grateful for her dedication to my education and the many doors of possibility that she has opened. A big thank you to my family for their continuous love and support. Also, thank you to Buurtzorg International Coordinator and my saving grace, Gertje van Roessel and her loving family; Jos de Blok for his kind welcome and enthusiasm; and most of all to the Buurtzorg nursing teams, who answered my endless questions with patience and spent long days speaking to me in English about the passion and work that is Buurtzorg.
Eisler, R., & Potter, T. (2014). Transforming interprofessional partnerships: A new framework for nursing and partnership-based healthcare. Google Books. Retrieved from http://books.google.com
Gray, B., Sarnak, D., & Burgers, J. (2015). Home care by self-governing nursing teams: The Netherlands’ buurtzorg model. The Commonwealth Fund, 1818(14), 1-11. Retrieved from http://www.commonwealthfund.org/publications/case-studies/2015/may/home-....
Monsen, K., & de Blok, J. (2013). Buurtzorg Nederland: A nurse-led model of care has revolutionized home care in the Netherlands. American Journal of Nursing, 113 (8), 55-59. doi: 10.1097/01.NAJ.0000432966.26257.97
Author and Mentor Bios
Colleen White is a senior nursing major from Malone, New York, and a member of the Honors in Major program at the University of New Hampshire. After graduating in May with a bachelor of science in nursing, Colleen plans to work as a Registered Nurse and then attend graduate school. Colleen’s interest in community nursing and the flat, team-based structure of the organization led to her summer study of Buurtzorg Nederland, funded by a Summer Undergraduate Research Fellowship (SURF) Abroad. She loved “the extent of time [she] had to get to know and learn from each nurse, and to interact with the patients.” Colleen encourages undergraduate students to conduct research abroad if they have the opportunity, saying that her summer “[gave her] experience and a greater appreciation for the research itself.” Colleen chose to publish in Inquiry to share her results and experience with a broader audience, as well as to make better known the grants available from the Hamel Center for Undergraduate Research.
Dr. Gene Harkless DNSC, ARNP, is an associate professor and chair of the Department of Nursing at the University of New Hampshire. A family nurse practitioner who has taught at UNH since 1985, Dr. Harkless is a frequent mentor and enjoys working with students such as Colleen as they take on international endeavors. “For past recipients of an International Research Opportunities Program (IROP) grant, it has been life-changing. They create a whole new lens through which to see the world,” she said. “Students grow to understand their own academic abilities, to ask a question and search for answers and perspectives outside of expert text materials.”
Lillian G. Maas RN, MS, is the International Coordinator and a faculty member for the Master in Advanced Nursing Practice program at the Rotterdam University of Applied Science. Originally from Houston, Texas, she received her bachelor’s and master’s degree in nursing from Texas Woman’s University. Professionalism, leadership, and internationalization of nursing curriculum are her research interests. She assisted Colleen with reviewing her findings and creating themes, and was her primary contact for questions, issues, and concerns. This is the second time Maas has mentored an undergraduate researcher.
Copyright 2016, Colleen White