Buurtzorg is amongst the more headline-grabbing organisations when it comes to alternative ways of working. Its name meaning ‘neighbourhood care’, the Dutch community care organisation is particularly known for its 900 or so self-managing teams of nurses and care professionals, totalling 10,000 staff (plus 4,000 involved in other services), and just one manager: founder and CEO Jos de Blok. Its fame has spread far and wide not just because of its unusual organisational model, but also due to its remarkable results: top scores in patient satisfaction, repeatedly voted Employer of the Year, AND delivering all this at lower costs than other care providers. No wonder it has featured in many case studies, conferences and books, the most famous probably being Frederic Laloux’ book “Reinventing Organisations”.
But what is it like to be working for Buurtzorg as part of a self-managing team? As it happens, my sister Marjan is a community nurse who does just that, so I asked her a few questions.
Q: How long have you been working for Buurtzorg?
I re-started my career as a nurse about 7 years ago when I was getting a bit bored in my administrative job. I had trained as a nurse straight out of secondary school, but for various reasons had ended up doing different jobs for most of the time. After I started volunteering with a local hospice I realised how much I had missed caring for people, so I did a refresher course on community nursing and then applied with Buurtzorg. At that time I didn’t realise quite how unusual its way of working is, but I have enjoyed it.
Q: As a nurse, what do you like so much in the Buurtzorg way of working?
Buurtzorg teams are small (our team consists of 10 people) and deliver the full range of care in a small geographical area, whether it’s complex or straight-forward, for a short period or long term. Working in such a small team for a limited number of clients means that we know all our clients well, and they know us. There is a high level of trust, which means we can provide better care. This doesn’t just cover the physical care element, it also includes the mental aspect. We look after the whole person, and by building a good relationship I have noticed that I can contribute so much more to the client and their quality of life.
We also have the autonomy and freedom to use our judgment to adjust our involvement as necessary. That sometimes means going from less intensive care to more, or from focusing on the reason why the client was referred in the first place to exploring other areas that would really make a difference to him or her.
The breadth of our work I also enjoy: sometimes dealing with clients who need rehabilitation after a hospital stay, sometimes it’s a chronic case, sometimes a client who is terminal. It keeps me sharp.
Q: Buurtzorg teams don’t have a hierarchy. How does that work?
Teams do have different levels of care professionals on the team, so you could have a few bachelor nurses together with a number of qualified nurses and other care professionals. This determines what you are allowed to do clinically (and sometimes we do carry out highly complex clinical tasks), it doesn’t drive how we operate as a team. All decisions are made together. Some of the more experienced members may take a bit more initiative in our team-based performance reviews or our strategy with other elements of the local care system, but that is not a given.
As one of the more experienced team members I enjoy supporting colleagues and passing on my knowledge. Like a few of my team colleagues, I have specialised in end-of-life care, and therefore help team members and also other Buurtzorg teams if and when they need support with palliative cases, and am often 'first responsible' for such clients. Several colleagues on the team bring their own specialisms such as dementia or wound care, etc. We all work as a generalists, but we bring in our areas of expertise where necessary to ensure that our clients receive the best possible care.
The fact that we don’t have a manager makes it sometimes harder to come to a decision, but we have a really cohesive team and can usually work it out. And we can make use of the regional coach in case we struggle with something.
Q: Have you ever experienced that this team-based approach became a problem?
I started off in a different team, and unfortunately the atmosphere there was very different, with a few dominant characters. The fact that I just re-started my career as a nurse didn’t make me feel hugely confident anyway, so I felt uncomfortable in the team. I tried to address it, with the help of the coach, but in the end decided that I was better off in another team. I am very glad I took that step, because I feel I have really thrived since then.
Another challenge I have experienced is sometimes the work-life balance. In a small team, for instance when someone goes off sick for a while, it is difficult to not sacrifice too much of your own time to keep things working well. It starts small but before you know it…
Q: Can you give me an example of how Buurtzorg’s approach really made a difference to clients?
I worked with a client with post traumatic dystrophy. She had been in care for a long time, was wheelchair-bound and had mental health issues. Together with the GP and rehabilitation specialist, we agreed with her to explore whether we could improve this situation, so started looking at reducing her pain medication with the help of a specialist. Our team came to her house three times per week to help with showering etc. and took a conscious decision to keep the pace low to see how the client responded.
We then brought in a physiotherapist who started working on rehabilitation, and gradually reduced our care component: she showered herself while we were present, then we were present but in the next room, then we were not present but her son was there, etc. Now this lady can walk again, albeit with the help of a walker. She doesn’t really need the Buurtzorg team, we pop in every week just for a chat and check-in. Pretty soon she probably won’t need us at all. That is what really makes me happy.
Another case involved a gentleman with cancer who had ended up in a terminal stage. His wife preferred to care for him herself and called us just to order a bed. I popped round to discuss what else might help. After a good conversation I made various arrangements that were also needed and asked the couple what support they preferred going forward. ‘It would be great if you could call us every Friday to check-in’, was the reply, so that is how we started. After a few weeks his situation deteriorated. Still the wife and daughter were managing to provide most of the care, and I supported where necessary. For instance, I dealt with anything involving the morphine pump. In the final stage, I was there three times a day, and I also checked in with them after the gentleman had died.
I love it that we are able to seamlessly adjust the approach and intensity of the care we provide and the role we play. And that we can do this on the basis of a trusting relationship with the client and their loved-ones.
Q: How have you and your team been impacted by the corona crisis?
Obviously this has been a stressful time. When the crisis approached, we quickly, as a team, decided to change how we operated to reduce the number of contacts with our clients and the number of team members our clients would see. They are obviously often very vulnerable, and we didn’t want to end up being the cause of any infection spreading. That also meant that we assigned three colleagues to be the ‘corona nurses’, who would be the ones looking after known or suspected corona cases.
The lack of PPE was an issue also in the Netherlands, so we started making our own. In the meantime, the Buurtzorg organisation had established a central crisis team who supported us in making sense of all the changing protocols, and by sharing good ideas that emerged from teams all over the country. We were lucky that one team member, who is a studying to become nurse practitioner, was part of the crisis team so we had great access to the latest guidance.
Jos has also been very vocal in the Dutch national political landscape to influence how community care providers are being supported. Care in the community appeared to be a bit of an afterthought even though we deal with vulnerable people on a daily basis. I feel very well supported by him and my colleagues.
Q: All things considered, would you recommend working in self-managing teams?
One hundred percent! It is not always easy making decisions in a team, or having to think through how to deal with the next challenge. Sometimes it would be easier to hand that off to a manager who makes issues magically disappear. But the fact that we have the trust and the autonomy to do what is right gives me so much satisfaction! I can see the results almost on a daily basis. The fact that I am able to continue to develop myself, take on different roles in my relationships with clients and colleagues and ultimately see that my contribution makes a real difference is what makes it all worthwhile. It is a model that I think all clients – and nurses - deserve.