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London pilot suggests Dutch community nursing model could take pressure off district nurses

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A new nurse‐led model of community care developed in the Netherlands has proved hugely popular with both patients and staff in London and could help solve some of the current problems in district nursing, according to a new study

The study, published in BMJ Open, set out to explore whether the Buurtzorg model of neighbourhood nursing, which is being tested in various parts of the UK, could help tackle the “workforce crisis” in district nursing. The Buurtzorg approach is based on small, self‐managing teams of community nurses who have access to coaches for ongoing support and spend at least 60% of their time with patients.

Looking at just one pilot site in London, the research led by Kingston University, found many patients preferred the service they received under the model.

Researchers, who compared the service with what district nurses offered, also noted real differences in nursing practice with stronger relationships between patients and nurses, who had more time to deliver holistic care.

Meanwhile nurses valued the freedom to make clinical and care decisions and felt they were providing a better service. However, they also highlighted challenges in getting to grips with a new style of working.

The study focused on a neighbourhood nursing team trialled by Guy’s and St Thomas’s Foundation Trust and used a range of techniques to look at how well it worked, including interviewing the nurses involved, observation of nursing practice and team meetings, and analysis of internal reports and electronic patient records. Researchers also spoke to patients and carers, GPs and other health professionals, and managers.

The researchers found that patients and carers reported high levels of satisfaction with the neighbourhood nurse service with one patient describing it as “first class”.

Of eight patients who had previous experience with district nursing services, all reported some negative experiences “resulting in poor clinical consequences”, including lack of continuity when it came to the nurses attending them and brief visits with a “lack of attention to any problem beyond that the nurse had attended for”. They all said they had noticed a big difference with the new service with one saying it was “like chalk and cheese”.

Positive care outcomes and feedback from patients were also reported by GPs and specialist nurses, who saw improvements in areas like the management of long‐term conditions, “which they attributed to the neighbourhood nurse team way of working”.

Meanwhile it was clear from observing nurses in action that neighbourhood nursing practice was “very different” from district nursing, said the researchers. However, they also noted the fact neighbourhood nurses had a small patient caseload compared with district nurses.

“Many clients gave unsolicited praise for their nurses”

“All nurses seemed to have a very personal relationship with their clients. They were often hugged and kissed by the client,” reported one observer. “Many clients gave unsolicited praise for their nurses, citing how much they appreciated the continuity of care and the relationship they had with the nurse.”

Patients were able to pre‐arrange times for visits, nurses were happy to get food and drinks for patients and were also able to spend time offering health promotion and preventative advice, said the same researcher. “During the visit the neighbourhood nurses placed much more focus on the total care of patients than most of the visits observed of the district nurses.”

There were distinct differences in approach. Out of more than 2,500 contacts with patients by neighbourhood nurses, 89% were telephone consultations or follow‐up chats. This compared with 0.04% of more than 303,510 contacts by district nurses. In all 2% of neighbourhood nurse contacts involved meal preparation compared with only 0.02 of those or district nurses. Meanwhile 3% of neighbourhood nurse visits saw them deliver personal care, compared with 0.03% of district nurse visits.

The neighbourhood nurses themselves “described their experience in very positive terms”, said the paper, which describes how the model led to genuine team work and aided work‐life balance.

“The neighbourhood nurse team described having to ‘unlearn’ dependent behaviour on managers and also having to ‘learn’ how to make and accept decisions as a team”

However, team members also reported it was “very challenging” when it came to learning to work as a self‐managing team.

“The neighbourhood nurse team described having to ‘unlearn’ dependent behaviour on managers and also having to ‘learn’ how to make and accept decisions as a team,” said the paper. “This included learning how to manage differing opinions in a group and commit to the decisions of the team.”

They also reported challenges when it came to the wider organisation understanding or recognising the concept of a self‐managing team. “I’m surprised that after all these months [managers] are still trying to manage us, tell us what to do,” said one nurse.

The researchers concluded that it was clear the model with its focus on patient‐centred care and nursing autonomy had potential when it came to addressing concerns about community nursing, including when it came to the quality of care, job satisfaction and linked staffing shortages.

However, the study was not able to compare the cost and cost‐effectiveness of neighbourhood nursing with district nursing and researchers said a larger longer‐term study was needed to work out whether the model could help revitalise district nursing.

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