If you have the autonomy
U.K. press on nurses in new roles
August 7, 2013 -- U.K. press reports on recent developments in health care systems have highlighted the autonomous contributions nurses are making to patient care. On May 27, the BBC News website posted a piece by Adam Brimelow describing the community nursing model employed by the rapidly growing Dutch home care firm Buurtzorg, founded and run by nurse Jos de Bloc. The article explains that the non-profit firm's "district nurses," who now number about 6,500, work in teams of 10 per neighborhood to provide comprehensive and cost-effective home care, doing everything from coordinating medications to washing and dressing patients. A weekly health advice radio show complements their work, which the nurses see as important community building. And today, the Stoke Sentinel (U.K.) reported that University Hospital, Staffordshire's largest, has launched a program in which senior nurses are allowed to discharge patients. Dave Blackhurst's piece explains that the new system allows patients to be discharged when they are ready, rather than having to wait for physicians to sign off. That system is reportedly making patients happier and reducing delays in making beds available to new patients from the accident and emergency (A&E) department. The report indicates that the nurses are well-qualified to assume this new work, in part because they are so familiar with the patients. Both articles quote nurses extensively on the merits of the projects. And taken together, the pieces suggest that despite the challenges of our cost-cutting era, nurses can still improve health care by using their skills in new (or old) ways. We thank those responsible for these reports.
Back to the future
The BBC News piece is "Dutch district nurses rediscover 'complete care' role." It is based mainly on a profile of one of the home care firm's nurses and expert quotes from Buurtzorg leader Jos de Bloc. The profiled nurse is Amsterdam's Cora Duinkerken, who does about four home visits a day, going "beyond the usual clinical tasks":
On a routine visit to an elderly woman with dementia, she began by clearing up the kitchen, checking the fridge, chucking out old food, and feeding the cat. It was only after she had made some coffee and chatted over breakfast that she got on with the "clinical" task of preparing medication for the coming week. Even then the visit was far from over. She washed the patient in the shower, then helped her dress and put on some make-up.
The report describes the atmosphere as "serene," with "no rush." It explains that the idea is that a single comprehensive visit like that by a "highly trained nurse" may cost more on a per-hour basis, but because the nurse can get more done than several visits by other workers would, patients need 30-40% fewer hours of care. Duinkerken explains why she likes it:
We choose to work maybe under our level but with that we can give the client complete care. That's better for the client, but it also makes our job a lot more diverse. You get a much closer relationship with the client because you spend a lot more time with them so they eventually will share a lot more with you.
The piece pulls back to describe the home care firm's overall practice. Each team of 10 nurses cares for a neighborhood of about 10,000 people, "working closely with GPs" but with "no managers." Making themselves available around the clock, the nurses "organise all the supporting care, drawing in families, friends, and volunteers," and "see themselves as community-builders." In Amsterdam the home care firm also runs a weekly radio show, Radio Steunkous ("support-stocking"), which features health advice and "puts people in touch with each other." District nurse Marjolijn Onvlee says the show allows listeners to have contact with others and share experiences, which ultimately "makes them feel better."
The rest of the piece discusses the larger significance of the Buurtzorg model. Jos de Blok started the company in 2007 with 100 nurses; he now serves as managing director and still practices as a community nurse part-time. The piece includes a number of quotes from de Blok, who explains that 60% of all community nurses in the Netherlands work for the firm. He adds:
And what you see is a lot of other homecare organisations are changing their models into more self-steering teams. And it's had a big impact on the national policy of elderly care. ... It's very critical that you do the right things at the right moment and support patients in their self-confidence, in a way that they feel they can do more than they thought they could do.
He notes that this means people can spend more time at home, rather than at nursing homes, and there are fewer hospital visits. The piece quotes Rieta van Staalduine of the Dutch health insurance firm Achmea, who praises Buurtzorg's care model, noting that "the government, and insurers, we all say it's necessary for people in neighbourhoods to develop more caring communities." And the report says there is "growing international interest in Buurtzorg's model of professional empowerment," although it does not give details. It does close with quotes from de Blok, who says he has gone "back to the future" by (in the piece's words) "re-instating the autonomy he enjoyed as a district nurse in the 1980s." He says: "What we want to show is that if you have the autonomy, if you develop your skills and craftsmanship, then it's the most beautiful job you can find."
Overall this is a very helpful piece, highlighting a community nursing model that could, if applied broadly enough, transform global health care and greatly improve health. The preventive and holistic approaches that make this model work are part of the long history of community health nursing, which the report at least refers to in describing de Blok's work in the 1980s. The article might have explored that history more and addressed what happened in recent decades to get nurses away from "complete care." The piece does include some specifics about what the district nurses do, though it might have described the clinical side a bit more. Most of the specific tasks listed in the account of Duinkerken's work may strike readers as, in her words, "under our level." And is there any clinical benefit when patients "share a lot more with you"? Likewise, it might have been helpful to know more specifics of how the care model has affected "the national policy of elder care" and if there has been any research on the cost-efficiency of the district nurse programs in the Netherlands. On the other hand, the article is very clear about the professional autonomy of the nurses, who coordinate with physicians but have "no managers."
Streamlining the patient journey
The Stoke Sentinel piece reports that the University Hospital of North Staffordshire has recently begun a program in which senior nurses have for the first time been allowed to discharge patients in order to "get them home sooner and free up scarce beds." The program has started on one general medical ward, where nurses have discharged 65 patients in the last two months, but it is now being expanded to other parts of the 1,200-bed hospital. The piece explains that in the days prior to discharge, a team of physicians and nurses agrees on a plan for the patient, and if the criteria in the plan are later met, the nurse has the authority to discharge the patient. The new practice means "many more patients are now leaving the hospital in the morning rather than having to wait until the afternoon for doctors to come on duty and release them," and beds become available "much earlier in the day to try to stop queues in the hospital's accident unit." The piece puts the change in the context of our time, when "nurse specialists" are increasingly prescribing drugs and doing other things that only physicians were allowed to do in the past.
The report includes reaction from several sources. Hospital nursing ward manager Jenny McLatchie notes that the new program "has given us much more autonomy within our positions" and "streamlined the patient journey and enhanced their satisfaction." Physicians also sound enthusiastic; diabetes consultant Ananth Nayak calls the project "a huge success." Chris Bourne, the hospital's senior steward for the Royal College of Nursing (RCN), says it seems to be "a really sensible approach to speed up the discharge procedure," reducing patient frustration and waits for A&E patients who will need a bed. Plus, Bourne notes, "nurses spend more time with patients than doctors anyway so they know their needs better." And even "health campaigners" sound positive. North Staffordshire Healthwatch co-ordinator Ian Syme is quoted as saying that the system is good as long as "safety is at the heart of the process," so that "patients don't have to be re-admitted and doctors aren't shuffling their workload on to nurses."
That last quote seems to reflect a bit less confidence that the nurses are qualified to do the job, but on the whole, the short piece gives readers little reason to doubt that they are. The quote from the RCN steward, of course, is especially pointed in that regard. The article might have addressed whether the number of patients being re-admitted has changed, and whether there are any plans to study that. The piece does explain in a basic way what the nurses are doing and why it's helpful to the patients being discharged and the patients waiting in A&E. The report might have given a little more detail about what training the nurses are getting before being permitted to do the discharges, as well as more detail about what is actually involved in patient discharges and why nurses are natural choices to do the work. After all, nurses are (when they have time) leaders in discharge planning, coordinating the various elements of a successful discharge and the transition to home or a different care setting, including vital patient and family education.
We thank BBC News and the Sentinel for these pieces, which suggest that nursing skill and autonomy are critical parts of the future of health care.
See the article "Dutch district nurses rediscover 'complete care' role," by Adam Brimelow, posted on the BBC News site on May 27, 2013. Also see the article "Nurses allowed to discharge patients at University Hospital of North Staffordshire," by Dave Blackhurst, posted on the Stoke Sentinel site on August 7, 2013.