Abstract
This study aims to identify positive experiences and challenges from the implementation of interdisciplinary teams in homecare and nursing, inspired by the Buurtzorg model, in two Danish municipalities. To address challenges in homecare nursing, Danish municipalities are adapting the Dutch Buurtzorg model of self-managed interdisciplinary teams. Understanding the goals, methods, challenges and initial experiences of these adaptations is essential for evaluating their impact on the quality of care. A qualitative descriptive approach was employed, involving researchers who supported, followed, and compared the municipalities over two years (2021–2023). The Standards for Reporting Qualitative Research (SRQR) checklist was used to ensure quality and transparency. Data collection included participatory observation, eleven focus group interviews and 10 individual interviews with managers and healthcare personnel, engaging approximately 197 individuals. Results highlight two main themes: (A) Positive experiences: team collaboration provided flexibility to adapt care to the patient's perspective, contributing to improved work satisfaction and (B) Challenges lie not in the concept but in the implementation: unclear structures and roles, and resistance to cultural change. Successful team establishment requires cultural and structural changes; without clear structures, sustainability and replicability are compromised. Unlike other studies, positive results are attributed to team collaboration rather than self-management.
Introduction
The global population is aging, and healthcare needs are becoming more complex as individuals live longer with multiple illnesses. 1 This has resulted in an increased demand for homecare and homecare nursing, as healthcare services shift from hospitals to people's homes.2,3 However, this transition also poses challenges in delivering high-quality care while effectively managing costs. 4 Administrative management methods aimed at controlling costs, primarily based on New Public Management, have led to increased bureaucracy and workplace control. 5 This has contributed to the services becoming rigid and impersonal the services becoming rigid and impersonal, posing challenges for homecare and homecare nursing providers in personnel recruitment and retention.6,7 The workload creates a constant sense of time pressure, while caregivers often face burdensome bureaucratic processes lacking meaningful purpose. 8
To address these challenges, many countries have turned their attention to the Dutch model of homecare nursing, Buurtzorg, 9 since this model has delivered promising results in patient and worker satisfaction, as well as cost reductions. 10 Buurtzorg aims to achieve person-centred and holistic care through self-managed, interdisciplinary teams that provide homecare and homecare nursing. 11 Key features of the Buurtzorg model include a flat organizational structure with minimal hierarchy. These self-managed interdisciplinary teams have autonomy and responsibility for coordinating and delivering care, which should enable them to adapt to the unique needs of each patient. 11 Some criticism has been raised against Buurtzorg, claiming that it ‘cherry-picks’ its clients avoiding especially patients with complexity of care needs. 11 However, it has been argued that there is no hard evidence to support this claim. 9
The latest review shows that the attempt to replicate Buurtzorg in other countries ‘is complex, challenging, and requires adaptations’. 9 Some attempts to implement faithful copies of the model were not economically sustainable, 12 while some examples of adapted methods which included only some principles of Buurtzorg, delivered mixed results. 13 However, it also can deliver positive experiences such as improvement in communication, continuity, patient outcomes and some cost savings. 9
Background for this study: Buurtzorg inspired teams in Denmark
In 2021, the Danish government invested 191.6 million DKK (27.5 million dollars) to support 25 Danish municipalities in experimenting with various Buurtzorg-inspired methods, 14 with a particular focus on implementing self-managed interdisciplinary teams. 15
The ongoing experiments primarily involve adaptations where municipalities select specific elements from the Buurtzorg model. The most prevalent element is the introduction of interdisciplinary teams with varying degrees of self-management. 16 However, with few exceptions, most municipalities have not adopted a model without formal leadership, where teams manage their own operations and finances. 15 The municipalities in this study are representative of the majority, as they have not implemented a model without formal leadership. Furthermore, very little attention has been given to the role of the local community and civil society as integral components of the Buurtzorg model. 16
The current Danish experimentation with self-managed interdisciplinary teams does not consist of one single method across municipalities. Instead, it comprises diverse interventions with some degree of common traits.15,16 Evaluating these interventions is challenging due to their diversity, requiring a thorough understanding of specific components in each implementation project. 9 Beyond the mere registration of possible outcomes (such as work satisfaction, reduction of sick leave among professionals or clinical outcomes among patients), it is necessary to understand how these implementations are perceived by those involved, as well as how different elements in these implementations might affect their experienced results.
Consequently, the aim of this study is to identify positive experiences and challenges from two Danish municipalities implementing interdisciplinary teams in homecare and homecare nursing, inspired by the Buurtzorg model. This can be achieved by comparing participants’ experiences across different municipalities. Therefore, this study examines and compares self-reported positive experiences and challenges arising from the implementation of two variations of Buurtzorg-inspired teams in Danish municipalities. One municipality (M1) embraced a flexible team structure, enabling healthcare professionals to create ad hoc teams according to patients’ needs. The other municipality (M2) established a traditional, fixed interdisciplinary team that met regularly for a predefined group of patients. The research question of this study is: How did healthcare professionals and managers, experience the implementation and participation in interdisciplinary teams?
Methods
This study utilized the checklist from the Standards for Reporting Qualitative Research (SRQR) 17 to ensure quality and transparency. The checklist includes 21 items, focusing on five essential sections of qualitative scientific publication. For clarity, the study does not always follow the order in which the 21 items are presented in the checklist. However, as a whole, the study meets the requirements of all the recommended items
Context
The context of this study was the follow-up and support of two development projects in different Danish municipalities, aiming to implement interdisciplinary teams inspired by Buurtzorg. Both projects involved research and competence development in homecare and homecare nursing.
These projects were conducted through a collaborative process involving the Research and Development (R&D) team from a nursing education institution and the Further Education (FE) department at a Danish University College, along with the two municipalities. Both projects had participatory research structure of an exploratory nature 16 because stakeholders (especially the ones representing practice, research, and education) maintained a close dialogue from the early stages of the project, reviewing priorities, elements of the intervention, research questions, and the meaning and causes of the problems addressed by the projects. 18 Both authors of the present study were involved early in the intervention design, using their research knowledge to support the design and implementation of the competence development process. They also participated in and observed the competence development process and the new practice of team meetings. This close participation amounted to hundreds of hours of observation, recorded in logbooks. This form of participatory observation 19 was useful for providing context; however, this material is not the main data for the present study, which draws its results exclusively from individual and focus group interviews with healthcare professionals and managers. This approach combined with an inductive and semantic 20 analysis method, was considered more appropriate to capture participants own experiences 18 in their own words rather than the researchers’ observations. Observations, however, were used to inform and support dialogue in focus group interviews.
Study design
To answer the research, question this study used a qualitative descriptive design, 21 as it aims to capture and describe professionals’ experiences. 22 Researchers conducted open semi-structured individual 23 and focus group interviews 18 with a representative number of healthcare professionals and managers who participated in the intervention. This method is well suited to allow participants to discuss themes not previously defined by the researchers 18 and for projects where the research topic is partly unknown to the researcher. 24
Description of the intervention
Both municipalities’ interventions rested on two main elements: a form of organizational restructuring to establish team collaboration and a competence development element, as presented in Table 1.
Overview of the main elements of interventions in each municipality.
In both municipalities, the introduction of these changes was gradual, determined by smaller geographically divided teams referring to different managers. These managers played an essential role, overseeing the implementation of organizational changes while ensuring that professionals participated in competence development activities. The process was supported by printed materials, such as posters and leaflets, which explained the structural changes, described the team structure and provided instructions on how to conduct team meetings. This material was important for supporting the implementation because the managers were often unclear on how the concrete team practices should be carried out, and so the printed material provided a common ground. For example, posters and leaflets would contain descriptions of participants’ roles, such as who leads the meeting or who ensures order in participation, as well as descriptions of the meeting's expected results and time frames.
Data collection
The data used for the present study comprises individual and focus group interviews. Ten individual interviews were conducted, three interviews in M1 and seven individual interviews in M2. In total, 11 focus interviews were conducted: eight focus group interviews in M1 and three focus group interviews in M2. The M1 intervention included a much larger group of professionals, and the data include 106 participants (out of approximately 180 employees), while, in M2, the professional group is smaller, and we counted 19 participants (out of approximately 120 employees). Both authors were involved in data collection, occasionally conducting focus groups together.
Five different researchers conducted the interviews, which were recorded on audio and transcribed.
Both authors, occasionally working together, conducted the focus group interviews in both municipalities at the conclusion of the implementation and competence development phase for each team unit to ensure a mature level of experience with the model. Since the M1 structure was flexible, there was no clear belonging to one team or another. For this reason, focus groups in M1 were conducted at the final competence development workshop of each geographical area in which the model was implemented. Running parallel to the team implementation, this was a natural ending where participants were expected to have sufficient experience with the model. Therefore, in M1, we see more participants in the focus group interviews, while, in M2, focus groups included a representative selection of team members. In M2, the choice of participants for the interviews was based on ensuring representation from different geographical locations, various professions involved and the manager of these teams (who were interviewed individually). Additionally, the change agent was interviewed separately. Individual participation was determined mainly by availability and calendar compatibility.
The individual and focus group interviews were conducted in an exploratory manner, 23 typically starting with a broad question such as “How have you experienced the implementation of teams?” Participants were encouraged to speak freely, with clarifying questions posed as needed to understand responses such as ‘good’, ‘bad’, ‘positive’ or ‘negative’. In both municipalities, the researchers reached situation, 18 where subsequent interviews yielded no new insights. During focus group interviews, the researchers regularly checked for consensus or discerned individual opinions, capturing nuances in experiences.
Participants and recruitment
The study included a wide range of professionals in the following called Healthcare Professionals (HCP) as a common definition. However, in reporting the results we will distinguish managers (M) from the rest of (HCP), as the distinction reflects the composition of the individual and focus group interviews. When needed for a better comprehension, we explicitly indicate the profession or position of the participant. All were employed in homecare and homecare nursing, including the following professional groups.
Registered nurses with a Bacheloŕs degree – some of the nurses had the title of ‘Specialist in Community and Primary Health Care Nursing’.
25
Social- and healthcare workers, which in other countries are called social workers, in the Danish context can be divided into homecare ‘helpers’, who have 1 year of education, and homecare ‘assistants’, who have 2½ years of education. Unless explicitly distinguished, we refer to both groups as care workers. However, in the interviews, they are commonly referred to as ‘helpers’ or ‘assistants’. Occupational therapists. Coordinators: Responsible for coordinating daily routes and tasks. Normally have a social- and healthcare education. Managers: This includes both direct managers with personal responsibility for nurses and social and healthcare workers in each team, as well as their managers. For anonymity, all managers are treated as one group. Change agents: An ad hoc position created to support competence development and conduct changes close to practice.
26
Participants were recruited among those involved in the implementation of the projects, aiming to have a solid representation of all the professional groups involved in this project, any exclusion of participation in a focus group was only based on coordination difficulties or time constraints.
Analysis methods
The results were achieved by conducting a thematic analysis of individual and focus group interviews using descriptive methods, which employ a relatively low level of interpretation. 27 The identification of themes was inductive, 20 as they were not identified from a preexisting coding frame. The identified themes are semantic rather than latent, 20 closely following the explicit meaning of the words instead of seeking unspoken underlying structures. 20 The method of analysis consisted of five main stages.20,27 The first stage was familiarising with the data, which was achieved by multiple readings of the data, but it was also supported by the authors’ involvement in the project from its early stages, that gave them great knowledge of the context of the data. Using NVivo (Lumivero) initiated the second stage of generating initial codes, generating more than 115 different codes generated loosely without an explicit predefinition of the areas of interest. In extended dialogue, both authors entered the condensation process by searching for themes. Once an overview of representative themes was identified, the authors started the stage of reviewing the themes, ensuring through discussion and confrontation with the data, that they agreed these themes properly represented the coded material. The final stage included Defining and naming the themes, which concluded with the identification of our main two themes while defining and naming two main themes and 4 and 3 subthemes, respectively (Table 2). The definition and naming of the codes were inevitably affected by the writing of this article which imposed stringency in the definitions and chosen terminology. The researchers ensured credibility and trustworthiness through various strategies. Interviews were analysed concurrently, with early findings discussed and nuanced with key participants for member checking and researcher triangulation. 28 Additional interviews were conducted for in-depth exploration in particularly relevant cases. For example, a focus group presented an especially complex case that demanded a further interview to corroborate both the events and the authors’ early understanding of them. The extensive empirical material allowed the team to distinguish between isolated comments and shared experiences across participants, disciplines and municipalities. The reporting includes extensive quotations for reader access to sources.
Overview of themes and subthemes.
Ethical considerations
This research adheres to Danish law, 29 which does not require ethical committee approval for this kind of qualitative study. However, it demands the informed consent of participants. Consequently, all participants were informed about the project and, for interviews, they their provided verbal and written consent. Participants had the option to decline or revise their participation. In the analysis, we avoided quotations that could identify individuals. GDPR rules were followed regarding data protection according to Danish government instructions.
Results
When teams were successfully established, participants reported positive experiences for both professionals and patients. However, diverse team structures in M1 hindered the continuation of the initial success, leading to a discussion of the project's flexible structure, considering whether fixed team frameworks would be preferable. Consequently, we categorize the themes into Positive Experiences and Challenges.
Positive experiences: flexibility to include the patient’s perspective contributing to improved work satisfaction and quality
Regarding the positive experiences reported by participants in the cases where teams managed to be implemented, four themes were identified. These themes are divided into experienced improvements and experienced benefits. This distinction reflects the fact that participants often describe clear positive experiences of improvement, such as better communication, flexibility or collaboration, but do not always explicitly state the benefits they experience from these improvements. For example, better communication might lead to experiences of better care for the patient and/or higher job satisfaction for the workers. However, the relation between experienced improvements and benefits is not always explicit or systematic.
Experienced improvement in flexibility, agility and common responsibility, responding to the patient’s perspective
The first point is that the new team structure allows participants greater flexibility to adapt their work to patient needs and faster implementation of these changes: “The model gives support to worker's flexibility.” (HCP M2)
This flexibility seems primarily to be possible by improving the inclusion of the patients’ perspective, and general structural acceptance and support of this flexibility. Some participants will speak of an ‘organized flexibility’: “We involve them [the patients] more as well. It's their own life. In the past, it was like the municipality decided. ‘I work according to my plan’, But today, it's like: “What would you like? What can I do for you?” (HCP M1) “We listen more to what the patient is saying. There is more listening. There is more human communication.” (HCP M1) “Previously, it would have taken longer because everything had to go through several instances and so on, but here it was just promptly dealt with.” (HCP M2) “I think I've never experienced something happening so quickly.” (HCP M2) “I am positively surprised.” (HCP M2) “[problems are] being addressed more quickly.” (HCP M2)
This speed is partly due to the structure of team meetings, which helps identify responsibilities and establish who should take on tasks that might otherwise have been no one's problem: “We could deal with it together because we don't leave the triage room until we've figured out who takes care of what and who does what.” (HCP M2) “The nurses who participated in the triage acted very quickly.” (HCP M2)
So, participation in team meetings is presented as the place to determine who should take responsibility for a task, but being part of a team seems to generate a feeling of collective responsibility for the patient: “It is a shared responsibility to support the patients.” (HCP M2)
While another participant states: “That's the feeling I have, that everyone is involved, and it's not just me because I have been out to see this person. Everyone takes responsibility.” (HCP M2) “When you are not part of a team and not permanently employed, you might not experience the same sense of responsibility for the patient's progress, and if you miss seeing the important things, it's just about completing tasks and moving on … You might not see the patients again, and you don't have that relationship.” (HCP M2)
Experienced improved interdisciplinary relations, collaboration and communication
Well-functioning teams allow more professionals to participate in the interdisciplinary dialogue: “There are more [colleagues] who come to speak, more come with their thoughts about the patient.” (HCP M1) “It was an unreachable group; you would almost get scolded if you called.” (HCP M2)
Similarly, a healthcare helper stated: “It was only the assistants who were allowed to call [the nurses]. You had to go through an assistant.” (HCP M2)
Nurses themselves report benefits from establishing a close relationship and improving communication with the care workers, as care workers tend to have more frequent contact with the patients. This provides context and allows a better understanding of the patient: “We also have three [homes] where we do not [often] come as nurses, so if I have to write ‘contact a doctor’ or ‘some kind of coordinator’, then I have no basis to know how to deal with the situation, If I don't have the observations from care workers.” (HCP M2) “The nurse intervened and utilized the observations we (care workers) had, thus preventing hospitalization. These treatments are essentially avoided because it was addressed before hospitalization was necessary.” (HCP M2) “Our knowledge is being used in relation to nursing.” (HCP M2) “The nurses have gained a lot of knowledge about the patients by listening to us talk.” (HCP M2) Interviewer: “You are a nurse. Is that how you feel?” Nurse: “Yes, that's how I feel, because we don't visit the same patient every day. We simply don't achieve that level of familiarity with the patient.” (HCP M2) “I experience that care workers have become more receptive to our requests for more information, that it legitimizes asking more questions, for example asking each time why is [the patient] falling again … I find that care workers perceive it as less critical and more investigative.” (HCP M2) “We can cover and support each other in a better way.” (HCP M2)
Experienced benefits for the healthcare professionals, higher work satisfaction
There have also been reports of improvements in works satisfaction: “… and job satisfaction, I don't go home with a stomachache, and I know I've had a good day, and I've done the right thing, and I've involved the colleagues I needed to involve.” (HCP M2) “When one must make decisions that can negatively impact the patient. […] The thing about working together as a team and feeling like a team. It´s actually a new thing. It is the teamwork that has made it happen. And it´s invaluable for all professional groups because we really need each other.” (HCP M2)
This report of increased satisfaction comes from both municipalities and is connected to various elements of the team's improvements. First, there is recognition that collaboration with colleagues, leading to a more coordinated patient pathway, is a source of ‘joy’: “It affects the joy of work that one can coordinate these patient processes in a proper manner, to assist patients in the best possible way. I think this collaboration across professions gives tremendous work satisfaction.” (HCP M2)
Similarly, a coordinator simply states: “I have become a happier coordinator.” (HCP M1)
This collaboration also improves work satisfaction, especially among care workers, as they feel acknowledged and appreciated by other professionals in their work: “It also gives a boost in making the necessary observations because one knows it is taken seriously.” (HCP M2)
Quite importantly, reports show that work satisfaction derives from the team's ability to better support the patient: “I feel good because XX [the patient] is taken care of.” (HCP M2)
The Danish expression we translate as ‘is taken care of’ corresponds to ‘det bliver taget hånd om’, which has a more literal translation as ‘hands are taken around the patient’. This reflects the spirit of the sentence better than a mere technical ‘take care’.
Furthermore, the teams also enable the discovery of more creative solutions to challenges, which is reported as more enjoyable or even fun: “The employees practised thinking differently, which made everything more enjoyable. It became more enjoyable to be involved in setting goals, and the patients became happier.” (M M1)
Another manager also points out that in his/her concrete district, quantitative indicators of work satisfaction also reflect the self-reported experiences: “[Teams] contribute positively to those parameters that everyone cares about … I have high well-being and low absenteeism and an okay patient satisfaction … I can recruit well. I can also recruit nurses.” (M M1)
Experienced benefits for the patient, satisfaction and quality of care through targeted collective efforts
Participants reported having experienced different benefits for the patients. However, it is important to stress that these are reports of the participants’ experiences, not directly the patients’ experiences. The first benefit seems to be what we can call patient satisfaction. However, participants do not use technical language and often speak of the patient as ‘happier’.
In the first group there is possible to find statements such as: Manager: “I can feel that the patients have become happy.” Interviewer: “How is that?” Manager: “They call me and say so.” M M1
Similarly, a coordinator says: “There are fewer people calling and complaining … there is a specific patient who used to call approximately every 14 days, who doesn't call anymore.” (HCP M1) “These are not angry citizens. There are also fewer colleagues who are upset about not having enough time.” (HCP M1)
Similarly, they report that patients are happy with the flexibility of the system: “Patients are very happy that we can do these things, but three years ago, it was impossible. It's not on my list … I don't have to do anything at all.” (HCP M1)
This quality of care can involve different elements such as an improvement in continuity, so some participants claim that: “I have noticed that the citizens are happier because there are fewer staff members involved.” (HCP M1)
However, above all, benefits seem to be clearer for complex patients, as it seems to be possible to better work with prevention: “But we manage to address all those who are a bit complex, and we come up with good suggestions for what we can try … for example, prevention.” (HCP M2)
Teams are reported to be more able keep a closer eye on patients’ possibly worsening conditions: “It is much more hands-on with patients who are ill or on the way to becoming ill.” (HCP M2)
But also, teams are able to better understand and adapt the care in what seems to be unclear situations. In this context, a care worker narrates how a patient who presented challenging behaviours and symptoms was able to receive better help: “There were a lot of strange symptoms – some psychological issues, some yelling, difficulty walking, many strange things – and through collaboration, we quickly got a doctor to visit at home and started some assessments both psychiatric and somatic. The patient was examined and diagnosed with vascular dementia. Some measures have been put in place to help the citizen. There are many good stories like this.” (HCP M2)
A nurse narrates a specific case where a patient, suffering from different conditions complicated by psychological and social problems, was receiving extensive care and services with little result. By personally engaging in a collective review of the case, there was a significant reduction in wasteful services and a better targeted collective effort: “We cut a lot [of unnecessary work] because we have started working purposefully with [patient's name]. Why should the patient have this treatment? I mean, who is responsible for the treatment? Is it at all necessary? We have spent a lot of hours on it. Treatments and interventions and services, and … One thing and another. So, we used to come every day several times a day, nursing for many hours, now we only come once every 14 days.” (HCP M2)
Crucially, the personnel reports improvements for the patient: “The patient stays overnight with family and friends, where before she was confined to her bed, and now she gets up in a wheelchair.” (HCP M2)
Without providing detailed information about this case, it is important to provide some context. The personnel mentioned that the patient's psychological instability led to unreliable information, often varying among different health professionals, resulting in an increase in services. A team structure allowed the establishment of a coherent and common overview of the patient, enabling the determination of a unified plan of action: “… and making it work in a patient´s home, they [the workers] could see that what they practiced and thought differently. It made everything more enjoyable. It became more enjoyable to set a goal, and the patients became happier.” (M M1)
As we can see, in this theme, participants report experiencing more satisfied or ‘happier’ patients and note improvements in the quality of care they provide, particularly for complex cases. This seems to happen mainly in two ways. First, by mobilizing the team's expertise to better understand the patients (and their ‘strange symptoms’), resulting in more effective ‘help’ for the patient. Second, by mobilizing the team to better understand the assistance being given to the complex patient. This allows for the provision of new and more coordinated care, which can occasionally save energy and resources but, above all, was experienced as beneficial for the patient's quality of life and health.
Challenges lie not in the concept but in the implementation: unclear structures and roles, and resistance to cultural change
Both municipalities faced challenges in the implementation of teams. Given the differences in the interventions and experiences, some challenges were more pronounced in one municipality than in the other, as we will clarify. However, it is possible to identify common elements in these challenges. It is important to stress that the challenges we report are specifically connected with the implementation of teams, and not generic challenges that could be common to any innovation process. As one participant concluded: “There is no resistance to the concept, but rather an implementation of it.” (M M1)
This assessment is consistent with further findings that do not reveal major criticisms of the concept of the teams but rather deficiencies in their implementation.
Unclear structures and difficulties in holding team meetings
The first and most evident challenge is the lack of a clearly defined structure for the teams and the difficulty in ensuring that these teams meet regularly. Though different challenges, they exacerbate each other. The lack of a clear structure makes it difficult to ensure that the team meets, and failing to ensure the team's meetings perpetuates the lack of structural clarity. Therefore, some workers complain that teams are not clearly established: “I do not know which teams are there, I am missing a team. But we are well on our way!” (HCP M1)
This final positive remark does not necessarily reflect the feelings of many others, especially in Municipality 1, as recorded in observations. There were complaints about the lack of clear frameworks in the implementation of teams. Here, it was difficult to know when, who and how to meet: “As an organization, we hadn't set up the structures required for the employees to attend that meeting, really.” (M M1)
In Municipality 2, the structure of team meetings was somewhat clearer. However, at least in the beginning of the process, there were complaints that people belonging to some teams did not meet up, as it was not clear who belonged to the teams. This problem could be worsened, as there were also complaints that there was no continuity in the members of the teams: “It is not possible to achieve continuity in the teams, if there is not team.” (HCP M2)
This comment was followed by a complaint that: “there are too many replacements.” (HCP M2)
And: “We are missing workers … that is what burden us.” (HCP M2)
In various instances, participants have experienced difficulties in prioritizing the meetings that the project requires. On many occasions, it is not clear whose responsibility it is to organize the meeting. During times of pressure, some participants experience that participating in team meetings is not prioritized: “I just don't think it can ever be the responsibility of the individual nurse when we don't plan our own day. And that is still a challenge.” (HCP M2)
The managers struggle to define their new role
The implementation of teams was considered demanding for the managers, especially those close to the workers, as it required a different practice: “You have to move yourself as manager if you want your colleagues to think differently, if our meeting with the patient is going to be different.” (M M1)
The manager's position was difficult in some cases as it required them to implement a project with a concept that was not completely clear to them. However, this concept also required the creation of a space where workers could have greater autonomy in reflection and decision-making. This required managers to take on a more supportive role.
It also required an increase in workload for the managers. They needed to find a new way of being a manager while remaining close to their employees, ensuring the promotion of what was necessary to ensure the change was implemented. It was also a struggle for the managers to find a balance between initiating a creative process where different solutions could be found and the desire to simply implement a finished and well-defined package of changes: “We should not reinvent the wheel, and it was too much work in a way … from my perspective, I think that it could also help to say that there is a specific tool that we can start implementing, like this meeting structure with the team, and start working in that way. Through that structure, we can identify a cultural change.” (M M2)
Difficulty in changing the organizational culture
The mere establishment of a new team structure is often reported as not sufficient in achieving the expected changes in daily work, which are commonly considered a ‘cultural change’: “a cultural change is a significant paradigm shift from having been time-controlled to trying to communicate differently with the patients, trying to use a bit of freedom.” (M M1)
And this cultural change is considered a longer and more difficult process: “It takes an insanely long time to change a culture” (M M1)
However, this cultural change is, in some ways, more crucial as a criterion for success than merely reforming the structure: “I'm not saying structure is everything because something else must happen for the patient, and that's a long process. I think we have succeeded to some extent in that, but it's a change in mentality” (M M1)
Some participants argue that changes in culture and competences might be necessary even before establishing new structures or frameworks: “I think, if you had asked me a year ago, I probably would have guessed that it was the framework that was most crucial. I mean, if you don't have a structure and an organization that supports the process, then you would be limited in unfolding it from the start. But I think, in reality, that it's the dialogues and articulation about being flexible with the patient that are the most important.” (M M1)
However, this can be a contested opinion. In a final evaluation of the implementation process, a healthcare worker expressed a view largely shared by the group: the need to establish clearer frameworks before focusing on cultural change and the development of specific competences: “The understanding isn't quite there. I mean, it simply needs to be completely outlined. What kind of framework do we have? Who does what? In terms of self-scheduling, how does it all fit together? Because it's really difficult when you don't know what it's about. And then I start talking about patients, wishes, and needs when I don't know the framework for it.” (M M1)
Changing the culture in both municipalities was, as pointed out before, related to some form of teaching or educational activity, such as courses or the implementation of change agents. Even though positive comments can be largely identified for both methods of competence development, they both encountered resistance. This resistance took the form of dismissing the need for such pedagogical support, as some stated, “we are already doing it”.
Therefore, it was possible to hear comments such as: ‘I learned nothing from the change agent’ (HCP M2), as well as similar criticisms in M1. These comments contrast with many others expressing not only satisfaction with the pedagogical support but also acknowledgments of improvements.
Discussion
The data revealed that, although the implementation of teams could be challenging, where teams were properly established, there were consistent self-reported positive experiences. Some of these positive experiences resemble those of other studies, such as the ability to be flexible and adapt quickly, 30 and addressing the patients’ real needs, 31 with teams fostering a collaborative solution-driven culture. 32 Additionally, supporting a more agile decision-making process consistently promoted work satisfaction, as seen in other studies, 9 and was experienced as beneficial for the patients. However, it should be noted that many of these positive experiences closely align with the findings of the latest scientific reviews of Buurtzorg-inspired teams.9,33 By contrast to other studies30,34 the data does not indicate an improvement in collaboration with the civil society.
Most importantly, it is noteworthy that, unlike other studies attributing positive improvements to autonomy,13,29 the participants primarily emphasize the importance of strong team collaboration. It is this collaboration that fosters agility and flexibility. This raises questions about the most relevant feature of the self-managed teams promoted by the Buurtzorg model: is it self-management or a well-functioning team structure? Indeed, in our data, as pointed out in literature reviews,9,33 there is an increase in work satisfaction. However, it is notable in our data that such positive experiences stem from a well-functioning team experience, such as involvement of relevant colleagues, team support with difficult decisions, improved coordination, feeling acknowledged by colleagues and satisfaction in interdisciplinary work. Other research points to the importance of shared decision making; 9 however, a closer look at the description shows that the focus lies in achieving consensus32,35 and the obstacles to this are established hierarchies 36 or professionals’ learned dependency on managers. 34 Second, our data also highlight challenges. However, it is important to note that the reported challenges do not question the ideal or the structure of teams but rather the difficulties in implementation. These challenges were mostly present in Municipality 1. Despite positive experiences, there were significantly more consistent complaints about the lack of a clear team structure. This absence not only impeded the establishment of stable teams, but also introduced difficulties in achieving a sustainable cultural change, making it challenging to build upon the positive experiences. Unlike other studies, our data do not identify challenges arising from different professional qualifications of the team's members. 13 There is also no indication that the implementation of teams will be better achieved in a setting with workers new to the institution, as some have suggested. 37 The reported positive outcomes rely on the sustainable implementation of the team, aligning with international findings that underscore the complexity of implementing such teams, 9 and the implementation challenges, such as lack of support structure, conflict with bureaucracy or change of managerial approach. 32
The findings reveal a tension between structural change and achieving what is referred as ‘cultural change’. This conflict stems from two elements. First, the current implementation of teams is not standardized, requiring municipalities to explore various approaches. Mere structural change does not achieve ‘cultural change’, which depends on developing new habits and skills. 9 Unlike other studies where the challenge is self-management, 9 our data highlight difficulties in collaboration, particularly in thinking beyond individual tasks. In other words, the challenge lies in true team collective action, not just coordination of tasks. Second, the expectation for flexible team structures leads to the assumption that establishing each team in itself should be a flexible process, focusing first on cultural change and leaving structural changes more open to exploration. However, especially in Municipality 1, this has proven too challenging to scale.
Reported negative experiences mainly highlighted shortcomings in the implementation process, such as irregular meetings and unclear roles. No negative experiences were reported after implementing teams that achieved the expected routines and roles. Even in Municipality 1, which faced significant setbacks, positive experiences were documented in teams that managed some meeting routines and established new roles. This leads us to conclude that, while not all team structures are sustainable in the long-term, 12 adopting the new structural and cultural changes required for these teams tends to generate positive experiences. At the very least, we do not find cases that achieve the expected structural and cultural changes and then report negative experiences.
Both projects emphasise the importance of a proper implementation process, where the participants, individuals and the group have time to achieve what implementation theory calls ‘normalization’ 38 of the implemented changes. In both projects, ‘sense-making’ 38 was an issue that, in the beginning, was difficult to ensure, but, as the process moved along, the context became clearer, which eased ‘cognitive participation’. 38 Both processes contained several elements of collective action along with ongoing dialogue and reflection on the intervention. 39 This happened in an iterative process, where the participants moved back and forth as the elements of the changes were embedded. This iterative process aided implementation by clarifying the proposed care model. While participants did not criticise the main concept, they reported confusion about its practical application. This raises concerns that unclear care models may hinder implementation. The lack of clarity in the model prevents progress in critical stages of the implementation process, such as ‘sense-making’ and ‘collective action’. 40 It has been argued that the Buurtzorg model, along with the implementation of teams inspired by it, represents a form of social innovation considered ‘emergent and not predetermined’. 11 However, the data – particularly from Municipality 1 – suggest that the absence of a clearly defined structure impeded the scaling of the initial results.
Positive improvements in the implementation of interdisciplinary teams align with findings in international literature that highlight both the general benefits of team implementation,33,41 and occasional benefits seen in teams inspired by Buurtzorg. 9 However, it is very important to stress that the reported positive experiences, in our perspective, signify more than mere improvements that enable doing the same tasks more efficiently. Instead, they indicate a leap or a paradigm shift, where participants seem to report experiences of a qualitative change, based on change in the ‘understanding of care’. 42 This distinction lies in the development of a collective sense of responsibility for the patient's overall situation, with a focus on creative solutions addressing this comprehensive situation, rather than merely coordinating individual services. These changes facilitate the exploration of new ways to provide more coherent service and care, benefiting patients and seemingly saving resources, especially in more complex cases.
It is worth noting that the Danish government is currently investing 376 million DKK (approximately 55.5 million US dollars) in the expansion of these ‘Stable Teams’. 43 However, if the focus remains primarily on replicating team structures, the benefits may prove limited. Research in methods for achieving cultural change in the healthcare sector warns that there is no ‘one size fits all solution to achieve cultural change’. 44 Therefore, exploring ways to provide more coherent service and care may require close-to-practice and participatory research 45 when aiming to better achieve the cultural changes needed to support these objectives.
Methodical considerations
It is essential to underscore the qualitative descriptive nature of this study. These findings should not be interpreted as quantitative measures of ‘effect’. Even when participants reported improvements for patients, occasionally with quantifiable data, it's crucial to highlight that these are participant experiences and not quantifiable measurements.
Furthermore, a considerable challenge for this (and similar studies) is the fact that Buurtzorg-inspired teams greatly differ from each other, both for Denmark and for international experiences. In the accessible literature, it is not possible for us to find cases that do not engage in some form of adaptation of the original Buurtzorg inspiration. There are even greater differences in the implementing, evaluating and escalating processes of the different projects, which forces us to be very careful when comparing the reported international experiences.
Given the authors’ close involvement in the projects, the present study adopted an inductive semantic analytical approach, aiming to faithfully represent the participants’ own voices. This required excluding material from the authors’ observations and experiences.
Conclusion
The present study aims to identify the reported positive experiences and challenges following the implementation of interdisciplinary teams inspired by Buurtzorg. These findings enable us to draw conclusions about key considerations for future attempts to implement Buurtzorg-inspired teams. First, it is notable that the reported challenges and negative experiences do not offer substantial critical arguments against continuing to experiment with these types of teams. However, it is within the positive experiences that significant questions arise regarding how and why to replicate these teams in different contexts.
As pointed out, our findings reveal that when teams adopt the structural and cultural changes, overcoming the early implementation difficulties, participants consistently report experiences of improvements and experiences of benefits such as work satisfaction and the perceived quality of care. Unlike other international experiences that put self-management or autonomy at the core of their achievements, our cases seem to indicate the possibility of achieving similarly positive experiences stressing the team element rather than the self-management or autonomy.
Consequently, our results challenge the necessity of strict fidelity to the Buurtzorg model, as the goal is not to replicate Buurtzorg but to achieve similar benefits.
Following on from this, there is also a clear need to conduct further research that can provide solid evidence on positive outcomes related to team implementation, but above all to determine the specific element of the teams that might explain such outcomes.
Finally, the findings, which distinguish between structural changes and a ‘cultural change’, suggest that merely replicating an organizational model is unlikely to achieve the necessary cultural transformation. Therefore, there is a pressing need for close-to-practice and participatory research to better understand and support the required cultural change.
Footnotes
Acknowledgments
We especially thank Mathias Mejer, PhD, from University College Copenhagen (Denmark), for his assistance in the project design, early data gathering and discussions on the preliminary results. We also express our gratitude to Associate Lecturer Therese Nørholm Christiansen, from University College Absalon (Denmark), for her contributions to the collection of empirical evidence and discussions on the early results. Special thanks must be given to leaders and project leaders of the municipalities that we were invited to participate, although their names have to be kept anonymous for ethical reasons.
Author contributions
BB and GS were both responsible for the study conception and design. BB and GS performed the data collection together. BB performed the data analysis. BB and GS were responsible for the drafting of the manuscript. Both authors made critical revisions to the article for important intellectual content.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical considerations
This project adheres to the requirements of Danish law, which do not require specific ethical approval from an ethics committee for this type of qualitative research. However, it does require the informed consent of the participants, which was duly collected.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported financially by The Danish Health Authority's grant for ‘Faste teams I Ældreplejen’ and the Municipality of Rudersdal.
