The implementation and outcomes of self‐managing teams in elderly care: A scoping review

Abstract

Aim

We aim to map the existing evidence and gaps in research on the implementation and outcomes of self‐managing elderly care teams.

Background

Due to increasing demand for elderly nursing care and an ageing workforce, recruiting and retaining community nurses have become challenging. Implementing self‐managing teams may be a solution to address this problem.

Evaluation

This scoping review included 27 studies, varying from narrative reviews to a quantitative cross‐sectional study. The studies' primary focus on self‐managing teams was essential for eligibility.

Key issues

Nurses' job satisfaction was high in self‐managing teams due to improved relationships with patients and increased autonomy. Continuity of care and patient acceptability were high. Transformation of managers to coaches in a team with a flat hierarchy is needed to empower nurses with responsibility for their own work. Trust and teamwork should be assisted by suitable ICT support systems.

Conclusions

International interest in self‐managing teams is large, but quantitative research is limited and guidelines for implementation are needed. Recommendations for potential successful implementation were made.

Implications for Nursing Management

Nurse autonomy and job satisfaction can increase by implementing self‐managing teams. This requires a change in management styles, from managing to coaching nurses.

1. INTRODUCTION

In light of demographic change, people become more dependent on health care services as a result of ageing‐associated chronic conditions (Kalache & Keller, 2000). As health care system dependency increases, more people require care at home (Robinson & Reinhard, 2009). Hence, homecare community nurses have a crucial role in managing the care of older people with chronic conditions (Lalani et al., 2019).

The use of homecare services may lead to a reduced use of in‐house care services in hospitals and nursing homes. Serious conditions and diseases could potentially be prevented at an early stage as community nurses proactively support patients in addressing health and well‐being problems (Drennan, Calestani, et al., 2018). However, due to the increasing demand for nursing care and an ageing workforce, it has become challenging to recruit and retain community care nurses (Drennan, Calestani, et al., 2018). Increased work pressure and work‐related stress have resulted in a high level of staff turnover, which makes working in this sector less appealing and creates a workforce shortage (Lalani et al., 2019). This results in less time to be spend per patient and potential fragmentation of care. Previous studies have aimed to improve working conditions and care outcomes through the introduction of self‐managing elderly care teams (SMTs). These small nursing teams provide holistic patient‐centred neighbourhood care, without bureaucratic organization structures and with more nurse autonomy and individual leadership. Increasing work autonomy is associated with increased employee performance and job satisfaction (Yeatts & Seward, 2000).

Although the implementation of these teams has been successful in elderly homecare in the Netherlands (de Veer et al., 2008), it seems difficult to reproduce these outcomes at a similar level and scope elsewhere. Therefore, this scoping review maps the evidence on the practical implementation aspects and outcomes of SMTs at various implementation sites to put light on variation to implementation under the label of SMT that potentially can be linked to differences in outcomes. It focusses on the implementation of the following SMT features; teamwork and management and ICT and back‐office support. Furthermore, literature is scoped on outcomes of care provided by SMTs, being patient and employee satisfaction and challenges for implementation.

First, more background information on the development of SMTs is given. Second, the aims, research design and search methods as well as the methods for result synthesis are described. Subsequently, the study characteristics of the included articles are described, followed by the synthesis of the results. Lastly, the results are analysed in the discussion and the strengths and limitations of this scoping review are reflected.

2. BACKGROUND

Since the 1970s and 1980s, a holistic self‐managed team approach instead of the traditional linear product development, was considered to better serve the rapidly changing economy. Working in SMTs aimed to address high employee turnover and increase performance and job satisfaction (Yeatts & Seward, 2000). The product development process was to be fuelled by a collaborative, multidisciplinary team. Personnel was empowered to contribute their personal skills and the team was expected to take responsibility and monitor its own performance (Narayan et al., 1996). Companies invested in employees instead of attempting to cut the labour costs. The main focus was on enhancing commitment, skills and knowledge and henceforth improve productivity (Bishop, 2014; Wageman, 1997). The implementation of SMTs quickly became the driver of successful businesses (Narayan et al., 1996) and the potential of SMTs in the health care sector was recognized soon. Hence, the appearance of this new management style within elderly care is part of a longer continuum.

2.1. Self‐managing teams in Dutch homecare

Since the 1990s, reforms have been made in the Dutch homecare sector and homecare organizations were merged to create economies of scale (Nandram & Koster, 2014; Schouteten, 2004). This resulted in a more ‘production’ oriented vision and care provision became more managerially focussed. As a result, nurses felt a loss of autonomy and a reduction of quality of care. Job satisfaction decreased due to time pressure and working overtime, which led to higher turnover (Drennan, Calestani, et al., 2018; Jantunen et al., 2020). Homecare nurses had more patients to take care of, but less time and autonomy resulting in stress, burn‐out and eventually resignation (Ruotsalainen et al., 2020).

As a result of these developments, Buurtzorg Nederland was launched in 2007, being a patient‐centred model of care with SMTs of community nurses. Buurtzorg Nederland emphasizes the autonomy of nurses, leaving decision‐making on the delivery of care with them. The team has a flat hierarchy and ‘coaches’ instead of traditional managers (Monsen & deBlok, 2013). Nurses are expected to support each other and rely on teamwork for completion of tasks. Administrative tasks are minimized by having an online system in which nurses can access scheduling and patient records. Buurtzorg aims to improve patient outcomes, reduce the costs of homecare services and increase both patient and nurse satisfaction (Monsen & de Blok, 2018). Furthermore, care is integrated meaning that the clients, their community networks and other care providers such as general practitioners (GPs) are involved in the chain of care (Nandram & Koster, 2014). Nurses aim to engage the patient and families in the care process, teaching them the essential practicalities of care provision for situations when the nurse might be absent. This may result in a reduced appeal on emergency care services. Thus, the implementation of SMTs in elderly homecare and nursing home care potentially addresses the issues of high demands on care services and nurse turnover.

The Buurtzorg model has gained appreciation widely, but there is very little evidence of the success of the model in other countries. As the service systems vary there may be different barriers in implementing SMTs elsewhere. It is clear that using SMTs would change the service system and the management of services thoroughly, by diminishing the number of managers, by changing the role of managers and the management culture.

3. METHODS

3.1. Aims and design

This scoping review aimed to systematically map the existing published and grey literature on SMTs and identify the available evidence in this field (Booth et al., 2016). It was aimed to gain insight into the existing research on the implementation and outcomes of SMTs and potential challenges that may arise. The available evidence was mapped, in order to generate information relevant to management and to inform policymakers. Specifically, we were interested in the implementation process taken under the label of SMTs by decision‐makers and nursing managers and how they potentially explained variety in reported outcomes. Hence, this research was guided by the question: What is the evidence on the implementation and outcomes of SMTs in elderly care?

Due to the heterogeneity of the literature, a scoping review was conducted to map the existing scientific knowledge. The five‐step methodological framework of Arksey and O'Malley (2005) was used and these steps were approached iteratively. The PRISMA checklist for Scoping Reviews was used to guide this review and increase the rigour of reporting (Tricco et al., 2018) (see Appendix 2). A review protocol was not created for this study.

3.2. Search methods

Following the five‐step methodological framework of Arksey and O'Malley (2005), relevant studies were identified by searching the CINAHL 1990–2021, EMBASE, Medline, OVID and EBM Reviews 1974–2021 databases. The search strategy was reviewed by two reviewers (J. B. and R. D.) and was tested, refined and lastly performed on 16 June 2021 (Table 1).

TABLE 1.

Search strategy performed in CINAHL, Embase, Medline, OVID and EBM reviews on 16 June 2021

1.	Self‐directed OR self‐organizing OR autonomous team* OR self‐manag* OR self‐regulat* team* OR Buurtzorg
2.	Homecare OR home‐care OR community care OR neighbourhood care OR district nursing OR community nursing OR assisted living OR nursing home
3.	1 AND 2

No specific time limits for publication were used. Studies were included when focussing on SMTs (Table 2). These SMTs are characterized by, among others, team autonomy, a flat hierarchy and being small in size. A specific focus on SMTs in the elderly homecare and nursing home care settings was required. Hence, studies analysing a patient's self‐management of disease treatment and the training of nurses in self‐management of disease treatment were excluded. Only studies reported in English were included. Qualitative, quantitative and mixed‐methods studies, as well as literature reviews and narrative reviews were included. Editorials, conference abstracts, letters to the editor and opinion pieces were excluded.

TABLE 2.

Inclusion/exclusion criteria

	Population	Intervention (or situation, exposure, context)	Language	Study design
Inclusion	Nurses in self‐managing teams, meaning teams with aspects such as autonomy, flat hierarchy, small team structures	Self‐managing teams in elderly care	English	All types of study designs, including qualitative, quantitative, mixed methods, literature reviews, reports
Exclusion	Studies focussing on nurse training and/or education	Self‐management of disease treatment through, e.g., telehealth or training programmes for the patient	Non‐English	Editorials, conference abstracts, letters to the editor, opinion pieces

Following the inclusion‐ and exclusion criteria, abstracts and titles of the search results were screened by the two reviewers using the Rayyan application for systematic reviews (Ouzzani et al., 2016). Disagreement between the reviewers was solved through consensus. Included articles were full‐text screened by the same reviewers. During the full‐text analysis, reference lists were searched manually for additional relevant studies. Subsequently, the search outcomes were screened.

3.3. Search outcomes

Performing the search strategy yielded a total of 1594 citations, of which 977 unique citations. After screening the titles and abstracts, 45 studies were considered eligible for full‐text reading (Figure 1). Reference lists of studies included for full‐text reading were screened, resulting in an additional six relevant articles. Eighteen articles were excluded after full‐text reading of which SMTs were a confounding variable in five studies. Three articles focused on nursing in general, three citations were conference abstracts and two news articles were retrieved. One study did not focus on elderly care but on community nursing in general. Furthermore, one article was not in English, one study was an editorial and one opinion piece was excluded. Due to deceased existence of the journal, one full‐text article was unavailable. Twenty‐seven studies were included, being narrative reviews, literature reviews, case studies, qualitative evaluations and quantitative cross‐sectional studies.

FIGURE 1.

PRISMA flowchart of literature search (Moher, 2009)

3.4. Quality appraisal

Given the nature of scoping reviews, a risk of bias assessment was not conducted in this study. A scoping review aims to give an overview of the existing evidence and literature on a specific topic, meaning that the retrieved study designs are heterogeneous. Scoping reviews usually pose broad questions and it is therefore uncommon to specifically assess the quality of retrieved studies (Arksey & O'Malley, 2005). Low quality study designs such as editorials, conference abstracts, letters to the editor and opinion pieces were excluded to account for a reasonable quality of results.

3.5. Synthesis

Based on an initial inventory of the key findings of the retrieved studies following the systematic search strategy, results were thematically mapped. The thematic analysis was performed in five phases: familiarization with the data, followed by searching for themes among the data, reviewing the themes, defining and naming the themes, and synthesizing the final results. Hence, a framework of four categories consisting of multiple elements that are fundamental to the establishment and success of SMTs was developed. Subsequently, the results of the included studies were synthesized according to the framework: (1) management and teamwork; (2) ICT and back‐office support; (3) patient and employee satisfaction; (4) challenges to the implementation of SMTs (Monsen & deBlok, 2013; Narayan et al., 1996). The first two categories focussed on characteristics of SMTs. The third and fourth section focussed on outcomes of implementation and potential challenges. This approach of result synthesis provided the opportunity to gain broad insight into the existing evidence on SMTs in elderly care.

3.6. Data abstraction

Prior to the data abstraction stage, a data charting table was created. Through the process of testing and refinement, the data charting table was developed (see Section 3.5). The two reviewers independently extracted data from the included studies following the variables of the data extraction table: author(s) and year; study type; type of intervention (if applicable); duration of intervention; study population; country of analysis; objective of the study; the concept (or care model) studied; methodology (statistical approach, hypotheses, method of analysis); outcome measures; results (ICT structure and back‐office support, teamwork and management, patient and employee satisfaction, challenges); main findings on the potential of implementation of SMTs. After abstracting the key findings of the included studies, thematic mapping of the key findings was performed.

3.7. Ethical considerations

Only findings of publicly available, published studies were used in this scoping review. No human subjects were involved. Therefore, ethical approval was not required for this study.

4. RESULTS

4.1. Study characteristics

Twenty‐seven studies were included for analysis. Nine of these studies were conducted in or focussed on the Netherlands. One study described the Buurtzorg Model in the Netherlands and related this to implementation in the United States. Six studies were conducted in England, four in Scotland and six in the United States. Furthermore, one study analysed the implementation of SMTs in Finland (Table 3).

TABLE 3.

Study characteristics

Author (year)	Study type	Outcome measures reviewed* (Appendix S1)	Care model and country	Research population #
Alders (2015)	Narrative review	1, 2, 3, 4	Buurtzorg model, the Netherlands	Homecare nurses
Dean (2015)	Narrative review	1, 3, 4	Buurtzorg model, the Netherlands	Homecare nurses
Dean (2018)	Narrative review	1, 3, 4	Buurtzorg model, London, England	Homecare nurses of the Lambeth and Southwark teams
Kreitzer et al. (2015)	Narrative review	1, 3, 4	Buurtzorg model, the Netherlands	Dutch homecare nurses
Monsen and de Blok (2018)	Narrative review	1, 2, 3	Buurtzorg model, the Netherlands	Dutch homecare nurses
Monsen and deBlok (2013)	Narrative review	1, 2, 3	Buurtzorg model, the Netherlands	Dutch homecare nurses
Sprinks (2014)	Narrative review	1, 2, 3, 4	Buurtzorg model, the Netherlands	Homecare nurses
Gray et al. (2015)	Narrative review	1, 3, 4	Buurtzorg model, the Netherlands and the USA	Buurtzorg CEO, NL & Minnesota USA staff, nurses, Dutch government officials, insurers, patient advocacy organization, competing homecare provider, primary care physician association, homecare trade association, principal investigator at KPMG
Hamm and Glyn‐Jones (2019)	Narrative review	1, 4	Neighbourhood nursing model, London, England	Homecare nurses, 2 teams
Lumillo‐Gutierrez and Salto (2020)	Narrative review	1, 2	Buurtzorg model, the Netherlands	Homecare nurses
Narayan et al. (1996)	Narrative review	1, 4	Self‐managing night homecare teams, Virginia, the USA	Night homecare nurses
Tennant and Narayan (1997)	Narrative review	1, 2, 3, 4	Self‐managing night homecare teams, Virginia, the USA	Night homecare nurses
Bishop (2014)	Narrative review	1, 3, 4	Self‐managing teams, the USA	Nursing home nurses
Zimmerman and Cohen (2010)	Narrative review	1, 2, 4	Eden green house and similar models, the USA	Nursing home nurses
Andersen et al. (2014)	Scoping review	1, 4	Eden alternative model, the USA	Nursing home models and modes of service delivery
Yeatts and Seward (2000)	Case study literature review	1, 3	Self‐managing teams, the USA	Nursing home registered nurses, director of nursing, supervisors
Dobie et al. (2019)	Case study	1, 2, 4	Neighbourhood care model, Coldstream, Scotland	Homecare nurses, 1 team
Jantunen et al. (2020)	Case study	1, 3, 4	Buurtzorg model, Finland	Homecare nurses, 7 teams
Drennan, Calestani, et al. (2018)	Mixed methods case study	1, 2, 3, 4	Neighbourhood nursing model, London, England	Patients, nurses, GPs, managers and conventional district nurses
Lalani et al. (2019)	Mixed methods case study	1, 3, 4	Buurtzorg model, London, England (homecare nurses, 1 team)	Homecare nurses, 1 team
Leask and Gilmartin (2019)	Qualitative case study	3, 4	Integrated Neighbourhood care, Aberdeen, Scotland	Homecare nurses, 2 teams
Leask et al. (2020)	Qualitative case study	4	Integrated Neighbourhood care, Aberdeen, Scotland	Homecare nurses, 2 teams
Nandram and Koster (2014)	Qualitative case study	1, 2, 3,	Buurtzorg model, the Netherlands	CEO, co‐founders, staff, coaches, nurses, clients and a trainer
Healthcare Improvement Scotland (2019)	Qualitative case study	1, 2, 3, 4	Neighbourhood care model, Western isles; Highland; Aberdeen; Argyll and Bute; Clackmannanshire and Stirling; Scottish Borders, Scotland	Homecare nurses, 12 teams
Drennan et al. (2017)	Qualitative case study	1, 2, 3, 4	Neighbourhood nursing model, London, England	Homecare nurses, 2 teams
Drennan, Ross, et al. (2018)	Qualitative case study	1, 2, 3, 4	Neighbourhood nursing model, London, England	Patients and homecare nurses, 2 teams
Maurits et al. (2017)	Quantitative cross‐sectional study	1, 3, 4	Self‐managing teams, the Netherlands	Dutch nursing staff panel, 191 nurses

^*Outcome measures reviewed: (1) teamwork and management; (2) ICT and back‐office support; (3) patient and employee satisfaction; (4) implementation challenges.

^# Number of teams indicated if specified within the study.

The overall table of study results can be found in Appendix S1. Study types ranged from narrative reviews (12), to systematic literature reviews (3), case studies (11) and one quantitative cross‐sectional study. The most frequently analysed care model was the Buurtzorg Model (12) (see Appendix S1). The Eden Alternative Model and the Eden Green House Model were both analysed once. These models provide elderly care in nursing homes with SMTs being responsible for all care, including meal preparation (Andersen et al., 2014; Zimmerman & Cohen, 2010). Two studies examined the Integrated Neighbourhood Care Aberdeen (INCA) Model which was created by the Scottish government in 2018 to integrate health and social care. Two studies analysed the Scottish Neighbourhood Care Model and four studies focussed on the UK Neighbourhood Nursing Model. Both care models were inspired by the Dutch Buurtzorg Model. Two studies analysed self‐managing night homecare teams in the United States. These teams were already implemented before the existence of Buurtzorg Nederland. Finally, three studies did not specify a care model but analysed the concept of SMTs. Thus, included studies in this review focus on homecare as well as care in nursing homes. The following sections provide more insight into the results of the included studies.

4.2. Teamwork and management

When aiming to transform a traditional elderly care team to an SMT, organization structures require extensive alterations. The implementation of SMTs requires a change in existing attitudes and beliefs on hierarchical management in a way that managers need to let go their control on the team (Narayan et al., 1996). Coaching through effective communication and cooperation were proposed as contributing factors to successful SMTs. Traditional hierarchies can be difficult to break down and a change to SMTs therefore requires a shift in management culture (Dean, 2015, 2018; Dobie et al., 2019). Hence, the introduction of SMTs must be supported by everyone in the organization (Jantunen et al., 2020).

The coach of the SMT was seen as an essential element of the new team structure by homecare nurses in the United Kingdom (Drennan et al., 2017; Drennan, Calestani, et al., 2018; Drennan, Ross, et al., 2018). Furthermore, the coach was considered as a ‘buffer’ between the SMT and the rest of the traditionally managed organization. The role of the coach was important for the successful implementation of SMTs to aid team decision‐making and ‘un‐learning’ the old mind‐set of the nurses (Hamm & Glyn‐Jones, 2019; Jantunen et al., 2020). Despite the importance of the supporting role of the coach, the team itself must remain responsible for its own performance (Yeatts & Seward, 2000). Leask and Gilmartin (2019) and Zimmerman and Cohen (2010) stressed that often teams need an explanation on how effective and efficient decisions through consensus in an SMT can be taken. Nurses could need training to feel more comfortable when becoming self‐managed, as they might think they are not capable of having the extra responsibilities that come with SMTs (Alders, 2015).

An SMT is comprised of eight different roles to be fulfilled by the nurses (Lumillo‐Gutierrez & Salto, 2020). The roles of patient carer and team player must be fulfilled by all team members. Individual nurses are responsible for the other roles, being (1) planning the schedules; (2) checking the nursing records; (3) financial management; (4) checking the record of the teams' productivity; (5) a mentor maintaining a good team atmosphere and resolving minor conflicts; and (6) cooperating with municipalities for internal and external projects.

During the transformation to a flat hierarchy, old team dynamics may be a barrier to change to this new role division, which underlines the importance of changing the old way of thinking or establishing the SMT from scratch (Lalani et al., 2019). Nurses should meet their client's needs through a collaborative approach which is built on trust and which results in creative thinking and problem solving through team effort (Nandram & Koster, 2014; Tennant & Narayan, 1997). Combined with the requirement to perform new tasks, the skill mix of the staff is important (Zimmerman & Cohen, 2010). The autonomy and ownership of nurses is reflected in the nurses' task of checking for potential new colleagues who fit in the team dynamics. They introduce their new colleague and mentor them in the first period of time, which provides the opportunity to get to know each other and creates team bonding (Tennant & Narayan, 1997). This may lead to higher employee satisfaction.

4.3. Patient and employee satisfaction

According to Jantunen et al. (2020), nurses in SMTs felt empowered as they could implement new ideas in the workplace, leading to decreased work stress and improved quality of care. The nurses could spend more time with patients and the responsibility to manage their own schedule resulted in a better work‐life balance (Lalani et al., 2019). Hence, job satisfaction in SMTs was relatively high in case studies on the Dutch Buurtzorg Model (Maurits et al., 2017; Monsen & de Blok, 2018). However, some nurses left their team during a UK pilot study, which suggests that working in SMTs does not fit everyone (Dean, 2018).

Nurses felt to have a more rewarding role due to the higher continuity of care and the greater engagement with the patients which led to an increase in trust (Dean, 2015; Healthcare Improvement Scotland, 2019). Besides that, it was aimed to retain nurses by giving them salary increases and an extra end‐of‐the‐year payment according to the number of years they have worked at the organization (Sprinks, 2014). The team cohesion and the increased time for front‐line patient care, further contributed to the nurses' job satisfaction (Nandram & Koster, 2014; Tennant & Narayan, 1997).

The productivity of Buurtzorg nurses was higher compared with similar homecare organizations. Furthermore, nurse turnover was halved and sick leave and overhead costs were less than half compared with other homecare organizations. Although the average hourly tariff is higher than in traditional organizations (€54.74; €48.74), the average annual time spent per client is lower (108 h; 168 h) (Alders, 2015). The hours of approved care spent by Buurtzorg nurses was 40%, compared with 70% by other organizations, respectively (Monsen & deBlok, 2013).

The provision of holistic and comprehensive care, following patient and family needs, is one of the main characteristics of SMTs (Kreitzer et al., 2015). Because most appointments are usually based on patients' needs and preferences, patient satisfaction has increased (Tennant & Narayan, 1997). The cooperation between nurse, patient and their family resulted in improved external support structures and optimized relationships between nurses and patients (Drennan, Calestani, et al., 2018; Kreitzer et al., 2015; Leask & Gilmartin, 2019). This was also stressed by GPs who noted improved communication and a more solution‐oriented approach (Drennan, Calestani, et al., 2018). Nurses in SMTs were directly accessible and patients were able to negotiate their appointments (Drennan, Ross, et al., 2018). Furthermore, patients' independence improved due to the training they received from the nurses in managing chronic conditions (Gray et al., 2015; Healthcare Improvement Scotland, 2019). Within the Eden Alternative Greenhouse nursing homes, residents and staff reported similar positive results (Andersen et al., 2014). Patient outcomes and emotional well‐being improved as satisfaction with the provided care was higher and in one Scottish case study increased to an average score of 98% (Leask & Gilmartin, 2019).

Continuity of care increased due to the small number of nurses involved with one patient and the joint decision‐making, trusting relationships and mutual respect within the team (Healthcare Improvement Scotland, 2019). This led to better treatment adherence and greater knowledge on the possible treatment options (Drennan, Calestani, et al., 2018; Leask & Gilmartin, 2019). The engagement in team decision‐making increased the team members' confidence, self‐image and job retention (Yeatts & Seward, 2000). Moreover, the use of the nurses' personal knowledge resulted in higher productivity (Bishop, 2014). In 2008, the Dutch Buurtzorg organization had the highest patient satisfaction rates in the Netherlands and in 2013 it scored high on the provided information regarding care, participation in care processes and quality of staff members (Alders, 2015).

4.4. ICT and back‐office support

In the studies analysing pilots of SMTs, the need for an ICT system was stressed. Back‐office support for administrative tasks, which also enhances communication between teams and the organization, should be implemented from the start (Dobie et al., 2019; Drennan et al., 2017). It was found that the absence of ICT and back‐office support creates difficulties in time management for nurses due to the obligation of reporting on patient records (Zimmerman & Cohen, 2010).

To reduce administration time and costs to third‐party payers, Buurtzorg Nederland has developed its own technology infrastructure based on the Omaha System (Monsen & deBlok, 2013). Not only scheduling can be accessed via this system, but it is also used for educational purposes and to access electronic patient records. Expert groups take care of the education, focusing on specific skills and knowledge, such as the treatment of Parkinson's Disease. Nurses can share information and experiences via ‘Buurtzorgweb’ and can seek advice from coaches and colleagues. Besides this, they can view data on their team members' workload, the team's performance and patient satisfaction (Nandram & Koster, 2014).

The user friendliness of Buurtzorg's ICT structure was tested by homecare nurses and back‐office employees and it was aimed to support the nurses' ‘autonomy, networking, communication and documentation’ (Monsen & de Blok, 2018). The use of this system resulted in a 30% reduction of administration time and saved approximately 20% of the administration costs (Lumillo‐Gutierrez & Salto, 2020; Monsen & de Blok, 2018). The necessity of live communication within teams was already stressed by the Visiting Nursing Association Night Nursing Team which used a ‘Client Scheduling Report’ listing the nurses' night schedule (Tennant & Narayan, 1997). Nurses were able to report to their team members through this early computerized patient record.

4.5. Challenges for implementation

To prevent challenges during the creation of or transformation to an SMT, an introduction on SMTs seems key to understand what this working culture implies and how it practically functions (Leask et al., 2020). Absence of knowledge may harm the implementation process because essential elements, such as the flat hierarchy without formal management, may be disregarded or not fully implemented (Yeatts & Seward, 2000). This challenge was addressed in a Scottish pilot by providing 1 year of training on SMT principles before practical implementation (Healthcare Improvement Scotland, 2019). Although nurses' knowledge was well‐developed, other challenges still arose such as a lack of support structures and integration of the system, as well as remaining bureaucracy and paperwork. Integrating care across care disciplines was also more challenging than anticipated (Dobie et al., 2019).

When transforming to an SMT, managers need to become coaches and thus give more responsibility to the nurses which might be challenging (Healthcare Improvement Scotland, 2019; Lalani et al., 2019; Narayan et al., 1996). The difficulty in overcoming traditional hierarchy and bureaucracy can harm the provision of holistic care (Sprinks, 2014). Furthermore, all team members must learn to cooperate and share responsibility for the outcomes, which may be difficult for nurses who are not used to this (Dean, 2018; Narayan et al., 1996). Hence, Bishop (2014) claims that it might be easier to implement SMTs in ‘start‐up settings’ with workers who are new to the organization.

Having a flat hierarchy within the team means that nurses with different skills and qualifications are mixed. According to Lalani et al. (2019), the composition of SMTs with nurses having varying qualifications and experience was challenging. The organization must be willing to give responsibility and autonomy to the nurses regarding management tasks, such as taking care of the programme budget. Drennan et al. (2017) argued that the ‘optimum mix of experience and skills’ must be understood to create effective SMTs. Nurses have different skill levels, but are expected to perform the same tasks. Consequently, the flat hierarchy might result in little opportunity for career progression (Dean, 2018).

The practical implementation of a flat hierarchy created challenges regarding the performance of the traditional tasks of the manager, such as signing for supplies (Hamm & Glyn‐Jones, 2019). Within Buurtzorg teams, this challenge was addressed by a nurse fulfilling the role of financial management (Lumillo‐Gutierrez & Salto, 2020). Regarding the international implementation of SMTs, the local payment structure on homecare services can be a challenge as these systems differ per country and thus need to be considered (Gray et al., 2015). Yeatts and Seward (2000) reported that collective decision‐making following consensus can be difficult, which may harm the efficiency of SMTs. If consensus could not be reached, the administrator of one of the experiment groups rather set aside the matter instead of making a choice for the team. Hence, decision‐making processes were slow and sometimes decisions were not taken at all.

5. DISCUSSION

This scoping review aimed to map the existing evidence on the implementation and outcomes of SMTs in elderly care. Analysis of the 27 included studies has shown the potential of SMTs as a new style of nursing management.

Firstly, the type of nursing team to be transformed might influence the potential success of transformation. Within nursing homes, it might be more common to work in teams with more hierarchical relationships and traditional management styles, whereas homecare nurses who provide care at a patient's home mostly work alone anyways. Therefore, the transformation to a flat team hierarchy might be more problematic in nursing home teams compared with homecare teams. Other challenges for implementation, such as the change from a managerial to a coaching approach, require attention since the role of the coaches is crucial in the transition to SMTs. The coach offers support whenever possible and helps nurses in ‘un‐learning’ the old way of thinking, which is required to create a supportive environment of trust and cooperation. Hence, it must be ensured that a coach can be approached from the start of the implementation or the team's transformation.

Secondly, the ICT systems were tested by nurses and other employees and resulted in less administration time and costs. It must be considered that this system, as well as the Buurtzorg teams, were created from scratch and therefore the reported outcomes in the literature on Buurtzorg might be better than the outcomes of teams that transform from a traditional structure. The supportive ICT system and back‐office support contribute to nurses' time management and job satisfaction. Therefore, it is important to realize that the absence of such ICT system support might hamper a successful transition. Sufficient back‐office support and a well‐functioning ICT system must therefore be implemented to ensure that nurses have the most time to do what they do best: providing care (Zimmerman & Cohen, 2010). Besides a well‐functioning ICT system, taking into account national culture and local context within the country of implementation seems essential. National payment structures within homecare differs between countries, which might limit the freedom of nurses to provide the necessary number of care hours. Whereas insurers pay for the delivered homecare on a flat per‐hour rate in the Netherlands, clients in the United States often pay for the delivered care themselves, up to a certain limit (Berg, 2021; Gray et al., 2015).

Thirdly, although job satisfaction in SMTs was high, not every nurse might fit in such work environment (Dean, 2018). Homecare nurses in traditional organizations might be inexperienced in cooperating with colleagues as much as is required in SMTs. Traditional homecare nurses often work independently in the patient's house, but it requires a shift in existing beliefs and manners to be able to work in an SMT. Nevertheless, increased nurse empowerment and improved relationships with patients result in high job satisfaction and quality of care. This seems to attract many nurses from traditional teams to SMTs and also seems to improve the retention of those nurses.

Patient's acceptance of SMTs was high (Leask & Gilmartin, 2019), and continuity of care has improved due to the joint decision‐making, better treatment adherence and greater cooperation with family and other care disciplines (Dean, 2015; Drennan, Calestani, et al., 2018). Hence, the retrieved evidence suggests that SMTs contribute to the development of integrated care. The literature on the implementation and outcomes of SMTs has shown positive effects on integration of care, resulting from the small team working culture. SMTs aim to provide integrated care by joining the different required elements, such as a flat hierarchy, back‐office support and ICT systems, small teams and a multidisciplinary, holistic perspective on care. This whole‐systems approach of patient‐centred care might provide a solution to the ‘wicked’ problem of health care provision in an ageing population (Kreitzer et al., 2015).

5.1. Strengths and limitations

Most of the retrieved studies were qualitative or narrative studies which impeded a quantitative comparison of the studies. Although the scope of the found articles varied widely, the results were reported as structured as possible. The relative novelty of the literature on SMTs in homecare made it necessary to take this wide approach. Furthermore, due to the extensive interest in the Dutch Buurtzorg Model, this model of SMTs might be over reported compared with the other care models. If a systematic review is to be performed, quality appraisal of the retrieved studies should be performed.

International interest in the Dutch Buurtzorg Model is extensive and different countries such as Germany, Sweden and the United States have implemented the model or are in the process of implementation (Drennan, Calestani, et al., 2018). Although screening of the reference lists has resulted in valuable additions to the analysis of the literature, the systematic search strategy and screening did not yield any officially published studies concerning the implementation of SMTs in Germany or Sweden.

6. CONCLUSION

When aiming to implement an SMT or transforming an existing elderly care team, timely and extensive preparation of this process is recommended. First, the care organization and nurses must receive training to increase their knowledge and enhance their vision on working in an SMT. Second, ICT and back‐office support structures need to be in place timely to ensure that nurses can spend most of their time on providing care instead of dealing with administration. Furthermore, coaches instead of managers must be present from the start of the team's work to support them in becoming an autonomous team and developing their own solutions for occurring problems. Finally, aligning with other local care providers, such as GPs, is recommended for the provision of holistic, multidisciplinary care which will eventually increase the continuity of care and treatment adherence.

Although SMTs have received much scholarly attention in the past decade, the number of pilot studies or experiments on the implementation of SMTs is limited. Moreover, controlled studies are largely absent hindering quantification of effectiveness. Gaining more insight into this will increase knowledge on successful implementation of SMTs. More studies focussing on nurse and patient satisfaction are required. This may lead to a higher retention of nurses and increase the much‐needed future workforce in this sector.

7. IMPLICATIONS FOR NURSING MANAGEMENT

Implementing SMTs requires a change in management style, from managing to coaching nurses. By transforming the current team structure and vision of traditional hierarchical homecare organizations with top‐down management to self‐managing bottom‐up teams with coaches, multiple aspects of the current problems of nurse retention and fragmentation of care can be addressed. This could increase nurses' autonomy and eventually contribute to higher job satisfaction and nurse retention.

AUTHOR CONTRIBUTIONS

DE BRUIN, J.H. – Corresponding author; DOODKORTE, R.J.P. – Second reviewer; SINERVO, T. – Reviewer feedback; CLEMENS, T. – Reviewer feedback.

CONFLICTS OF INTEREST

No conflicts of interest has been declared by the author(s).

ETHICS STATEMENT

No ethical approval was required for this study.

Supporting information

APPENDIX S1: STUDY RESULTS

APPENDIX S2: PRISMA‐ScR CHECKLIST

de Bruin, J. , Doodkorte, R. , Sinervo, T. , & Clemens, T. (2022). The implementation and outcomes of self‐managing teams in elderly care: A scoping review. Journal of Nursing Management, 30(8), 4549–4559. 10.1111/jonm.13836

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.