Table 3 Case vignettes: Shaping of interactions

Fostering self-management in patients and relatives

I had a patient [...] who suffered from severe heart failure. [...] She had weighed herself, measured her own blood pressure and always recorded it. [...] One time she had received intravenous diuretic from her home care nurses in consultation with me. After that I told her, ‘We have to check this when you report it.’ [...] I then asked her, ‘When did you first notice the breathlessness?’ or ‘What made you notice this?’ [...] With questions I found out that, aided by a rollator, she walked the same short walk every day - and that she suddenly noticed that that short walk did not go as well anymore. Then I said ‘Now we have it. If you notice that this short walk does not go as well, then you have to call me so I can come by. Even if it is a week earlier [than our next planned appointment].’ And that worked. (APN_2, interview)

When a patient independently reached out to the APN after a hospital release, of which the APN had not been informed, the APN described it as a success. (APN_1, interview)

Collaborating with GPs in tandem care of patients

The condition of an 85 year-old residential long-term care resident with decompensated heart failure and elevated inflammation parameters worsened clinically with antibiotic treatment and intravenous diuretic infusions. After consultation with the treating GP, the APN talked to the patient and family members, on-site at the residential long-term care facility, about the goal. Treatment focusing on stabilizing the patient's quality of life allowed a regular hospital admission the following day rather than an emergency admission that evening.

In the meantime, the long-term care resident is back in the residential long-term care. She isn’t dyspnoeic and the oedema was gone. (APN_3, interview)

Serving as primary contact person in residential long-term care facilities

In the care facilities I have fixed visits. There I know I will be present [on these two days] from 10am. [When I arrive,] the nurses ask me any questions they have or tell me who I have to see. [I] also have ongoing cases; so I say, this one I want to see, this I want to check, because I know the importance of continuity. (APN_4, interview)

Visit at Residential long-term care facility V:

Ms U (Nurse): Mr W has blood in his urine. After a few specific inquiries the APN asks Ms U, "Please run a Combur [urine] test and let me know the results." She notes the test in Mr W's file in the facility's care folder.

APN: On my last visit we reduced Mrs X’s Meto-zerok (anti-hypertensive medication). Ms U: Now you surely want to see the results. They are very good. Neither the pulse nor the overall condition have changed. APN (reading the results): From now on pulse control once a week is sufficient. Ms U: Thank you.

Ms U: We have newly a married couple together here, the Y's. Ms Y suffers from severe dementia; her husband has a calming effect on her. Both would like to return home. APN: Mr Y was previously hospitalized because of gastrointestinal complaints. Because of Ms Y's dementia she would be cared for better on a special care unit. They want to recover here and go back home. We can evaluate their progress as we go along.

APN: How is Ms Z's erysipelas looking? Ms U: better. The two decide afterwards to visit Ms Z together. (APN_1, go-along)