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Background/Problem: Quality therapeutic communication and relationships are key to delivering effective integrated care management ICM, known to promote health and wellness for elders with multiple chronic conditions MCC, disability, and depression. HHC nurses are in a unique position to establish these relationships because they communicate and engage with elders during routine home visits, often as the sole provider of care. A major barrier to nurse-pt. communication is the high prevalence of untreated comorbid illness/depression interfering with patients’ abilities to collaborate and engage in self-care. Further, therapeutic communication skills empathetic are rarely practiced by nurses, instead they use task-oriented, directive, and controlling communication. Not surprisingly, these types of communication barriers persist in HHC, since the quantity and quality of communication training is almost nonexistent, nor mandated by policy. The in-depth analysis of nurse communication data from observation home visits by this team, found a pervasive underutilization of nurse engagement in therapeutic relationships. Consequently, elders in this study felt insecure and alienated, engaged less in self-care, and experienced more mental distress, which was not expressed/explored. Nurses, experienced similar ambivalent feelings and distress because they lacked the confidence and skill to adequately deal with patients competing demands.  This unspoken but shared mental distress and upset led to a parallel process in which both nurses and patients experienced discomfort difficult to express in words – the proverbial elephant in the room. These unaddressed conversational gaps in communication diminished nurses' abilities to therapeutically engage patients in mutual problem solving and self-care action plans. Design: The purpose of this 3-part qualitative descriptive study is to illuminate nurse-patient communication occurring during nurse visits to elders with MCC, depression, disability. Methods: The analysis part 3 focused on 338 transcribed audio-recorded communication incidents in an attempt to shed light on the dynamics underlying nurse-patient relationships; addressing: a common contextual visit features; b what nurses do and don't do to support productive interactions; c therapeutic communication: managing the “elephant in the room.” Findings: Three categories of communication emerged: 1 Connections: 72% social conversations, setting focused agendas, patient assessment, and directive guidance. 2 Disconnections: 25% missed opportunities to engage in patient-centered communication and patient-expressed concerns; impeding productive therapeutic interactions. 3 Therapeutic Communication: 3% active listening, prompting patient expression, and verifying nurse’s perception of patient's messages, nurse-patient collaboration on actions plans.   Communication categories highlighted how nurse-patient relationships, typically involve close interpersonal connections, but are susceptible to conversational shifts that create periodic disconnections within HHC episodes. There is much that nurses do to support productive interactions over the course of managing demanding agendas and establishing positive patient-centered connections. Lessons Learned, Future Research: Evidence from this study, was used to develop and pilot-test an educational on-line course, designed to enhance nurses' ICM skills and build capacity in therapeutic communication to improve mental/physical health. This course will be a foundational part of a feasibility test of a nurse-led ICM intervention, for elders with MCC- INSPIRE Interactive Nursing Support to Promote Integrated care for elders REcieving HHC designed to prevent disability worsening and improve psychosocial health.

Managing the Elephant in the Room: What Home Health Care Nurses Do and Don’t Do to Support Productive Interaction