10 years ago, I was a new grad occupational therapist. I was equipped with the knowledge I gathered through sleepless nights of studying and field work experience.
I started working full time in a skilled nursing facility 3 years into my career. I was blessed to have a wonderful boss, a senior occupational therapist, a senior occupational therapist assistant, and a senior physical therapist. They all had more than 20 years of experience, and they maintained a patient-centered approach. It was about the patient, even though PPS was already in play. With them, I became the good clinician I am today. As the US economy tumbled, the cost of running a SNF increased while reimbursement for therapy services became limited or more tedious. The focus shifted from patient to corporation. Not wanting to take part in this new culture, the experienced therapists left the company. Sadly, the company hired new grads to fill the position.
Looking back, I would say I started my career with a vision of the ideal world of occupational therapy. I still had the curiosity, somewhat gullibility, of a student. Also, I was a bit shy and unsure. For the first time, I was practicing on my own. I can freely practice clinical reasoning but I am also solely responsible for every decision I make. And yes, I was also picked on. I was fresh blood, a clean slate, a new dog that can be taught new tricks. What would have happened to me if I had a corporation-focused boss and rehab team?
I was a judge at a poster presentation by OTA and OT students a few months ago. Their energy was inspiring, but I could tell that they were still idealistic in their approach. It was all about the patient, all about “doing the right thing” according to the books.
I am at the stage where I feel protective of the OT students and new grads. I do not want them to be corrupted and lose their energy. New grads are so full of life, hopeful, and excited to spur change and help others. OTs are health care professionals and we entered this because we want to care for others.
Sadly, corporations see new grads as new meat to tenderize, season and cook the way they want it. I’ve heard it several times, “they want new grads, they don’t know any better”. Corporate people know it, new grads are at the point where they’re trying to blend in, they don’t have a lot of experience so they don’t have as much negotiating powers like the “old ones”, they have student loans to pay so they’ll need a job, so on.
My brother is in OT school and my cousin is a new grad. If they were to practice in a SNF, this is what I would tell them and I want to share this to all new grads:
1. Bosses from hell exist – Christina from Grey’s Anatomy is real
2. Research and EBP is not too important – the bottom line for payor source? “how long does the patient have to stay? are they improving? well, what are you doing that home health cannot do?” the bottom line for the corporation? hit the ultra high RUG. I will not forget that boss who refused to hire an OT because of his research experience. Reason? “he might question what I want him to do?” Thankfully she’s no longer a boss. But yes, they exist.
3. OTs are NOT glorified CNAs – you will hear it from almost every profession in the SNF “CAn you take Ms/Mr __ to the bathroom and get him/her dressed? ” Whenever you see a patient for ADL, ask yourself “what am I doing that a CNA cannot do?” and yes, don’t be afraid to say ” No, I am not your personal CNA”. If you want a more diplomatic answer, say “that’s not in my plan of care today, I’ll see the patient when I am ready to do what I plan to do”.
4. Therapy is probably the most hated department in the SNF - because most staff and departments think we get special treatment, we get paid a lot, and we don’t do a lot. I was asked several times, “how many months did you spend in school to do this?” . My answer? “4 years to get my bachelor’s and 2 years to get my master’s. You?”
5. Sammons and Preston is a picture book - don’t expect that every SNF has the equipment in the therapy catalogs. At times, you have to beg for a dynamometer. But understand, SNFs run on a tight budget (don’t get me started on how much is spent on corporate christmas parties).
6. You are raw meat in a pressure cooker - like I said, people will test you. On top of that, you have to juggle between patient care, documentation, non-patient responsibilities, and listening to a co-worker’s daily drama all in 8 hours while maintaining 90% productivity and efficiency. Maybe you did not experience this in your field work. This is because corporate ignored as student like you. But now they can bill for the service you are providing.
7. You are not just a therapist – you are also an advocate for your patient. But don’t over do it or you may find yourself being the social worker, maintenance guy, counselor, house keeper, dining room aid … etc.
8. YOU ARE NOT A STUDENT ANYMORE - you will be responsible for your patients. You don’t have your field work coordinator or clinical supervisor with you. You actually have a say whether or not a patient has to stay in the facility or go home. And if things go wrong, it’s your license on the line.
9. You are responsible for stimulating your own brain - in school, you practice critical thinking and learn new things daily. You might be surprised that in the real world, not everybody thinks and common sense is not common. You may find your self being the mentor to the “seasoned” therapists. I will always remember the new grad DPT I worked with briefly. A brilliant mind amidst a sea of non-independent thinkers. I salute her for following what her critical mind was telling her.
10. You can walk away from it – and I don’t mean quit your job. What I mean is you now have the luxury of disengaging at the end of the work day. You get paid, you have money to spend (and spend it wisely). You don’t have homework, you don’t have a thesis to work on, you don’t have book chapters to read. WHAT HAPPENS AT WORK STAYS AT WORK. It ends in 8 hours. After that, go to the gym, drink, draw, paint, whatever.
In the real world, corporate wins because they keep the facility going. Without them, we won’t have a job. Their job is to make sure there is enough money to give the patient what they absolutely need, run the building, pay the staff including you, pay the administrators and make profit for the owners.
Your challenge now is to keep the energy going, balance what you learned in school with what corporate wants, and find time to do what you want to do.
Congratulations and welcome aboard colleagues!