A Reflection on Completing My CFY in a SNF


Last September I had the joy of publishing a guest post from Megan Nosol. She wrote about finding a CF position in a SNF. When she completed her CFY, I asked her to write a follow up post about how the year went. Thanks so much to Megan for sharing her CFY experience with us. Please leave comments or questions for Megan in the comments section below.

At the end of May, I completed my clinical fellowship in a skilled nursing facility. My fellowship was filled with exciting highs and some tough lows, but I made it to the finish line and I am going back for more. The very fact that I continue to wake up excited for work each day is a testament to my colleagues, patients, and, ultimately, the facility. Working in a SNF has incredible advantages, but like all job settings, SNFs also have their unique challenges.

Hindsight is always 20/20, as they say. In parenting, in relationships, and in work, I often catch myself wishing, “If I had only known…my life would have been easier.” Yet, life is funny this way; I wish I knew more, but the lessons have made me who I am, so I have no regrets. When Rachel Wynn of Gray Matter Therapy asked me to write a follow-up blog post to my “New graduate’s perspective on finding a job in a SNF,” I could easily list my greatest lessons during my fellowship in a SNF (of which you will read later on in this blog). However, as the sequel to my decision to pursue a CF position in a SNF, I will let you in on my new perspectives of life as a new CCC-SLP in a SNF.

On SLP forums, I frequently read about new CFs who have too little supervision. Admittedly, before obtaining my CF, I was scared that my mentor would not follow through on her supervision hours. Without a doubt, my friends who are now also my colleagues, Sherri and Kelly, led me to an excellent CFY. They told me about my mentor before I met her, and they were right; she was experienced, passionate, and a patient teacher. During my interview with Sally, my CF mentor, she promised me much more than the minimum number of supervision hours. I could call her whenever I needed her and she would come to the facility or walk me through it over the phone. She gave me her personal cell phone number and asked me to call her anytime. By the end of my CFY, she provided me with 70 plus hours of supervision, opportunities for countless hands-on training, and meaningful constructive criticism during my evaluations and treatments. Now I call her my mentor and friend. Facility recommendations from people you trust are invaluable in your search for the best-fitting job.

A strong rehab director reduces the amount of ethical dilemmas and conflicts that SLPs face in a SNF, but rehab directors will not be able to completely eradicate them from your work life. My rehab director is strong. She is a cancer survivor. She is a passionate physical therapist. She is an experienced rehab director. She is feisty and protects her therapists. She advocates for a better rehab department to facility directors all the time. I knew this before I accepted the job. However, even the strongest rehab director in the world cannot shield you from, to put it nicely, the “difficult” personality types who place you in problematic situations pertaining to ethics. Everyone, regardless of employment setting or position, has a colleague or two (or seven) who refuses to collaborate, has a negative attitude, fights recommendations, rejects attempts of kindness, and declines opportunities to learn something new. You have to learn to either work with these people in a professional manner or avoid them whenever possible.

On two occasions, I had to downgrade patients to an all-liquid diet. One patient had multiple esophageal strictures and could not keep any other consistency down. The other patient had a massive stroke and preferred liquids due to her fear of choking. A head nurse in my facility rejected both of my recommendations for these patients, arguing that my recommendation “deprived them of their dignity”. The nurse and I had a heated debate that ended by her saying she would void my recommendation orders. I immediately went to my rehab director for support. After explaining the situation, she talked to the nurse about my concerns and advocated for my recommendations. I forced myself to take a step back and see it from the nurse’s perspective. She has good intentions, but I needed to present the potential consequences of a regular consistency diet versus an all-liquid diet for these two patients and then I had to leave it in the physician’s hands.

I have also learned to speak up when I am asked to conduct an unnecessary evaluation or treatment approach by a colleague, but to make sure I have solid evidence on hand to support my arguments. I recall having to defend my reasons for not treating two “repeat offender patients”. Both of these patients happened to have dementia were constantly referred to SLP services for coughing and choking during meals. One patient was treated with antibiotics for aspiration pneumonia without a chest x-ray for evidence. Initially, I evaluated both patients and treated them. I asked my CFY mentor to come to my facility and provide input during the evaluations and treatment sessions to ensure all of my bases were covered because these patients were inconsistent during therapy. One day, these patients would show no signs or symptoms of dysphagia, and the next day, they were coughing like crazy throughout meals. After weeks of treatment, trialing techniques and exercises, assessing for diet tolerance, and caregiver education, I discharged them on the safest, least restrictive diet.

A month later, I received another request for evaluation for these patients. I investigated their charts, assessed them for diet tolerance during meals, talked to nursing and family caregivers about their concerns, but with no change in medical status and all bases covered in terms of treatment, I did not see a reason for treating them again. My rehab director and another SLP colleague of mine felt differently, however. I argued that these patients were on the safest, least restrictive diets and were not stimulable to treatment, but they felt pressured to address the referral requests. I felt confident in my arguments because I had enlisted the advice of my supervisor, trialed all techniques, and conducted extensive testing and education. Ultimately, I lost both arguments and my colleague treated them. In the end, objective testing indicated no signs or symptoms of aspiration with either patient. After being placed in this ethical dilemma for the second time, I learned something new to prepare me for these kinds of requests in the future. With repeat offenders, I now consider obtaining an instrumental study prior to discharging them from treatment in order to have objective evidence to support my treatment.

I enjoy the diversity of patients I see at my SNF, collaborating with OTs and PTs, and the flexibility of hours at my job. My rehab director has given me freedom to start an outpatient program for head and neck cancer patients, which was also a highlight for me during my CF. I love most of my colleagues. Could I do without the productivity standards? Sure, but, this productivity standard makes the job challenging and it is one of the reasons why SNFs pay SLPs the highest salaries. Would I like more time for documentation? Of course! But, this challenge has forced me to manage my time better. My most important recommendation to new CFs is to do your homework on the rehab director and your colleagues because they are instrumental in your success at a SNF. Surround yourself with collaborative people who value patient-centered care and have a willingness to learn, and you will thrive, too.

Here are my other suggestions, based on my top 10 lessons I wish I would have learned before starting my CF.

  1. Stay on top of your paperwork.
  2. Learn more about what OTs do in the SNF setting and how you can collaborate with them to help achieve patient goals.
  3. Take quick snack and hydration breaks! Don’t worry, it won’t kill your productivity.
  4. Resist your inner perfectionist and settle for bare minimum productivity numbers. It’s not about numbers, it’s about patients.
  5. A little preparation at home for treatments the next day can make a huge difference in the quality of your treatment sessions.
  6. Learn the strengths of your colleagues–therapists and nursing–and pick their brains as much as you can.
  7. Some nurses do not believe in your profession and no matter how kind you are to them, they will continue to fight with you and your recommendations. These are useless battles, so move on. Make friends with collaborative nurses.
  8. Patients have the right to refuse recommendations and treatment. All you can do is educate and make recommendations.
  9. Keep more data on your treatments to have tangible numbers to support what you do as a SLP or change your approaches.
  10. Speak up when you think an evaluation on a patient is not needed, but be professional with your passionate views.

Guest Blogger Bio:
Megan Nosol, MSEd, MS CCC-SLP is starting her clinical fellowship year in a skilled nursing facility. She graduated from the University of North Carolina at Chapel Hill. During her graduate studies, Megan published Love After a Stroke, a children’s book about aphasia and stroke. She is also co-authoring a book for SLPs working with laryngectomy patients. Her main interests are dysphagia, aphasia, and head and neck cancer. Megan has created a Speech Therapy Tool Box for patients and caregivers to provide them with a go-to resource for more information about speech-language disorders. She has two very active and adorable sons and lives in Raleigh, North Carolina.

Rachel Wynn
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Rachel Wynn

Speech-Language Pathologist at Gray Matter Therapy
Rachel is a speech-language pathologist and creator of Gray Matter Therapy. She started making noise as a patient-centered care advocate in 2013. She believes great care happens when patients are informed and engaged.
Rachel Wynn
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  • Jessica Schell

    I’m so glad to read a positive story on SLP’s in SNF’s. I did my CFY 9 years ago, and am still in the building that I did it in. It’s a challenging area to work as a therapist, but you are right, that’s why we are so well paid. I had a great CF supervisor that I could call on whenever I needed assistance, and have now been a CF supervisor 6 times over. This is not the setting for everyone, but for those of us who enjoy working with the geriatric population, it is an intensely rewarding setting.