Today I am pleased to feature a guest post from Megan Nosol, MS SLP-CF, who shares her perspective as a new graduate in the skilled nursing setting and what she did to find an ethical job.
Unrealistic productivity standards. Lack of supervision. Empty promises. Ethical dilemmas. No time to complete patient documentation. These are just a few of the stereotypes that I once associated with skilled nursing facilities. I had heard horror stories from new graduates who resigned a month into their CFYs. I had spoken with burnt-out SLPs who were jaded by the heartless politics within SNFs. I had read about the daily struggles of SLPs working in SNFs throughout the country in the ASHA Leader and on online forums. For these reasons, I purposefully requested a semester placement in a SNF for my first medical practicum. I wanted to see first-hand why clinicians were sometimes leery about working in SNFs.
My CF experience in a SNF
In the days leading up to beginning my SNF practicum, I prepared myself for the worst. I envisioned managers with whips in hand, pressuring SLPs to screen and treat all patients regardless of their diagnoses. Well, not exactly, but I worried that all of the rumors were true and that my first medical practicum experience would be a rough taste of reality. I lucked out.
My mentor, who had won “Mentor of the Year” awards twice from my university, was knowledgeable, encouraging, and treated patients as if they were her own family. The rehabilitation manager at the facility cared about her therapists, because she once was a physical therapist. Therefore, she understood why some patients are not appropriate for certain therapies and did not challenge the recommendation of therapists. This autonomy created a caring and collaborative work environment between the patients, therapists, co-workers, and managers—most of the time.
No facility is perfect, I learned. I witnessed a number of heated exchanges between therapists and nurses about the care (or lack of care) for patients. There was an ever-present tension between therapists and nursing staff regarding each side’s territory of skills. The facility had four physical therapists, two occupational therapists, and two speech-language pathologists and only two computers to record patient documentation.
Every day, my mentor had to wait her turn to type her notes on an old desktop PC, which often resulted in her extending her jam-packed 8-hour day by 2 hours. Due to her high caseload, she had no time during the day to record her notes, let alone eat lunch. At the end of my practicum, I felt confident in my bedside evaluation and swallowing therapy skills and I was grateful for the opportunity to get a glimpse one SLP’s work life in a SNF.
A desire to work in a SNF
I secretly knew I wanted to work in a SNF ever since my first medical practicum. Armed with lessons I learned during my SNF practicum and from other SLPs in that setting, I prioritized my career needs and deal-breakers. Ultimately, my goal was to find a CF placement that not only met my needs as a working mom, but also met standards of good business practice and patient centered-values. I set off to find the chupacabra of SNF clinical fellowships—one that went above and beyond the measly 4 supervision hours per month requirement, set fair productivity standards, allowed me an efficient way of systematically documenting patient activities, a collaborative work environment, and management that genuinely cared about me and their patients.
Before I was ready to hit “submit” on those job applications, I researched questions I should ask employers during the interview to ensure they met my criteria. I came across Gray Matter’s “Interviewing Tips for Finding Ethical SNFs” blog post and took Rachel’s advice to heart. My practicum experience in a SNF also gave me ideas about what to look for in terms of red flags and I developed questions based on those ideas.
Then, I reached out to my SLP network when I was ready to apply for jobs. I am the kind of person who likes recommendations for services from people I know and trust, so I asked for recommendations for reputable facilities, too. Two fellow classmates from my university SLP program, both a year ahead of me, told me about a CF opening in their facility. The key here was that I respected these classmates, Sherri and Kelly, for their integrity and passion for the profession and their patients. If they worked at this facility and loved it, then I felt obligated to check out the facility.
After several conversations, I learned that after three years of working in this facility, Sherri and Kelly were both still very happy with their facility, colleagues, and management team. Best of all, Sherri was mentored by the same mentor who would supervise the facility’s next CF. She had nothing but high praises for this mentor, whose main job was to provide mentorship. To this day, Sherri still considers her a mentor and friend. This next CF would fill Kelly’s spot since she was leaving the facility to work for the same company but in a different state—and that says a lot, too. She wanted to stay with the company.
Interviewing a rehab company and CF mentor
After doing more research of my own on the company, I completed the application online and received a call from the HR department the next day. When the HR representative asked me if I could come to the facility that Thursday, I told her there was one minor issue preventing me from doing that: I was living in Poland for another month. Thankfully, I had VOIP and a local number that allowed us to do a phone interview, but I still worried. Would they want to wait a month for me to start working? Since I could not meet them in person, would I still be in the running as a candidate? The rehabilitation manager called me a day later and was very understanding of my situation.
I asked her my list of questions and her answers met my criteria and then some. She told me that I would have an iPad to do patient documentation in between seeing patients throughout the day, which made the process seamless. My mentor would spend at least 100 hours with me during the course of my fellowship and that I could depend on her for guidance, since mentoring was the focal point of her job.
Later that night, I spent two hours talking to the mentor about our approaches to patients with dementia, aphasia, dysphagia, and head and neck cancer. We talked about typical work days, challenges of the position, personalities of the management, library of material in the therapy room, and a little bit about our personal lives. I felt an immediate connection to the mentor because she was a working mom and had such enthusiasm for her job and her patients. I accepted the job offer that day.
Advice from a CF and former teacher
What advice can I offer to other new graduates looking for a CF placement in a SNF that truly cares about their patients and their staff? Everyone’s situation is unique; I am a mother, so my deal-breakers and needs may be different than another new clinician. Yet, prioritizing your wants and needs in a facility and mentor is a must before you start the job hunt. Spend a couple weeks, if you can, asking for recommendations for facilities or mentors and thoroughly research them to determine if they meet your standards.
Prepare a list of questions that you will ask when being interviewed by the manager and your mentor. Keep in mind that the manager may not have SLP knowledge and expertise, so ask him or her questions related to the facility, the company’s values, and their expectations of SLPs. Design different questions for the mentor to decide if your approaches and personalities mesh, the quality and quantity of your supervision is sufficient, and expectations about patient-care are clear.
Although this is not my first career, I remember having romantic ideas about my first job as a teacher and how easy it was to be fooled by those who were more experienced in the workforce. I remember being disappointed with myself for not asking more difficult questions, doing more research on schools that met my needs and standards, and talking with other teachers about their experiences and advice. Perhaps if I would have not taken that teaching position that seemed too good to be true, I would still be teaching today.
Megan Nosol, MS SLP-CF 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.
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