One professional’s fears about the direction of the field
Editor’s Note: C.W. is an occupational therapist from New York who’s spent the past 30 years working in various settings. Over the past several years, she has grown increasingly worried over the direction she sees the profession taking. The following is her story.
In 1987, President Ronald Reagan signed the Federal Nursing Home Reform Act, or OBRA. OBRA created a set of national minimum standards of care, as well as a set of rights for people living in certified nursing facilities. The legislation marked a turning point for both the nature and the reputation of these facilities, and greatly increased employment opportunities for occupational therapists.
There was a time when you dropped a loved one off at a nursing home, it was the human equivalent of putting them into a warehouse. Now, accommodations were made to take patients for walks, take them to and from the bathroom, and address any other needs on an individual basis.
When I first started my career, everyone was worried about their elderly patients falling. As a result, patients were regularly tied to beds, wheelchairs, etc. Part of the OBRA legislation was a movement to untie people and address their needs in other ways. Anyway, at the outset of my career I was a part of that, going to various facilities and teaching therapists innovative ways to prevent falls and increase strength in their patients. The campaign was called “Cut ‘Em Loose.”
It may sound primitive now, but this was progress at the time. Before OBRA, OTs were written up regularly for failing to tie their patients to a bed or chair.
But at the time (late 1980s/early 1990s) this was a service of great value. Patients in nursing homes were now treated as individuals, each with their own plan for strengthening, mobility or other considerations. As a new occupational therapist, I was proud to be getting into a profession that was making such a noticeable difference.
My first several years in the profession were spent gaining valuable experience in settings from hospitals to nursing homes, assisted living, and home care. Progress continued in caring for our elders, but looking back I think a turning point occurred when Medicare began breaking into different HMOs.
When I first started, OTs were not even permitted to know our patients’ insurance providers for fear of making decisions based on those conditions. We were expected to go in with a free mind, determine what each patient needed, and the facilities and insurers would be obligated to provide those services.
I was in the process of raising my three children, and admittedly didn’t follow the daily occurrences within OT as I should have. Suddenly, we were making more phone calls to verify insurance and get an approval for coverage. There were some more hurdles to clear, a little more red tape, but the mantra of “patient first” still reigned supreme.
Sadly, that’s somehow changed over the past decade. There was a time when you got hired to work 32 hours a week…you worked 32 hours a week. If there were fewer patients, you’d attend in-services, train staff, go out on the units and help with care. Today, that’s all gone. When you stop billing, you leave. If you’re hired for a full-time position, but they only have 15 hours of patient care, that’s all you work. In my opinion, it’s not a real job anymore.
It’s gotten to a point where CNAs and other professionals are making decisions on patient care based strictly on what actions are or are not billable. And the patient is the one who suffers. There was a time that ignoring a patient’s request to use the bathroom was a fireable offense. Now? Patients are made to go to the bathroom in their protective undergarments regularly.
The most horrifying thing I’ve seen? People in long-term rehab, two days away from discharge and going back home, STILL wearing diapers and not being taken to the bathroom. Recently, we had a woman with a broken leg in rehab who wanted to get onto the toilet. But the therapists couldn’t get her out of bed without putting weight on that leg.
Any experienced therapist should be able to list the potential solutions. Get two people to help her, or get a bedside commode with a drop-arm next to the bed, or get a lift. There are so many possibilities, but young therapists just don’t know these things. It’s not that they’re incapable. It’s that their entire focus is productivity. There’s no time or value in the creativity it takes to assist these patients. What’s important isn’t getting this woman on the toilet; it’s that the therapist reaches her goal of 90 percent productivity.
The constant pressure to think about those billable minutes and hours eradicates the desire to learn or to create new means of helping patients. Think about it—an eight-hour day with a mandate for 90 percent productivity leaves between 45-50 minutes for non-billable activities of any kind.
Another reason therapists won’t take the time to learn? Once the patient returns to the nursing unit, no one will attempt these sorts of toilet transfers. The people in the building don’t care, and there are never enough CNAs available. So they figure it’s easier to just lie the patient on the bed and change the undergarment. The concept of using all this extra energy to figure out a way to make the transfer happen is past. It’s outdated, and it just doesn’t happen anymore.
Of course, if you stop 100 OTs on the street and attempt to have this conversation, they won’t tell you these things for fear of losing their jobs (Why do you think I’ve written this article anonymously?) But think of this from a therapist’s perspective—a patient’s daughter comes to visit, and asks how their parent is doing. Now this isn’t billable unless the patient is sitting right there, but you can’t exactly walk away. So depending on what type of person you are, you have two choices:
- Pass her off to the rehab manager, and duck out to continue fulfilling your productivity, or:
- Address the daughter’s concerns, but then later “get creative” with your minutes so you won’t get fired.
- Talk to the daughter, and work “off the clock” at the end of the day
No matter what you choose, you’re compromising your ethics. And it’s a miserable feeling. For my first 20 years or so in the profession, I thought being an OT was the greatest. You make good money, you’re well-respected by the public, and you’re doing a good service. Now? I get mailers asking if I want to pursue my doctorate, and i just throw them away. It wouldn’t change anything.
I’d estimate I’m using about one quarter of my overall skill. I used to teach, go to committee meetings, attend patient meetings with doctors… all of that is gone.
I recently attended a baby shower for one of my daughter’s friends, and saw a couple of her friends at the wedding. These women are in their mid-20s; one is a PT, the other an OT. The PT is seeing 17 patients a day, while the OT works in skilled nursing. “I have a patient who’s 97 years old,” she told me. “They want me to get 60 minutes with him. What am I supposed to do?”
I was devastated. I wanted to tell her there are dozens of things she can do. I wanted to tell her about when I was a young therapist, and would regularly go to see one of my mentors in a similar situation, and subsequently developed the skills that made me so proud.
The truth is that she doesn’t know any of those skills, and won’t ever have the chance to learn because of the emphasis on productivity. The senior therapist on her unit won’t teach her, she’s on a schedule of her own.
And I hear these questions at work every day. I want to tell all of these young therapists that I’ll take some time one of these days to teach them a few things that would give value to the time they spend with their patients. Skills that would give each therapist pride in what he or she does for a living, and which they in turn could teach to future classes of incoming OTs. Oh, how I’d love to do that for just one OT.
But that would cut into my productivity.
Do you have your own story to share or a different perspective? Email us at firstname.lastname@example.org.