Acute Care Occupational Therapy: A Dying Art?

This is Part 1 of a series about OT’s role in the acute care setting.

Acute Care OT Series.png

In August 2018, I had my one year anniversary as an OT working in an acute care hospital setting. If you’d asked me two or three years ago where I thought I’d be working, I NEVER would have thought I’d be in acute care! Ironically, my first-ever OT fieldwork experience was with an acute care OT at a large teaching hospital, and while I enjoyed the learning experience I was certain that the setting was not for me. I disliked the hectic pace, limited opportunities for occupation-based practice, and short time spent treating clients. Ultimately, I felt that I was better suited for a setting where I would be able to do things with clients that initially drew me to the profession – such as cooking, leisure activities, home modification, and community outings – and acute care didn’t seem conducive to any of these goals.

 

Fast forward three years, and I found myself working with a small team of OTs and one OTA at a 650 bed community hospital on an interdisciplinary acute rehab team. Initially I spent much of my time on the ortho floor, evaluating and treating patients after hip, knee, and shoulder surgeries. From there, I branched out into providing care for patients on the neuro, general medicine, oncology, bariatric, intensive care, and cardiac units. It has been a whirlwind experience, and I am learning something new every day – including what my managers, coworkers, and teammates believe is “within the scope” of OT practice in the acute care setting. I don’t always see eye-to-eye with them about what types of OT interventions are appropriate in the acute care setting, but our ongoing discussions and my desire to learn more inspired me to dig into the literature, talk with professional mentors, and reach out to other acute care OTs to learn how how I could serve hospitalized patients while still practicing in a way I know is skilled and demonstrating my distinct value as an occupational therapist.

Read on to learn more about the precarious position of acute care occupational therapists in today’s demanding healthcare environment.

THE CURRENT STATE OF ACUTE CARE OT

A few years ago, there was virtually no information online about OT’s role in most settings that came directly from practitioners. Fortunately, there are now many resources available to OT students, new grads, or others who are interested in the acute care setting (and many others).

Most blog posts about the acute care setting offer a similar description about OT’s role in acute care. The authors are well-intentioned and each post includes a decent overview of acute care OT, but none identify the scope of practice in this setting as much more than “ADLs, therapeutic exercise, adaptive equipment, and discharge planning.” Every time I read one of these articles I cringe inwardly, because can’t help but think that I didn’t spend my time and money earning a master’s degree so I could just hand out hip kits and bedside commodes and help get people out of bed! These are certainly important parts of what OTs can do in the acute care setting, but the harsh reality is that instructing patients in how to use lower body adaptive equipment and perform toilet or tub transfers and upper body exercises are not skills that couldn’t easily be subsumed by another discipline. Professional encroachment is a very real and ever-present threat, and it’s part of the reason why I’ve been determined to identify other areas in which OT can demonstrate its distinct value in the acute care setting.

The Ideal

A second source of information about OT in acute care is our professional association website. As with many OT practice settings, I have found that while AOTA does a great job of identifying the myriad ways in which we can be involved and make a valuable impact in the acute care setting, their “best practice” documents are FAR different than reality. For example, the AOTA Fact Sheet on occupational therapy’s role in acute care does go beyond most of the aforementioned blog posts, describing “a holistic view of recovery” and identifying several additional areas of OT evaluation and intervention that are often neglected or ignored, such as:

  • A focus on mental health and cognitive factors, in addition to physical symptoms, to reduce noncompliance issues.
  • An analysis of pre-hospitalization roles and the patient’s likelihood of resuming them. Factors such as discharge destination, the potential need for adaptive equipment or modifications for safety and driving, and/or community mobility support are addressed.
  • Training patients who are unable to verbalize basic needs in how to use mobile devices or tablets to communicate or for other desirable activities.
  • OT’s role in psychiatry and behavioral health, including
    • Assisting patients in organizing their daily activities to maximize performance, including self-care, home management, leisure, and community and social participation
    • Teaching stress management techniques and coping skills.
    • Addressing the needs of clients in behavioral or mental health units who also have physical impairments.
    • Developing protocols for and facilitating therapy groups to address goal setting, community re-entry strategies, sleep hygiene, prevocational skills, body image issues, and basic to advanced ADLs such as money management.

 

While this description is significantly more inclusive and indicative of a wider scope of practice than indicated in the aforementioned blog posts, it still leaves much to be desired in the way of OT’s role in community- or systems-level change within hospitals and our role in reducing readmissions related to chronic conditions.

The Reality

In contrast to this rosy picture of acute care OT, internet forums reveal what many professionals are actually feeling and experiencing in as acute care OTs – and the reality is ugly. People (most of whom appear to be OT practitioners) voice many of the same frustrations and challenges I had (and still have) about the current state of OT’s role in acute care settings:

  • “Although OTs are respected [at] the hospital I am at (we are well staffed and have plenty of referrals) I am frustrated w/ the setting and the career in general. I am often doing ROM, strengthening, and ADLs… not rocket science! At the same time, I feel that at any given moment I may be expected to be a vision, psychiatric, hand, etc. specialist.. I am not skilled in any one of these areas yet. I feel bored and overwhelmed at the same time. I think that our profession is spread too thin. In a way I would love to build my skills, on the other hand I would like to engage in a career that is more clearly defined…Sometimes I have really successful treatment sessions in which I am sure the education I provided them will make their lives easier. But to be honest, more often I feel useless.
  • “If want to provide hours of direct treatment and get to know people thoroughly, Acute Care is not where you need to be. I believe that Acute Care is not a good place for a new grad. You need to be a “Jack of all trades” who is willing to toilet people, Masters Degree or not. That’s the reality of Acute Care.
  • The other big reality is education. Not only for the patients, for the staff. In my small community hospital I am the only OT, with the number of referrals per day varying between 1 and 14. Many of them are inappropriate, and I often don’t get referrals for those who are appropriate. So my goal now is to educate the nurses and MDs in what is an appropriate OT referral.”
  • “Most of the time whether or not a patient can put their pants on isn’t of big importance in the acute setting. The bigger question is will a patient have someone to assist. If yes than [sic] that answers that question. Most patients in acute, even family members don’t care if a patient can put their pants/ socks/ shirt on because there are much bigger issues going on (medically stable/walking/eating/ talking/etc) in the acute setting. That’s one of the things I don’t like about this setting. In this setting, our ADL work is of the lowest priority…I try to prioritize our caseload- so I focus on those with the biggest needs… I am lucky if they can stand up. I’m still very frustrated with this environment, and my field. ”
  • I find the acute care setting extremely frustrating. I’m constantly seeing patients that drink/drug/eat their way into an accident/stroke/heart attack/ etc. It’s definitely depressing. Also It’s really frustrating when nurses/ CNAs don’t listen to what you have to say and look down on you because they from their perspective they could do your job. I’ve tried educating nurses/CNAs etc, to follow through with ROM for SCI patients or to follow splinting schedule to avoid pressure sores, or do Hoyer lift transfers so the patient gets up…. It’s rare for them to follow through even if you bother to do handouts or write the information on a board. We have this problem at our hospital. “

 

These posts highlight some of the biggest challenges I face every day in the acute care setting, such as:

  • Poor awareness of the scope and value of OT interventions by physicians, nurses, and other rehab professionals
  • Mismanaged referrals – many are inappropriate, and many others who could benefit from OT services are not referred
  • Wide breadth of diagnoses and conditions to treat with a generalist knowledge base
  • Lack of carryover of patient/family training by hospital staff
  • “Traditional” OT intervention (ADLs) is often not as highly valued because patients rely on staff or family members to assist
  • Medical acuity limiting patient participation or consistency of therapy

 

Although it’s difficult to read, the comment below sums up what acute care OT has become – AND what will end up happening if we as a profession don’t wake up and begin doing things differently.

“In the hospital setting however, it is frustrating and stressful, not to mention our country’s healthcare system is a joke, where productivity [supersedes] pt’s well being, it’s absolutely discouraging when you get an eval and the pt is medically unstable or compromised and you have to see if they can put on their socks and transfer to the toilet?! There is just something wrong with that…and I just feel ridiculous saying to a patient, ‘Well I need to see if you can dress yourself.’ Sometimes they are not even aware they will be required to do 90 min of therapy a day, nobody told them or even got their consent, and by the way I don’t feel what I am doing is skilled either, not Master’s level skilled! In theory OT is a wonderful profession, in reality it is lost cause, I feel like a glorified CNA more than anything else, if there isn’t a shift in the direction the profession is going I feel its days are numbered. I may anger a lot of OT’s out there, but just to be frank, I don’t see its value in the hospital setting, nursing can do OT, PT can do OT, anyone can, so what makes us special?”

 

…ok, deep breath. I don’t believe that “anyone can do OT,” but the reality is that in fact anyone can do toilet transfers, adaptive equipment demos, and upper body strengthening exercises without a degree and with a very minimal amount of training. So if these things are all that your acute care OT practice encompasses, you may need to take some time to reflect on why that is and whether it’s truly what’s best for your patients or your profession. (Hint: It’s not!)

The Goal

Fortunately, other commenters in this forum identified areas in which OTs excel and offer distinct value in the acute care setting:

  • “Yes, most likely the rehab director doesn’t feel like OT is important. But isn’t that an opportunity to educate what OT does? Not only to your department but to the staff and the physicians. In acute care, the OT is the first point on the continuum of care before skilled nursing, long term care, acute rehab or home. If you don’t have OT referred at the first point of care, they won’t be referred in the other settings! OT’s have a knowledge base that isn’t covered by physical therapy! We do cognition, activity modifications, and more… In acute care, your job IS to rehab the patient INCLUDING discharge planning. Whether it is 1 day or 30 days, you as an OT need to provide the education that the other disciplines don’t provide so that they can continue to get better!”
  • “Your job as a OT is huge in that short period of time. Ortho patients are a great example of OT, as someone else said, does it really matter if you can walk 200 feet, but to be able to dress yourself, feed yourself, etc is so much more meaningful if you think about it. I see patients who stay a few days (ortho) up to months (oncology) and I rarely do exercises or ROM. OT has the opportunity to teach adaptations (think how is someone going to function at home after an abdominal surgery, not just ADLs but cooking, cleaning, driving, etc), assist with vision, cognitive concerns, delirium, etc. Yes we make discharge recommendations. And as I tell all my students, the long term goal is to assist a patient to discharge to the least restrictive environment. Your job is to help with that. If you feel like a glorified CNA then you need to refocus what you are doing…why are you not teaching during that time? Every patient I take to the bathroom has to try to do [their] own hygiene because that is what rehab is. The thing to remember is you therapy is what you make it. If you aren’t doing “therapy” then you need to take a look at how you can change your ways. That is what OT school taught you.”
  • Acute care can be VERY challenging. However, this is the setting where you will truly learn the effects of physical & mental disabilities on a patient’s ability to function!! If you can conquer this setting, you can transition to any other setting fairly easily. The key is to LISTEN TO THE PATIENT….the rest will fall into place! I think most rehab directors do understand and value OT, it’s a matter of third party payers not getting it. Why all of the sudden is Medicare pushing PT for more “functional goals”, when that is what we have always done?! Once Medicare and insurers get what OT is TRULY about, then there will be a huge shift in how things are done!!!”

 

Ultimately, we as OTs need to be more vocal and more direct about distinguishing ourselves from our PT, ST, and other disciplines in the acute care setting to demonstrate our distinct value, increase awareness and involvement from non-rehab colleagues, and provide more holistic, client-centered care in hospital settings. And with professional encroachment and degree inflation as very real issues, our profession needs to set ourselves apart and demonstrate our distinct value as part of the acute care system before we are edged or forced out.

What are your thoughts on OT’s role in acute care? Leave a comment and join the discussion.

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2 thoughts on “Acute Care Occupational Therapy: A Dying Art?

  1. _OT_ April 14, 2019 / 3:04 pm

    Great write up. I am going to be started a position and Acute care and enjoyed the perspective.

    • lej1123 May 7, 2019 / 7:45 pm

      Thanks for the feedback! Stay tuned for more posts on acute care OT. 🙂

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