I know most SLPs want to spend more time on treatment than on documentation, so how do our skills-writing goals directly benefit a patient? Firstly, good documentation is required for reimbursement. Without good goal-writing skills, we cannot explain what our targeted outcomes are in order to justify our services. Simply saying that we want a patient to improve does not support the need for skilled therapy. We have to communicate how they will benefit from therapy, and why, and in which ways we will measure that progress.

Secondly, a well-written goal is the framework for a well-structured and well-implemented therapy program. When I sit down with each patient, I have already reviewed my short term goals and pulled therapy materials that support that goal. I can document in my daily notes the type of stimuli presented, the patient's response, and the accuracy of those responses. Because I have a well thought out goal that is clear and measurable, I can clearly show the patient's progress.

Sometimes I have to document a lack of progress. I may have to discharge a patient who does not make progress, but before I do that, I can modify the short term goals to reflect the patient's current function. I can also modify the therapy activities to determine if the patient might respond better to a different approach. I can discontinue certain goals and create new ones that will facilitate progress toward long-term goals.

To me, goal writing is not some form of necessary drudgery, but a sort of road map toward a patient's recovery. I always discuss the goals with a patient when appropriate, and include family when available. I want the patient to understand and identify with therapy goals as much as they can; in the case of persons with dementia or cognitive impairments, I try very hard to get the family and caregivers to invest in the goals.

I will be discussing goal writing and giving examples of specific ways to write goals in the coming weeks. I'm looking forward to feedback and input on the ADVANCE for SLPs Facebook page and on the ADVANCE website.

And don't forget to tell us how you are celebrating BHSM in the Geriatric and Adult settings!

To execute the bulletin board without spending a few hours off-the-clock, I have chosen a few higher level cognitive and communication patients to plan and create the board with me as part of therapy. I introduced the idea last week, asked for ideas and opinions, and made a few preliminary plans. This week, we will problem-solve for simple and more complex decorating tasks: How much background paper will we need? How will we measure and cut the borders? How will we attach everything? Is the lettering large enough? What colors should we use? Does the information make sense? And so on. At least one resident is looking forward to a creative activity.

I ask some residents to proofread information (I make some errors on purpose), sequence letters and words, and discuss or review some of the strategies, which they may already know, that I am presenting on the board. Other residents follow directions to place backgrounds, borders, information and illustrations in the correct place. I ask for opinions of colors, styles and placement, and I have teaching opportunities for all sorts of information on communication, cognitive and swallowing impairments.

While not terribly original or difficult, starting with a simple bulletin board reminds the staff, residents and families of the scope of our practice as SLPs and the many ways we can help residents and families. I incorporate as much as is appropriate into skilled therapy tasks, and many residents express pride and enjoyment at their ability to help.

The benefits of working PRN:

• You have a flexible schedule, which can be important to parents, people returning to school, and others desiring to work only a few hours a week.
• You have access to a wider range of work settings and professional experiences.
• You get to experience a wider range of patients and gain experience.
• You are not committed to working any time you do not find it convenient. (However, if you do constantly decline opportunities to work, you may be placed further down on the PRN list.)
• Obviously, you can earn extra income at times when you might need it. Again, this is without a commitment to work a certain hours per week every week, and you can reduce your hours when you no longer have a specific reason for working more often.
• PRN work can allow for professional networking and the opportunity to meet fellow therapists. This can be especially rewarding if you are usually the lone SLP in an SNF.
• One of my favorite parts of PRN work is access to materials and ideas from other therapists! Other facilities may have therapy books that I have not purchased yet, and I get to try them out before I lay down any money.
• You often have reduced requirements for completing weekly documentation, as the full-time therapists may take care of the majority of this.
• If you do not have a need for medical and retirement benefits from your job, the higher hourly rate can be appealing.

There are also some drawbacks, or pitfalls, to avoid:

• If you are a new graduate or are less experienced in geriatrics or long-term care, you may feel overwhelmed with the differences in protocols, scheduling and professional dynamics that are evident among different facilities and settings.
• You are expected to be very efficient as a PRN therapist. You are generally making a higher wage per hour than a full-time therapist who works 40 hours per week with full benefits, and your rehab manager will expect you to be aware of your schedule and complete your work in a timely manner.
• There are no health insurance, retirement or vacation benefits.
• You need to negotiate your reimbursement carefully to make it worth your while, and it might be good idea to seek the help of a mentor if you have no experience working PRN in your area.
• You are not guaranteed any hours per week. During some weeks you may have enough offers that you have to turn down work. However, there might be stretches where you are not called for several weeks. PRN work depends on the caseloads and staffing of the individual facilities.
• It is easy to bite off more than you can chew! Do not get burned out by working a full-time job and then adding enough PRN hours so that you never get a day off! Be honest with yourself and with your employers so that you are always performing at your best.
• Avoid making vocal comparisons about different settings. You will definitely have preferences for certain buildings or companies but remain positive about any setting you agree to work in. If it is truly a negative experience for you, then opt not to return.
• You may be required to purchase another uniform for your PRN job. Many companies ask that rehab staff wear scrubs of a certain color or style or a specific type and color of pants and tops. Some facilities require lab jackets. PRN staff are almost always required to abide by the same dress code as full- or part-time employees.
• Many companies will ask that you work for more than one building or location when you sign on. In rural areas take mileage into consideration. For instance, is it worth it to drive for 45 minutes to see one patient? Will you be paid to drive to outlying locations? Some companies are willing to reimburse for travel time if you are willing to cover buildings over a certain distance away.

Overall, PRN work is a viable way of gaining experience, having a flexible schedule when you need it, or earning some additional income when you have the need or the time for that as well. If you maintain your professional standards and stay organized, it can be a very rewarding way to practice.

I always have a patient or two help me with the bulletin board. It is a fun activity for higher-level planning and problem-solving, expressing opinions, and following directions. Last year, a resident helped me decorate a very bright and cheery board with artificial yellow daisies. I keep the boards as decorative and whimsical as I can to attract interest and avoid a "clinical" or "academic" look. The wording is important, too, because the board is for patients, families and staff who might not recognize our professional terminology. Last year, I framed a plastic page protector with a paper border and inserted a BHSM Fact of the Day. I will probably do the same this year and have a contest to see who among the CNA staff can recall the most information.

In-services can be tricky because you are pulling the staff off of the floor to attend, or you are asking them to attend on their own time. Food always helps to draw in people, but I find that most people are not really excited about any type of mandatory in-service. A door prize might make it more appealing as well. In-services for family members and the residents themselves can be approached as an informal talk, and coffee and donuts are good motivational tools! I try to keep in-services light and focus on a few practical, functional ideas rather than try to address every aspect of communication and swallowing.

I also like to do something little for my co-workers in the rehab department, like bringing in snacks one day and giving out pens. Everyone needs pens, right? I appreciate our rehab team, and this is a good time to say "thank you." This year, I want to focus specifically on how I feel PT and OT help support ST goals by pointing out to them exactly how our disciplines interact to help our patients.

Finally, for a little self-indulgence, I like to sport a couple of new SLP t-shirts under my lab jacket during BHSM month! I have one with a Superman logo that always gets comments and another that says "Speech Language Pathology Rocks!" They are fun, and they open the door for people to ask, "What exactly does a speech-language pathologist do?"

Firstly, let me remind everyone that the resources and equipment available in the SNF might be far different than your graduate school clinic's resources. Begin with the basics, and use the foundation skills that you developed in your years of education to guide your treatment approaches. Whether or not you incorporate treatment approaches such as oromotor exercises, DPNS  and neuromuscular electrical stimulation, commonly known to many therapists as VitalStim, may largely remain up to you to determine as a professional. Equipment for VitalStim and Iowa Oral Performance Instrument (IOPI) can be costly, and many facilities are not going to invest in them unless a rehab company or team of therapists lobby for their use. ASHA's National Center for Evidence-Based Practice in Communication Disorders (N-CEP) can provide help for clinicians in making treatment decisions.

To complicate matters, clinicians who work in the SNF will frequently have to consider end-of-life issues in conjunction with any treatment decisions.

Most therapists will find their tried-and-true textbooks and treatment manuals to be their best resources for dysphagia therapy in the SNF. I personally recommend books by Jeri A. Logemann, Nancy Swigert, Groher and Crary and Hegde. The last link includes treatment instructions and handouts in both English and Spanish.

The SNF should have the basic supplies any therapist would need, including mirrors, tongue blades, gloves and lemon glycerine swabs. Clinicians can also educate themselves about other options in swallow treatment and exercises, including ice fingers in lieu of lemon glycerin swabs or laryngeal mirrors or oromotor and oropharyngeal exercises, and The Breather^TM for resistance training. Tiffani Wallace, of Dysphagia Ramblings, conducted a survey of treatment approaches used to address swallowing, and her results were shared on ASHAsphere as well.

Part of our job in the SNF is to educate professionals and caregivers about how to maximize any patient's safety and health during swallowing treatment. Oral care is always a big concern to SLPs and nurses alike and should be provided to patients whether or not they take in food orally or are NPO. ADVANCE for Nurses has a good article that addresses the importance of oral care, as well as some of the pros and cons of using lemon glycerine swabs. ASHA also has an article on the importance of oral care in Perspectives on Swallowing and Swallowing Disorders.

I personally like to use objects that the patient will use every day and that can be found readily in the home or facility. Here are some ideas for categories of items to collect:

• Personal hygiene items, such as brushes, toothbrushes, travel or sample size shampoo and lotions, and fingernail clippers.
• Office supplies, including pens, pencils, notepads, stamps, paper clips and envelopes.
• A cosmetic bag filled with lipstick, lip balm, a mirror, comb and perfume.
• A toolbox with tools, nuts and bolts, duct tape, measuring tape and so on.
• A snack box with crackers, peanut butter, jelly, small bottles of water or juice, candy, gum, napkins, condiments, straws and utensils.
• Small plastic toys, including cars, animals, dolls with clothes, and familiar childhood toys like decks of cards, jars of bubbles, yo-yos, and Slinkys. Toys are great conversation starters!

When using manipulatives and objects, it is important to know your patient and prepare. For example, will a confused patient try to eat plastic food? Does the patient understand that these are not his personal grooming items, or will he put the toothbrush in his mouth? Patients with dementia may need items that are personal to them and are used in a functional context. In that situation, the SLP might want to foster expressive language by working with the patient in his room with his own belongings. Some patients will need to be monitored closely for safety; we don't want anyone drinking shampoo!

Any actual food items will, of course, have to be replaced periodically. The clinician should always know what dietary restrictions the patient has.

Commercial kits often include photographs of the objects or pictures that show items being used, as well as therapy workbooks. I have found that the decks of Webber photo cards can be a great supplement to the objects. Many generic language and speech workbooks will have sections on following commands, naming, and descriptive tasks that can be modified to fit the objects you have collected.

This week I'd like to continue with specific therapy material suggestions for new graduates and the books and manuals that have worked for me, with a focus on cognitive-linguistic resources.

Cognitive-linguistic therapy is a very important aspect of our work in geriatrics and long-term care (LTC). At the very least, we should be supporting patients who have been diagnosed with any of the many disease processes that are characterized by dementia by creating a Functional Maintenance Plan (FMP) to help the patient, family, and caregivers as they navigate through the reality of dementia and cognitive impairments.

One of my favorite resources is My Past is Now My Future: A Practical Guide to Dementia Possible Care by Lanny Butler, MS, OTR/L. This concise, 88-page book is my first suggestion to clinicians, patients, family members and caregivers who want to know more about the stages of dementia and how to help maintain an individual's dignity and independence as dementia progresses. Mr. Butler includes practical and clear advice developed in his years of work with people with dementia. I suggest this book first because the signs and symptoms of dementia must be addressed in order for the patient to experience success in other therapies, including dysphagia therapy, communication, physical therapy, and occupational therapy, as well as to participate in the daily routine in whatever their discharge environment might be, whether it's a home or a facility.

The next resource I'd like to recommend is Memory Books and Other Graphic Cueing Systems, by Michelle S. Bourgeois, PhD, CCC-SLP. Dr. Bourgeois has developed many strategies for communication for dementia patients, and her book is full of ideas to help the new clinician create memory books and wallets and to develop strategies for patients. It is another concise book, with all the good, practical knowledge you need to start creating memory aids with and for your patients. The author includes suggestions for books and aids to be used at home as well as in facilities.

For people who are in more middle to advanced stages of dementia, I suggest Montessori-Based Activities for Persons with Dementia, edited by Cameron J. Camp, PhD, psychologist and senior research scientist at Myers Research Institute, and A Therapy Technique for Improving Memory: Spaced Retrieval, by  Jennifer A. Brush, MA, CCC-SLP, speech-language pathologist and researcher, and Dr. Camp. There are two volumes of the Montessori activities that target successful, meaningful activities alongside cognitive stimulation to promote socialization and interaction in the person's environment. Specific activities are well thought out, and the books include models for cueing and adjusting the difficulty of the task to the specific patient's abilities. Spaced retrieval is a simple but very effective therapy technique and the book includes a screen to determine if a patient is a good candidate for the technique, as well as specific therapy goals to incorporate into spaced retrieval training.

Susan Howell Brubaker, MS, CCC-SLP, has authored a well-respected and highly recommended line of books targeting aphasia and cognition. For very high level patients, I pull out The Workbook for Cognitive Skills, which many of my patients enjoy because it is full of puzzles and word games to stimulate cognitive function. The Workbook for Reasoning Skills is another favorite, and slightly less difficult than the Cognitive Skills volume. Brubaker's book can save you time in finding cognitive exercises for those patients with good visual acuity and literacy skills. Some of my patients can work the puzzles more independently, while others need step-by-step guidance. I never let them "fail" at a puzzle, so if we start one, I make sure we have time to complete it. I also present the same exercise more than once with many patients.

For evaluating and assessing current cognitive levels, I suggest new clinicians become familiar with the work of Claudia K. Allen, MA, OTR, FAOT, and the Allen Cognitive Levels, which is a superb resource in determining treatment goals based on the cognitive level at which the patient is functioning.

This is by no means an exhaustive list of cognitive therapy materials, and these are resources that I have purchased or that have been available at facilities where I work. I know there are many, many more workbooks and texts available to us, and I'd love to hear your suggestions for purchases new graduates and new clinicians might want to consider.

Recently, I posted an interview with Christine Costello, a CFY-SLP who shared some of her experiences and thoughts about working in long-term care. As spring approaches, I know that many graduate students are anticipating graduation and beginning a search for employment. While graduate programs offer a variety of clinical experiences, they do not always include placements in skilled nursing facilities. Long-term care settings can be uniquely challenging but also very rewarding, and students who are interested in working with adult and geriatric patients in these settings should gather all of the information and experience possible as they consider where to start their professional career.

The CFY process is unique to our discipline. While it may seem unfair to new grads that physical therapists and occupational therapists leave school and begin treating patients without supervision requirements, the CFY process should provide support and mentoring that can ease the stress of starting a new career and provide practical guidance in areas the student clinical experiences might not address. In the long-term care setting, the CFY clinician may be the sole SLP at a facility, depending on the number of residents. The CFY supervisor should provide advice that can assist a new clinician who might not be used to working without the support of fellow graduate students, teachers and clinical supervisors.

One challenge, which Christine also experienced, is developing a professional relationship with staff, including nurses, CNAs and other therapists. In any setting - education, outpatient, acute care - you are going to have co-workers who are more receptive to your ideas and input and those who are less so. Because students have worked so hard and are often so excited to enter the field and treat patients, they often do not expect to have other professionals doubt their suggestions or ignore guidelines. Interpersonal relationships in the work environment must be honed, and the CFY clinician has to educate and direct staff regarding a patient's plan of care, while remembering that not all staff will understand or even appreciate what we do. This struggle is constant, and it is important for new clinicians to bear in mind that not all staff have the education or training that graduates in our field possess. What seems like common knowledge to us might make no sense to a CNA or a cook. Nurses might expect us to work with dysphagia patients but not understand the purpose of developing a functional maintenance plan for cognitive skills.

Medical settings of any type are going to involve coding, billing and documentation. Rules concerning billing and documentation are quite specific and, to complicate matters, most therapy companies have efficiency goals for therapists. Unlike salaried jobs, the hours a therapist can work depend upon caseload and productivity.

I highly suggest that students who are contemplating positions in long-term care seek clinical experience in this setting or find an SLP in their area who they might observe and consult with. In the meantime, next week I will continue with some practical "do's and don'ts" for beginning a CFY experience in long-term care. I welcome any specific questions in the Comments section.

This week's blog continues with the theme of preparing for life beyond graduate school. I gave some advice to new clinicians who are just entering the field of long-term care (LTC) last week, and back in September I wrote about gathering every day supplies for therapy in September 2011. I also talked about some simple, inexpensive ideas that you can integrate into your therapy back in November 2011. Now, in response to a suggestion via Facebook, over my next few blog posts I am going to share some of my favorite "tried and true" materials that I have purchased.

Leaving your graduate school clinic can be a real eye-opener. Most university clinics are well-stocked with diagnostic materials, books, treatment manuals and so on, but your first professional placement may lack these expensive items. Having to get creative with therapy ideas and materials is not unique to working in LTC or with geriatrics. I remember being somewhat dismayed at the basically non-existent therapy resources at my first job in the public schools. The skilled nursing facility (SNF) I transitioned to after a few years had few SLP materials as well, and what was available was largely outdated.

Of course, all situations are different. I worked for several years in a school that was like a speech therapy wonderland as far as therapy materials were concerned, and I have had other employers that were willing to purchase some books and manuals for the speech department. Some companies create a bank of diagnostic tests and therapy materials, while others leave the purchasing requests up to individual rehab teams. I could write at length about my thoughts on why SLPs seem to get overlooked when purchases are made (I addressed the issue a bit when I talked about work space issues in LTC settings back in October of 2011), but in brief I think that there are several reasons why SLP materials might be scarce in a clinical setting:

• The absence of a full-time SLP in the building. This leads to a lack of consistent requests for books and therapy materials.
• The portability of treatment materials. Books, flash cards, games, and other tools get left behind in rooms, or borrowed for use in another building if a therapist covers more than one site, never to be seen again.
• Misunderstandings about what SLPs actually do. No, we don't just feed people, but it seems that many colleagues have that misconception. Supervisors and directors might not know what types of resources we actually use, or think that SLPs always buy their own materials and books.
• Budgets. Whether in LTC, acute care, private practice or a school-based setting, budgets are a reality. When budgets are tight, SLPs have to lobby hard to get a piece of the pie, and often it comes down to number and perceived use. As I mentioned in this post from October 2011, rehab directors and administrators might spend more on occupational therapy and physical therapy equipment because they  actually see the patients using it. It's easy to overlook an SLP using a treatment book or administering a standardized test because we often hide away to work in quiet places.
• SLPs who desire to own their own materials. I have quite a collection, but it has been amassed over a 10-year period. It's not anything near what I dream of owning, but still I have most of what I need at my fingertips. I buy new books, treatment manuals, flash cards, and other materials several times a year. I rarely ask employers to buy materials, but I do often make suggestions or request that employers purchase diagnostic materials simply due to cost.

I'll divide my therapy material suggestions by disorder/treatment focus over the next few weeks. This week, I'll leave you with my first practical suggestion for treatment materials: flash cards/ picture cards! They are versatile and relatively inexpensive. I still use my decks of photo cards that I bought while working in the schools, as well as some that I have purchased with adult clients in mind. I use them for:

• getting a baseline for naming and speech intelligibility;
• targeting memory activities;
• eliciting conversation and expressive language;
• conducting speech intelligibility or naming drills;
• cognitive-linguistic tasks for attention, thought organization and reasoning, such as making comparisons, categorization, finding errors (i.e. what does not belong), predicting outcomes, and identifying problems.

If your budget is small or non-existent, start collecting pictures from magazines and books and make your own cards. Look in dollar stores and thrift stores for flash cards that might be marketed for children, but often can be used with adults. Search for images online and print them out to create cards if needed.

My final piece of advice this week is not to run out and buy everything you think you will need at once (unless you have a budget that allows for that!). If you are a new graduate, ask your Clinical Fellowship Year (CFY) supervisor for suggestions. Ask your employer if they have therapy resources for you, or if there is an SLP working for your company locally who might loan you some materials and help you build your treatment library. Look on eBay and Amazon for used items. Add items to your collection over time, and don't be afraid to re-sell books or materials that weren't as useful as you had hoped.

This week, I'd like to offer a quick re-cap of what I believe new graduates must know before entering the long-term care (LTC) and skilled nursing facility (SNF) settings. These tips are based on my personal experience and discussions with other clinicians and students. 

1. You May Be on Your Own. Of course, you will have a Clinical Fellowship Year (CFY) supervisor, and hopefully that supervisor will use professional standards and model ethical behavior. Most clinicians I have met experienced excellent or at least satisfactory mentoring and interaction from CFY supervisors. However, if your supervisor is not in your building everyday, you must be prepared to use your clinical skills independently and present yourself as the qualified professional in your field. That may initially mean extra time spent both on and off the clock researching diagnoses, treatments, medications, etc., and extra time spent reviewing charts, learning about specific residents, and becoming familiar with the day-to-day operations of the facility. Don't worry - you will become competent and familiar, and one day you will be mentoring others.

2. Do Not Give Away Your Time. Yes, as I said before, you may spend some off-the-clock time researching specific disorders or finding treatment materials (I really enjoy this. Don't you?), but avoid doing hours of paperwork on your own time or arriving to work hours earlier than everyone else to prepare. Learning and personal growth happen throughout our professional lives, and the desire to investigate therapy techniques, disorders and treatment options on our own time separates the exceptional clinician from the mediocre clinician, in my opinion. Let your CFY supervisor, director of rehab or other supervisor know if you feel that you need help with therapy planning, billing and documentation in order to remain efficient and work a realistic daily schedule. Chances are they already expect new clinicians to require additional help and time to complete paperwork. Don't worry - you will learn the documentation and billing systems, and one day you will be super-efficient at them!

3. Expect to Be Questioned. New graduates have new ideas, and hopefully they're utilizing the latest research and treatment options from their recent graduate clinical experiences. Your treatment methods and skill sets could vary greatly from your predecessor, or perhaps the building you are assigned to did not have a regular speech-language pathologist. Be prepared to teach, and be patient. At one of my first LTC positions, everyone thought SLPs fed patients. Don't worry - people will come to respect your skills and knowledge when you demonstrate to them how you help patients.

4. Admit That You Do Not Know Everything. Oh, the panic of being asked a question or consulted on a patient, and not having the perfect reply! It's going to happen. Get the detailed facts, consult the patient's chart and history, review your notes, do some research if you have to, and get back to the professional or family member who asked the question in the first place. Don't worry - no one expects you to know everything about everything, and it is always better to take time to put together a well-reasoned and well-researched reply than to present yourself as an expert in everything.

5. Remember That Learning Does Not Stop at Graduation. I applaud every student who graduates and enters our field. It takes dedication and hard work to earn an advanced degree, and you have chosen to work in a field that serves some of the most vulnerable and often most misunderstood patients. Don't stop studying, learning, questioning, and evaluating your diagnostic and treatment techniques.

6. Be Flexible. Skilled nursing facilities and long-term care facilities operate seven days a week. You may be on call a few evenings a month, or on weekends occasionally for evaluations. Let go of your university student schedule, and remember that a SNF operates 365 days a year. Vacations must be planned in advance, and there will be limitations on when you can take time off. Don't worry - most rehab companies want to work with you concerning vacations, and the upside is that you may also have flexible daily work hours when you need them. Just prepare in advance.

7. You May Have to Repeat Yourself Over...and Over...and Over. "No, Mrs. X cannot have ice cream if she is labeled as NPO (nothing by mouth)." "No, shouting does not help Mr. Y understand what you are saying." "No, Mrs. Z does not remember that she just ate, and she probably never will." It's frustrating, but true: you will teach the same people the same thing over and over and over again. Don't worry - eventually, enough people will "get it," and many staff members will ask you familiar questions because they want your reassurance. Be understanding, and remember that not everyone is an expert like you!

Next week, I will present a basic list of therapy tools for new SNF/LTC clinicians. Please keep posting questions and comments on Facebook or in the comments section below.

Last week I posted an interview with a CFY-SLP, who shared some of her experiences and thoughts about working in long-term care (LTC). As spring approaches, I know that many graduate students are anticipating graduation and beginning their search for employment. While graduate programs offer a variety of clinical experiences, they do not always include placements in skilled nursing facilities. LTC settings can be uniquely challenging, but also very rewarding. Students who are interested in working with adult and geriatric patients in these settings should gather all of the information and experience possible as they consider where to start their professional career.

The CFY (Clinical Fellowship Year) process is unique to our discipline, and while it may seem unfair to new grads that physical therapists and occupational therapists leave school and begin treating patients without supervision requirements, the CFY process should provide support and mentoring that can ease the stress of starting a new career. It can also provide practical guidance in areas the student's clinical experiences might not address. In the LTC setting, the CFY clinician may be the sole SLP at a facility, depending on the number of residents. The CFY supervisor should provide advice that can assist a new clinician who might not be used to working without the support of fellow graduate students, teachers and clinical supervisors.

One challenge, which Christine also experienced, is developing a professional relationship with staff including nurses, certified nursing assistants (CNA) and other therapists. In any setting - education, outpatient, acute care - you are going to have co-workers who are more receptive to your ideas and input and those that aren't as receptive. Because students have worked so hard and are often excited to enter the field and treat patients, they do not expect to have other professionals doubt their suggestions or ignore guidelines. Interpersonal relationships in the work environment must be honed and the CFY clinician has to educate and direct staff regarding a patient's plan of care and while remembering that not all staff will understand or even appreciate what we do. This struggle is constant, and it's important for new clinicians to bear in mind that not all staff have the education or training that graduates in our field possess. What seems like common knowledge to us might make no sense to a CNA or a cook. Nurses might expect us to work with dysphagia patients, but not understand the purpose of developing a functional maintenance plan for cognitive skills.

Medical settings of any type are going to involve coding, billing and documentation. Rules concerning billing and documentation are quite specific, and to complicate matters, most therapy companies have efficiency goals for therapists. Unlike salaried jobs, the hours a therapist can work depend upon caseload and productivity.

I highly suggest that students who are contemplating positions in LTC seek clinical experience in this setting or find an SLP in their area that they might observe and consult with.

Next week, I will continue with some practical "do's and don'ts" for beginning a CFY experience in LTC. I welcome your questions in the comments section or on the ADVANCE Facebook page.

This week's post is an interview with Christine Costello about her Clinical Fellowship Year (CFY) experiences. Last year I had the privilege of supervising Christine for a few months in the skilled nursing facility (SNF) setting. Although Christine decided to explore an opportunity in the public education system while still in her CFY, I know she will excel there just as she did in geriatrics.

I wonder sometimes if our graduate school experiences truly prepare us for the day-to-day logistics of working in the field. I know that when I was in school I was eager to graduate and put all of that knowledge to good use. I could not wait to enter the professional world, work with patients and, of course, earn a living doing it. All settings - public schools, private practice, home health, acute care, long-term care, and outpatient clinics - have their unique challenges, advantages and disadvantages. I encourage all graduate students (and undergraduate students!) to seek out a variety of experiences. Contact some local speech-language pathologists and ask them for their take on their profession and the environments in which they work. Observe them at work whenever you can. Additionally, try to find a mentor who can guide you and answer the real-life, nitty-gritty questions about case loads, salaries, work environments, expectations that are not always presented during clinical practicums and classroom experiences.

I do love our field because it encompasses so many settings. A clinician can choose between a number of settings, which can provide new professional experiences, new learning challenges, and a variety of options in workday schedules. From the flexibility of PRN work, to the salaried field of the school systems, to the hourly wages earned in long-term and acute care settings, there are many opportunities that we can take advantage of over the course of our careers.

I want to thank Christine for taking the time to answer these questions for me. I truly enjoyed supervising her, and I know that she will bring her professionalism, love for the field, and caring heart to her school-based clients. I hope to check in with her later in her career.

My interview with Christine is below.

How did you decide to start your career in the SNF setting?

I knew that I wanted to work in the medical setting. After a few different experiences in acute care I knew I didn't feel ready for that type of setting. It was just too fast-paced for me. I thought the SNF would be a good setting to help grow my confidence in the medical setting with a slower pace.

Did you have any experience in this setting or in geriatrics while in school?

I didn't have any experience in this setting while in school. Before applying to grad school I did do some observation hours at a geriatric hospital in Atlanta, GA. However, that was quite different than the SNF I work in now. I know some of my classmates were placed in a SNF, but I was never placed in one.

Did many of your fellow graduates choose or consider a SNF setting?

I'm not positive, but I'm pretty sure it was only me and one other person who went into the SNF setting. Everyone else went into the school system.

What (if any) worries did you have about working in a SNF? Did you have any ideas about working in a SNF that you found to be untrue?

The biggest worry I had was I thought it would be really depressing. It can be really sad sometimes, but I also think it's a wonderful place to work. The reality is there are people there who don't have any family or there are people who won't remember you from one minute to the next, but I love being able to bring positivity into their day and make them feel, if even only for a few moments, that somebody does care about them.

What is the biggest challenge for you as a CFY clinician in this setting?

Having the confidence I need to stand up to the individuals who doubt that I know what I'm talking about. What I mean by this is there are people who have been in the facility I work in for years and there are people who have been working with them for years. I came in and started telling people to do things differently, which didn't go over very well. Since then people have warmed up to me, but it's still a challenge I face on a daily basis.

What do you think of the CFY process so far? Can we do anything differently to better support new graduates?

Overall, I don't have any major issues with the CF process. I think that the six hours of indirect/direct supervision every three months is too much, especially when the CF and supervisor are not in the same building. I think the process would be just as effective with fewer hours.

What is you favorite part of the CFY process so far? Least favorite?

The best part has been getting great feedback from my supervisor. I am the only SLP in my building so she is really the only person I have to go to who can answer SLP questions. She gives me great ideas for how to improve my skills. As for my least favorite aspects, please see my answer to the previous question.

What advice would you give to graduate students about geriatrics and long-term care based on your experience so far?

I would say it's definitely not for everyone, but it can be a very positive experience. You have to get the nurses and certified nursing assistants (CNA) on your team if you really want them to follow through with what you tell them. However, be prepared for some people to continue to disregard you completely. When that is the case, don't be afraid to go to the director of nursing. Be prepared to have to be creative and try a variety of therapy techniques to obtain your goal.

Did graduate school prepare you to work in this setting?

Yes and no. As far as evaluations and therapy planning I would say yes. I didn't learn anything regarding Medicare in school. I still feel like I don't know what I need to know really. School also didn't prepare me for the business side of things. In school we learn it's all about helping individuals and we never talk about the fact that there are also businesses that need to make money.

What is the most important thing you've learned from working in a SNF?

As with any setting, it's important to be as productive as you can be and to make sure every therapy session is as effective as possible.

Good luck, Christine!

Without continual growth and progress, such words as improvement, achievement and success have no meaning. - Benjamin Franklin

Since I've written quite a bit recently about the changes and challenges the elderly face. I wanted to balance that out with some quick facts about aging in general. Although I often work with the frail and dependent geriatric patients, the happy truth is that most of us will not face nursing home placements and severe debility as we age. In truth, barring any accidents or sudden illness, we often age as we lived our lives: active or sedentary; healthily or sickly; dependent or independent; alone or with loved ones.

Guess what? Aging is not a disease! Contrary to popular misconceptions, the majority of seniors are not senile, they do not live in nursing homes, they are able to learn new things, and they often continue employment or hold volunteer positions. Yes, our body declines and we can see the effects on our strength, senses, reaction time and flexibility beginning in our thirties, but this does not mean that debility is inevitable or that elderly people have to give up hobbies and activities they love.

Illness is not an unavoidable part of aging for most people, although lack of medical treatment early in disease processes can lead to more serious illnesses later, and of course there are many diseases that are difficult to detect and may be unavoidable in some people. Likewise, seniors are not doomed to lose their mental prowess and watch their memories, attention and reasoning skills fade. It should be noted that reduction in or loss of senses such as hearing and vision may reduce the amount and type of information that an older person can receive or process, which can interfere with cognitive function. Try this interesting quiz about aging, and compare your beliefs to some facts.

As I work with the aging population, I tend to focus on what I can help them with - swallowing, communicating, maintaining and using cognitive skills - but it is equally important to remember that older adults are no different from any other person in that we all have strengths and weaknesses, we can all face a health problem or medical crisis at any age, and we all might be dependent on caregivers and family for help at some point in our lives. People at any age can and do have ambitions, and so-called late bloomers often try a new career or focus on creative projects that they put off or had not discovered earlier in life. There is no reason why a person has to be finished learning, achieving and experiencing life by a certain date; there is no expiration date for achievement and ability to learn stamped on us somewhere.

Mid-life has been described as an age range from 35 to 65 years of age, and neurologists and psychologists are learning that our brains remain much more elastic than we might have thought. There are many examples of famous late bloomers, including authors, creators of musicals, and artists.

Well, we deal with them. We allow seniors to wear extra clothes or another blanket. We become OK with hats or gloves inside. We reposition people frequently, even if they cannot or do not ask. We offer them a snack, a meal or a drink of water, even if they have "just had one." In short, we enter their experience as often as we can.

• Look for conditions that bother them, such as restrictive clothes, too many or too few bedclothes.
• Think about what the loved used to wear (if you are a staff member or caregiver, find this out). Did ladies wear skirts? Did men wear hats? Jeans or polyester slacks? Pajamas or a nightgown?
• Understand, though, that preferences can change. Gentlemen who always wore slippers in the house might begin to refuse them. Ladies who never left their room unless dressed in slacks or a skirt might begin to prefer a house coat or soft pajamas. Elders may begin to dislike binding waistbands, constrictive or tailored clothes, hats or other items they were known to wear.
• Staff might be comfortable, or even warm, during treatment sessions on a warm day, while a patient complains of "freezing." Get that patient a sweater, and be aware of drafts from air conditioning units.
• Remember that patients may feel pain, but might be unable to communicate it.
• Teach staff about the various stages of dementia. Look to the Allen Cognitive Levels or the Global Deterioration Scale, among other resources, for characteristics associated with stages of the disease. Patients may "look happy" but have underlying impairments or discomfort that the trained clinician or staff member will identify or anticipate.
• Look for small changes. A bruise, which you or I might write off if we spotted it on our arms or legs, can be an indicator of the onset of necrosis. In layman's terms, we are looking for pressure ulcers or bedsores, whether they are actual sores or just the beginning. Forewarned is forearmed, and so many patients with communication or cognitive deficits will not complain of minor pain.
• Tastes may change. Be flexible if favorite foods become unpalatable. Offer some natural sweets in moderation, like fruit, for the patient who experiences a strong desire for sweet tastes. Some elderly people may not recognize spoiled food. They also may not consume enough food because the decrease in their sense of smell reduces the desire to eat.
• Remember that patients might not register hot or cold as readily, and could burn themselves on hot coffee, soup, or tea.

Read the related post, "Changes in the Elderly: Pain, Temperature and Hunger."

As we consider sensory changes that occur throughout the aging process, it is important to remember the subtle differences that will manifest and how they might affect a patient's participation in therapy and daily activities, as well as his or her quality of life. My colleagues and I often notice that while we are usually warm, often uncomfortably so, in the treatment gym most of our residents are asking for the heat to be turned up or to have another sweater. In the summer, we want to turn up the A/C to full power while they want to sit in the sunlight.

It has been well documented that aging brings changes in touch, vibration and pain. It can be difficult to determine which changes are due simply to the aging process or to a disorder common amongst the geriatric population. Medications and surgeries can interfere with sensation, as can nerve damage and the effects of disease processes. A person might notice that water is hot, or that he is experiencing pain, but may not rate the pain to be as intense. This places elderly people at increased risk for burns, hypothermia, accidents or injuries, and even weight loss or dehydration if they fail to recognize hunger pains or thirst.

Weight, metabolism, dress, and how a person was used to regulating temperature will all affect how an individual interprets sensations of hot and cold. Family members may become bewildered and worried when they notice grandma wearing several layers of clothing, hats or gloves in the house, or even pulling blankets over her head.

On the opposite end, some patients will remove clothes, either because they are too warm, or perhaps because their clothing now feels irritating. Patients may be at an increased risk for pressure ulcers if they don't fully register the discomfort of remaining in one spot for long periods of time, or fail to feel the onset of skin breakdown. It's important to conduct frequent skin checks in order to look for irritation, breakdown and bruising.

As speech therapists, we need to develop strategies and intervention based on the individual patient's strengths and needs. While some patients may constantly voice their hunger or a drop in their core temperature, others will sit quietly for hours, seemingly content and wanting for nothing. But this person may be ignoring - or unable to identify - the pain from a shoe rubbing on a blister or the feeling of thirst. A good functional maintenance plan and treatment plan of care should cover the protocol for addressing these needs, including how the staff should communicate and interact with the patient to avoid potential problems relating to the reduced sensation of temperature, pain, pressure, touch, hunger and thirst.

In next week's post, I will highlight specific interventions and compensatory strategies related to the sensory changes mentioned in this post.