If you are considering an occupational therapy career in the acute care setting as a new grad, this article is for you. In this guest interview, Ashley Hayward shares her experiences, knowledge and practical tips that helped her thrive and successfully navigate the acute care environment in her first year.
Be sure to also check out the article, Occupational Therapy in Acute Care by OT Miri for a full compilation of resources, tips and tools to help you get started in this practice setting.
When I was in college, one of the alumni from my sorority (who is an OT – shout out to Tara!) told me I would make a great occupational therapist based on my personality and interests. She taught me a lot about this amazing profession. I started shadowing OT’s in different settings. I immediately fell in love with occupational therapy. When I went to OT school, one of my Level II fieldwork was in acute care at a trauma hospital and I loved it! I managed to land a job in acute care when I graduated.
I started applying to jobs about a month or so before I graduated. I wrote a Resume and a general Cover Letter, and then tweaked each of them for every position I applied for. I mainly used Indeed.com, or went to the actual website of the hospital to search for open positions. Indeed.com is great because it will email you when a new OT position is posted within the city/area you are looking for! LinkedIn, AOTA Career Page, Monster, CareerLink are also other websites you can use to Search for OT Jobs.
If I did not hear back from the employer after a week or two, I’d email the recruiter and follow-up with my application. I would often remind them that I’m scheduled to take the NBCOT on X/XX date, or when I did pass, I would remind them I recently passed the exam and have applied for my license. I also wrote a quick 1-2 sentence blurb about how I’m very interested in the position and how my skills would be a great match for that position.
Since I live in a saturated area, it took me around 5-6 months to secure a job. This can definitely be a long process that requires patience and persistence!
Did you have any difficult or unexpected questions during the interview?
- Tell me about a time when someone made an unreasonable request. How did you respond to it?
- Tell me about a time you made a mistake and had to own up to it.
- Tell me about a time someone was clearly uncomfortable. How did you approach this?
- What are your areas for growth/weaknesses?
- Tell me about a time you saw a need for change. What did you do?
For more OT Job Interview questions and sample answers, check out the article FAQs for OT Job Interview.
Is there anything you wish you had asked during the interview?
- Productivity expectations
- Average caseload/number of patients per therapist
- Is co-treating allowed?
- When are new employees expected to carry a full caseload?
- More details about mentorship: Are new employees allowed to shadow their first day? Will someone give feedback on my notes?
What are some ways to best prepare for an interview in this setting?
Do research on the missions and values of the hospital (every interview question I was asked had something to do with their core values) – they want to ensure their employees exemplify these values. Also, review your resume and reflect on your experiences in fieldwork (or as a tech, or volunteer experiences, school experiences) and think of how they can relate to this setting. For example, I had a level II fieldwork at a skilled nursing facility and the skills I developed during that time absolutely carry over for acute care. So I spoke to that in my interview.
Be sure to also create a list of potential interview questions and practice answering them. In addition, prepare your own questions for the employer. This is a great way to show why you are interested in this position/hospital/facility. I had them written down and took notes while they were giving me the answers. Finally, send a thank you card. Here’s a sample thank you letter.
Acute care is the inpatient hospital setting where you work with medically complex and critically ill patients. The main goal of the team is to medically stabilize the patient. The acute care environment is fast-paced and constantly changing. You are always on the go and people are always coming in and out of patient rooms, even during your treatment sessions.
Since there is no rehab gym in acute care, 90% of my treatment sessions occur in the patient’s hospital room/bathroom. If my patients are more ambulatory, I’ll take them out of their rooms and into the hallways/nutrition rooms. Because most of the treatment sessions occur in the room, there is less equipment available to you. You are often carrying around a hip kit and theraband in your pockets. I also spend a lot of time organizing lines, leads, and tubes.
Set up your environment. Take your time in organizing all the lines, move the IV poles, catheter bags and chest tubes to the side of the bed you are getting up on. Don’t let your patient rush you. I usually explain what I’m doing so they understand the safety aspect: “Don’t sit at the edge of the bed yet, just wait a minute I’m going to move the IV pole to the other side of the bed and organize some of these lines so we don’t pull anything out when we get up.” Safety is our #1 priority!
How do you describe OT to your patients and team members?
“Occupational therapy helps individuals of all ages get back to participating in all of the activities they normally do on a daily basis. This can be anything from getting out of bed, to dressing and bathing, or more complex activities such as cooking, grocery shopping, or returning to work.”
I love the fast-paced, challenging environment. I’m always learning something new and am consistently challenged to further develop my skills as an OT. In acute care, you don’t always have the equipment, materials or resources that you would in other rehab settings, so you always need to get in touch with your creative side to develop meaningful and engaging treatment sessions with your patients.
What are some challenges you see in this setting?
In the acute care setting, you will have critically ill patients whose medical status can change rapidly at any point during the day. Daily chart reviews, good communication with nurses, frequent monitoring of vitals during your session are crucial for patient safety!
Also, you’re working with limited resources in acute care. You don’t have a rehab gym with exercise equipment, parallel bars, cognitive activities, ADL kitchen, etc. You always have to be creative with the resources and equipment you have.
Finally, it’s not always easy to make discharge recommendations. Doctors, nurses, families, and social work expect you to have a recommendation right after evaluation. This is hard because it can be difficult to tell what a patient will need after only one visit, especially if you have a limited evaluation. Be sure to review and Know the Post Acute Discharge Settings.
Can you take us through your typical shift?
When I arrive at work, I get my list of patients for the day, which is usually 10-15 patients. From there, I create a tentative schedule to determine when I will be seeing my patients. For me, this begins with the chart review: Is the patient going to X-ray/surgery/MRI? Is the patient discharging home that day? Is the patient having a Palliative Care meeting? Do they have dialysis that day? Usually, I can find this information in the chart and try to plan my day around these things. If I know “Mr. Smith” is going down for MRI at noon, I will prioritize him for the morning. If “Mrs. Johnson” has a palliative care meeting at 10am, I will usually wait till the afternoon to see if her goals of care have changed after that meeting. If “Ms. Stone” is discharging home at 10am, I will try to get one more OT session in with her to practice any last minute transfers and provide my final education on home safety, DME, and ensure she has no further questions before leaving. In addition to all these things, I try to prioritize evaluations first thing in the morning because you have to complete (or attempt) the evaluation within 24 hours after the order is placed.
Here are the areas of the chart I typically review: Patient history and physical (H&P), activity orders, lab values, active lines/tubes, respiratory needs (how many liters of O2 or vent settings), MD/RN/RT/OT/PT/SW notes, medications, vitals trends, imaging, surgery schedule. During my chart review, I write down information I find from the sections above. This is helpful in case I have questions for the nurse or need clarification from the doctor. Before I see each patient, I review my notes.
You’ll have to find your groove with chart reviewing. Some therapists prefer to do all their chart reviews first thing in the morning. Some therapists prefer to complete 2-3 chart reviews and then see those patients. Some therapists prefer to do one chart review, see that patient, document, and then chart review again. I’ve tried all three of these ways. I must still be figuring it out because so far, one way does not seem quicker or more productive than another for me.
CHECK IN WITH THE NURSE
After completing chart review, I head to the nurses station and write down all the names/numbers of the nurses for my patients that day. Before seeing a patient, I always check with the nurse. Sometimes, the chart isn’t 100% up-to-date, and the nurse should know how the patient is doing at the time you are trying to see them. Additionally, if there is anything questionable in the chart, or if you need clarification, you can discuss this with the nurse.
Before lunch, I have the goal to see at least 5-6 patients. The afternoons can be hard because patients have been sitting in the chair most of the morning and are usually tired and wanting to get back to bed. I tend to get more refusals in the afternoon.
At lunch, all the OTs do a quick huddle about how many patients each of us have left, and then distribute all the new evaluations that have come in that morning. After lunch I finish up all the patients I didn’t get to in the morning, any new evals, and then if I have time circle back to the patients who declined my OT session earlier in the day.
How did your expectations differ from the reality of your actual experience?
- The biggest thing I was expecting from my first job was a mentor, and to my surprise, I didn’t have one.
- Documentation: real time documentation requirement at my current job vs. being able to see several patients before documenting at my previous job.
- Productivity expectations: Where I did my clinicals, I got extra units for doing an evaluation, which really helped with productivity. At my current job, I don’t get extra units for evaluations, so productivity is harder to meet.
- Co-treating was allowed at my clinical hospital, and it’s not allowed at my current job.
- Pulmonary: COPD, exacerbation, respiratory failure
- Trauma patients: Motor Vehicle Accidents, gunshot wounds, SCI, TBI
- Ortho: Total knee/hip/shoulder arthroplasty, ORIF of various bones/joints, external fixations, back surgeries, amputations
- Cardiac: Coronary artery bypass grafting (CABG), Transcatheter aortic valve replacement (TAVR), Congestive heart failure (CHF)
- Random: Altered Mental Status, sepsis and Med-Surg things like small bowel obstruction, pneumonia and the flu
- Mobility & Self Care: Boston 6 Clicks (used most often by the therapists at my hospital for G-codes)
- Cognition: MoCA | SLUMS | Mini Mental State Exam
- Balance: Tinetti | BERG | Timed Up and Go | Functional Reach
- Hands & Fine Motor:Nine Hole Peg | Box and Blocks
- Coma-Recovery Scale
My hospital now requires “real time” documentation to increase accuracy of our notes, which means that we have to document during or right after our therapy sessions. Real time documentation, also known as “Point of Service Documentation” is ideal because the chart is up to date and accurate, and you can more accurately describe your session.
TIPS FOR DOCUMENTATION
- Demonstrate the distinct value of OT: Sometimes the pressure of productivity causes therapists to skimp out on a good note. But remember to show the value of our profession in your note. Think about why the patient needs occupational therapy services and how these services will progress the patient forward in their recovery process.
- Provide strong clinical rationale: It’s easy to write an objective – what you did and what you observed. But, the true beef and heart of our notes is in the assessment section. The assessment shows your clinical reasoning, and why this patient will greatly benefit from your services.
- Stay Organized: Create a Daily Flowsheet to take notes on what happened in your session, or record vitals. This is helpful to jog your memory when you go back to write your note later.
Note: The Documentation Manual for Occupational Therapy by Crystal Gateley and Sherry Borcherding is a great book that gives awesome examples of each part of a SOAP note!
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These are the equipment and tools I carry on my person every day. While these are optional, I’ve found them most useful in my acute care practice:
- Clipboard: I highly recommend the Whitecoat Clipboard that folds in half. It fits in your scrub pockets and is great for maintaining HIPPA regulations if you leave your clipboard sitting at the nurses stations.
- Safety pins: I keep these attached to my badge reel. These are great for pinning lines, NG tubes, etc. to the patient gowns to prevent them from pulling/tugging when mobilizing your patient.
- Trauma sheers/scissors: I always find a use for these, whether it’s cutting some bandaging for wound care dressings, cutting a slit in socks for patients who have swollen legs, or cutting some theraband
- Pulse Oximeter: You can purchase these at a good price on Amazon and I highly recommend carrying one. Even though patients have pulse-ox’s attached to their fingers, the cords are never long enough to reach the bathroom. If you have someone standing at the sink, showering in warm water, or even just using the bathroom, it’s always good to check their O2 sats to monitor how they are doing. When you put this in your note, it’s also helpful for RT and nursing to determine if patient requires increased/decreased O2 needs with activity.
- Non-skid socks: Nice to have a pair handy because sometimes you get caught in the moment and don’t have time to run to the storage closet/wait several minutes for someone to bring you a pair (usually run into this with bathroom emergencies or impulsive patients).
- Long piece of theraband: I tie the theraband in a large loop and use this to simulate LE dressing tasks. In the hospital, not everyone has a pair of pants (and at my facility scrub pants are hard to come by for patients) and this is my alternative. Great to practice threading legs in the hole and pulling it up to your hips.
- Patient handouts: I personally believe these are important for carry over of education. I carry a folder full of patient handouts and make copies as I need them. Patients are often on pain meds and may be experiencing hospital delirium so I always like to give them a point of reference to refer back to in case they forget what we discussed. This is also helpful for family members to refer to in case they are not present for my OT session.
I get a lot of my HEP and educational handouts from the Occupational Therapy Toolkit by Cheryl Hall OT/L. The handouts are top notch: great pictures, great descriptions of each exercise, and all the information is neatly organized and easy to read for patients/families/caregivers.
HEP2Go is a neat website where you can create your own home exercise programs. You get to surf through exercises by body part/joint/position and build a program specific to your patient. The best part is, it’s free of charge!
Keep handouts on precautions (hip, sternal, back), energy conservation techniques, body mechanics, creating a safe home to reduce fall risk, walker and wheelchair safety, transfer techniques – truly anything! You can usually find a handout for almost anything, and if you can’t, challenge yourself to create one!
For those who are exploring this setting for the first time, what would you recommend they review?
- Lab Values
- Precautions: Hip precautions, weight bearing precautions, back/spinal precautions, sternal precautions, pacemaker precautions
- Post-Acute Discharge Options: You’ll often hear from doctors/nurses/social worker to “put in your recommendations.” We are an essential part of the team for determining appropriate and safe discharge location. The team always expects you to have a recommendation after the evaluation – which is sometimes hard!
What are some attributes or skills you need to be successful in the acute care setting?
Have plan A, B and C for treatment sessions. The patients you are working with in acute care are critically ill and it can be hard to plan treatment sessions. For example: you might want to walk your patient to the sink to work on hygiene and grooming, standing endurance, and dynamic balance at the sink. You may find that when your patient goes to stand up they get dizzy/lightheaded, or get fatigued after a few steps and can’t make it all the way to the bathroom. That’s when your plan B needs to be able to kick in!
Also, it’s almost guaranteed in acute care that you will get new patients every day, even if you always work on the same unit. That means, you may only get to do an evaluation and find out that the patient gets discharged to the next level of care. Your caseload is constantly changing and you don’t always get to build the same type of rapport with patients that you do in other settings.
Time management is crucial in this setting. If you have 12 patients to see, you also have to allot time for documentation, communication with nurses/social work/doctors, answering random call lights/bed/chair alarms, and other unforeseen activities that happen throughout the day. You really have to have good time management to meet (or come close to meeting) your productivity standards.
Highly recommend. You get OT Practice Magazine and American Journal of Occupational Therapy sent to your door! So effortless, you don’t even have to search for the articles yourself! Plus you have access to everything online, and get discounts on CEU courses/books.
My job recently started a monthly journal club. If your place doesn’t have a journal club, get one started. We pick out an article and meet over lunch to discuss it! It’s great to get everyone’s insight and talk about various topics.
Advocate for our profession and demonstrate the distinct value of occupational therapy. If you notice a patient has PT orders, call the doctor or nurse and ask why there are no OT orders and explain why OT would be beneficial for this patient.
Also, be confident and comfortable calling doctors, nurses, social workers, PTs/SLPs to advocate for your patients and their needs. I often find myself calling the doctors to clarify what types of exercises patients can do after a certain surgery, or what type of brace/sling/splint they need. I often call a social worker to talk about my discharge recommendations and why I’m recommending that particular plan.
I am very passionate about the neuro population. Our brains are amazing, and principles of neuroplasticity absolutely fascinate me! So I plan to become a Certified Stroke Rehabilitation Specialist (CSRS) in the near future.
In the “future” future, I aspire to develop a community reintegration program for individuals with acquired brain injury. During my doctoral experiential component during my OT program, I got to work at a day neuro program in which I had the opportunity to take my clients out in the community to practice and develop their skills in a higher level setting. This was an amazing experience, and so fun helping people get back to the activities in the community they love and enjoy!