OT Across America: St. Louis, MO with Natalie Flaugher, OTR/L

For our OT Across America: St. Louis edition, I was so excited to get back to my hometown and meet with Natalie Flaugher, OTR/L for great sushi at Wasabi with great conversation about what life is like working as a PRN OT in multiple inpatient rehab facilities, along with her upcoming career plans.

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Tell us a little bit about your background and what drew you to occupational therapy?

When I was younger, back when I was in high school, I was interested in healthcare. I didn’t really know where I was going to go. I toyed with psychology and wanted to help people and get to work with people whenever I chose. And then I got to undergrad, and I went to a career fair. The OT program came up and we talked about nursing, OT and PT and other fields that were starting to really grow and be relevant in the way that the population is changing and its healthcare needs.

So I did some shadowing in undergrad and getting to see outpatient clinic and getting to see what OT did and what PT did. And actually what kind of drew me in first was going to a peds clinic and really getting to see working with kids and it was so fun and engaging and really making a difference in a kid’s life in a way that was really fun for them and meaningful.

But when I got into occupational therapy school I completely flipped and ended in geriatrics and adult rehab since then. So those kind of experiences really helped me connect with OT to begin with. Everyone asks me know, “Now would you ever work with kids?” I’m like, “Absolutely not. I love older people!”

What setting are you in? What school did you go to? How long have you been practicing?

First, I’ve been practicing for just over a year in August. I graduated from the University of Kansas back in May of 2017. And I went there for my undergrad and then I went through their master’s program for occupational therapy school.

For the last year, I’ve worked PRN in two different inpatient rehab hospitals. So that’s been really my main setting. And now I’m getting ready to transition into long-term acute care.

What does your typical day look like?

As far as inpatient rehab, my day starts early in the morning. OTs are encouraged to start earlier than PT to do ADLs and help patients get up, eat breakfast, and get ready for the day. The normal hours are from 7:00 or 7:30 to 3:00. I see patients back to back to back before lunch and after lunch and do as much documentation as possible during lunch.

Sessions can be 45 minutes, an hour, or 90 minutes, but the main thing is that the patient gets a total of 3 hours of therapy a day. So a treatment can look like an ADL or it can be different treatment interventions based on what that patient’s diagnosis is.

In inpatient rehab you see a lot of older adults now – a lot of hip fractures and a lot of debility I’ve noticed in the last year. But it can really vary. Being PRN as a new grad was a very challenging experience. I had a difficult time finding a full-time job straight out of school. And before I graduated I’d really narrowed down that inpatient rehab is where I wanted to start from. I really held myself to that goal and didn’t really want to shift my focus too much just to find a job even if I got desperate or was struggling.

But I think PRN has been really good for me and getting me out of my comfort zone, being okay with not knowing what each day brought, being comfortable jumping into a different facility with different patients every day, not really getting to choose, just being comfortable with stepping into whatever I was asked to do.

And when I took on two different facilities, managing two different schedules with two different managers, learning how to work with two different hospital systems, and two different teams of therapists. It’s really so good to have a meaningful impact for patients. It’s definitely the thing that I worked hardest at over the last year.

What is your productivity like? How many patients do you see in a day?

It’s been not as big of a factor in my experience thus far being PRN popping in and out of facilities, doing half days and full days. But in inpatient rehab, it’s usually four to five patients over the course of the workday and getting all of their hours of OT. That’s really been the main focus of being productive.

The place where I’ve seen productivity be its most challenging has been having to carry a laptop around and finding ways to do point-of-service documentation with patients in a way that’s meaningful but not putting their safety at risk.

So that when you come to lunchtime or the end of the day, you’re at least a chunk of the way through your documentation. That’s definitely the thing I’ve experienced the most as far as the pressure to do your job well but also stay on point so you don’t get to the end of the day and have so much documentation that you’re working longer than they would like.

Do you see multiple patients at a time?

One of my facilities did have that approach. The other one did not. One facility had multiple patients in a group treatment setting. So being PRN there were several times where I ran groups. But that was really the only time where it was two to four people doing some sort of exercise or group activity for a therapeutic purpose.

My other facility did do some concurrent treatments where you would have two patients paired together (hopefully) at the same functional level, appropriate, able to socialize, able to gain meaning from it. It was interesting being able to contrast two different facilities in the same setting, with their approaches to things like that.

What are the most common diagnoses you see?

Being in this area it seemed to be quite a few more older adults. But we get occasional younger patients, whether it’s a cancer diagnosis or a major trauma. Very few were in there adolescence or early 20s; it is mostly older adults or people in their 50s and 60s.

I see lots of orthopedic, cardiac, and occasionally brain injury diagnoses. So a good mix of everything and it was interesting to compare one of my facilities being freestanding inpatient rehab versus one being a part of a larger acute care hospital to see the differences in the patient demographic we would get.

The rehab unit connected with the hospital would get more complex patients which I enjoyed when I transitioned to start working there back in January or February. I was getting patients that were a little bit more complex, a little bit more challenging, and just not your typical patients.

What do you like most about your job?

So far what drew me to inpatient rehab – even when I was a student – was the ability to connect with patients and see them multiple times a day for several weeks and really get to develop those relationships. And get to see the impact that you’re having on a daily basis and to really be involved in their plan of care and their time when they’re either facilities.

I think that’s really what I’ve enjoyed the most. It’s been challenging being PRN because I’m getting to see those people maybe on their eval, then maybe halfway through, and their family training the day before they go home.

So one thing that I’m looking forward to when I transition to full-time [in long-term acute care] is getting the chance to be more of a presence on a day to day basis. That’s really what drove me to that setting versus other settings that are out there that we’re able to practice in.

What are the biggest challenges for you?

The main thing would be the less consistency. I knew that it was a trade-off getting to be somewhere full time in a setting I didn’t really love as much or I could be somewhere where I really enjoyed what I was doing but I could be in and out as needed as a PRN employee. That was definitely something that’s pushed me to continue looking for full-time in the last six months. It was just that desire for stability, for consistency, for being a part of a team every single day, for really being valued, and for getting to contribute more than those select times.

That’s been my goal driving me. I’ve enjoyed the flexibility and getting to say “I really want to work that weekend” or I can work a holiday or I want to go out of town. But definitely when the work is high it’s high, when it’s low it’s low. And a couple of months ago I had a month where I worked maybe 13 days the whole month.

So I think one of the challenges with inpatient rehab is that census can really fluctuate. And when it goes low, the PRN therapist is the first one to go. I definitely felt that sometimes where I work, other PRN therapists just work two days a week to pay their student loans or they have adult kids in college and really are not so much worried about having a steady income.

So it’s definitely been challenging. I think being in my shoes at the beginning of my career and wanting to be more involved, I’ve been constrained being in the role I’ve been in.

What is the job market like in St. Louis?

My experience was challenging, but I know that partially it’s because I narrowed down my focus so much as far as setting. I knew I wanted to be in inpatient rehab. It was where I felt like I really knew what my role was. And I had really enjoyed it and connected with it. So, when I came out of school looking for jobs, that’s where I was looking. In my experience a lot of facilities around here were looking for some sort of experience. Whether it was in the fine print or in the not-fine-print on the job descriptions said “requiring one year of experience.”

That was definitely my biggest challenge in finding something. I ended up having to go the PRN route because of that. I’ve gotten to meet really great managers in the hospitals I’ve worked in that were really willing to take a chance on me and give me the chance to gain that experience in a role where I could work on building my resume. I was working towards where I wanted to be which is about where the point I am now. It was definitely way more challenging than I expected.

I went to school in Kansas City, but  family and a long term relationship in St. Louis drew me back here. Coming here with no connections in our profession was definitely something that made things a little harder. I’d done all my clinicals in Kansas City and worked as a rehab tech in a couple of hospitals. I was definitely jumping out my comfort zone and taking a leap of faith, and I think it wasn’t as smooth of a journey as I would have liked. But I think I’ve grown a lot from it to get to this point.

How long did it take you to find your first job after you graduated?

I didn’t really get a lot of guidance from people I knew in the profession or my own program as far as when the right time was to start applying for a job. So I applied a little bit late. I had applied for a few jobs before I graduated, but really wasn’t getting any hits or anything. And then I took the NBCOT. I graduated in May and took it at the end of June.

I got my license in July and started at the hospital in August. But I had made a little bit of a connection with them a few months before. So I went back and said “I’m ready; I have my license.” So about a month or so after, I had everything completed in order to work. And then I stayed there until just after the first of the year, and that’s when I took on the second facility. So I’ve been managing those two until the last two weeks.

Have you heard that it’s harder for OTs in St. Louis to find jobs?

Yeah, I definitely have. I’ve worked with a couple veteran PRN therapists who have been in different areas and have been in St. Louis for a while. I remember a couple months into starting working she told me, “Every time I work with a student or I work with a new grad, I tell them you need to get out of St. Louis to build your career. Because you’re going to struggle, you’re going to make choices that don’t necessarily fit with your values. Or it’s going to take you longer to get to where you want to go in your career.”

And it was hard to hear that after the fact, but I think she’s been right to a certain extent. But, what makes it a little more challenging is that all of the hospitals here are owned by three main companies from Columbia to right across the river in Illinois – all the same companies. So when you’re applying for one and it doesn’t go well…they have a lot of control I would say. They can be super picky.

I know compared to nurses or other healthcare professions, the number of therapy jobs are not anywhere near what the demand is. So I definitely feel like that’s been a pressure that I didn’t know to expect. In school, they make it sound like our profession is growing and there’s so many opportunities. And I think it’s true if you’re looking at it across the spectrum of pediatrics, outpatient, acute care, and mental health. But definitely when I decided I wanted to go into medical settings, I thought I could walk into any hospital and there would be an opportunity.

But it definitely has been a little bit of a challenge so far. But I’m hoping that, whether for better or worse, it’s been a temporary barrier. It’s just having that year of experience.

Is there anything unique about OT in the region?

The saturation of occupational therapists here. There are three OT programs in the city. And I had never thought about that until I started looking. I was like, “Oh, I’m competing with everyone else in St. Louis that’s graduating in the next few months.” At the hospitals here, there’s a big funneling of students through the hospitals and then they’re going to hire one of their own who’s been there for clinical before they hire someone from an outside school who’s gotten the same level experience.

I’ve run into that before where they end up hiring someone who was a student who went to PRN. And then of course when an opening comes up, it all transitions smoothly. The number of PRN jobs is more than the full time jobs. When I’ve been looking, it seemed to be that full time jobs are rare. But when they come, they come a bunch at once and then they’re gone for a while.

Do you feel like OT is appropriately represented in your setting?

I think in inpatient rehab, occupational therapy is pretty well respected and held equivocally to all three disciplines. In settings where OT is not required, we can get lumped in with PT orders without any understanding of what we do and why is it different than PT. And I’ve run into a challenge with patients getting them to participate in therapy.

Every evaluation I do, PT’s main goal is to get the patient to walk. I think there’s so much more of an understanding about what physical therapy is and what they do. When people come into the hospital they’re worried about will I walk again, will I be able to use my legs again, will I be able to do my normal routine? And the first thing is mobility that people think of.

So that’s been hard in trying to advocate or justify what my role is and why it’s so important to patients. They’re like, “I don’t need to work on putting my socks and shoes on. I don’t need to work on showering. I don’t need to do those things. I want to walk. I want to go up and down the stairs.”

I think that’s the way that I ran into it the most so far. Not necessarily with other disciplines or physicians or anything like that. But I know that it does happen in other settings where there’s less of an understanding of what our profession is, and we just get lumped together with PT. I’ve seen a lot of acute care transfer orders, when they come to rehab, it just says OT/PT orders. And not really any kind of justification of what the difference is between them.

How would you rate the compensation in this area?

Obviously PRN rates are going to be more than your full time rates. That’s my knowledge so far. I think they kind of go on a range based on experience level. So based on where I was in my career, I was OK with it. Being a student before, it’s 2x more than I’ve ever made ever. And the most I had never made before was $15 an hour being a rehab tech. So that’s all I’d known. And that’s OK. I was living at home at the time – that’s plenty, I’m not worried.

Then when I started at another facility they had a standard rate for everyone. It was decently higher than what I was getting. So being PRN and balancing two facilities, it’s hard to be as excited about going to one where you’re not making as much versus one where you enjoy everything, you enjoy everyone, and the pay is quite a bit more. And then one of them had a weekend differential as well.

When I was making priorities about which facility to work, I was influenced by the fact that I’m in my mid 20s and I need to have a stable financial income. That influenced my thought process when I was prioritizing scheduling. As far as the offer I just got for a full time, it was definitely less than PRN which makes sense. It was still more than I expected as far as hourly rate full time. I don’t think I have experienced much of an issue so far. But I don’t necessarily have a lot of perspective as far as other areas or other settings.

What are your future plans for your career in OT?

My main goal in the short term has been finding something full time. So the fact that I’ve achieved that, I know that will bring a lot of new challenges in learning how to be a therapist with one caseload, being there every day, taking on more responsibility. I think that’s my short term goal is to get good at that new role.

Part of what drew me to a complete setting change was that after a year, I was looking for something new, less monotonous, something a little bit more challenging where patients had a lot more acuity in their diagnoses. I wanted something that refreshed my excitement about why I chose medical setting OT. I will get to work with PT a lot more, there will be less individual treatments, more co-treats, and more collaboration.

Right now I’m trying to get the education so I can step into that role with patients who are on vents, trachs, and things I have no experience with. It’s hard to say now that I’m gonna make this change. I have also looked into specialty certifications in neuro with that being my area of interest in the last year and it’s something that’s really prevalent in inpatient rehab. This past spring I did the first two levels of the NDT certifications, and I see myself going in this direction in stroke and brain injury rehab. I think at least this will push me to be a better therapist and give me a new set of skills that will make me more marketable going two years out, five years out.

The other thing that I’m looking forward to in the near future is getting to have fieldwork students now that I’ve been into my career for a year. I had some great therapists that I worked with when I was still in school. And at the facility I’m getting ready to start, they’ve been up and running for nine months. So I’m hoping I can have an influential role in establishing a student program and getting that started.

I know there’s a big need with Wash U, Saint Louis University, and Maryville for fieldwork placements. Long term acute care is definitely a setting that isn’t well talked about and isn’t as common knowledge compared to the ones out there that most of us end up going into a when we graduate.