To Tuck or Not to Tuck? Making Sense of Swallow Strategies

Speaker1:
[0:16] Hi, everyone. I'm Emily.

Speaker0:
[0:18] And this is Eva.

Speaker1:
[0:20] And you're listening to Speech Talk.

Speaker0:
[0:22] We're your research book club so you can do evidence-based practice and practice.

Speaker1:
[0:27] So let's start talking.

Speaker0:
[0:28] To introduce today's topic, Emily, how many hours did you work today?

Speaker1:
[0:33] So many. So I was listening to episode 34 where we're talking about how it's so nice in the summertime and we get all this time off. But that also leaves room for extra PRN work because people are taking vacations. So sometimes you end up working two full-time jobs And I'm so tired. I don't know why. It was like all of those summer weeks where I was working nothing and I was just like scraping by on these hours. And I'm like, yes, give me that vacation time. And now I'm like, give me sleep. I just want my bed.

Speaker0:
[1:13] The kids in our friend group do this like, are you one? Are you two? After a happy birthday song. So I'm going to do that for like for work hours. But I'm going to start at six. Was it six? Was it seven? Was it eight? Was it 9? Was it 10? Was it 11?

Speaker1:
[1:30] It was 11!

Speaker0:
[1:31] It was 11 hours today! So much documentation. And if you didn't know that sometimes your speech therapist is working 11 hours, now you know. Multiple sites, multiple jobs, gotta hold it all together.

Speaker1:
[1:49] That's the hard part about an hourly job, because if the hours aren't there, you're not making money, So then you're really crunching an hour sometimes.

Speaker0:
[1:58] Yeah, I would love to know what like the average annual salary is, but at what times, you know? So like obviously your salary gets averaged over the year when they're doing projections on what speech therapists make. But I'm like, some weeks you make nothing and other weeks like you're raking it in. And I would just wish that was more of a part of the conversation when we're learning about our profession. Like, guess what? Some weeks you will have like three hours of work every day, and other weeks everyone will be trying to get you to work as many hours as humanly possible.

Speaker1:
[2:34] And it's always on holidays.

Speaker0:
[2:36] Always around the holidays, man.

Speaker1:
[2:38] I always want you to work 15 hours on Christmas, except for the people on your schedule. They want you to go away.

Speaker0:
[2:45] That's right. It's like, do I have to show up? We all know they don't want me here. Wear a Santa hat. Make it festive. Bring them a Noro. Whatever. Okay. So here is a number that I want to open with from our 2024 study of therapists in skilled nursing and assisted living facilities. Across all the rehab disciplines, so OTPT, SLP, one in five practitioners scored in the extreme range for burnout. So not just stressed, but extreme on some well-established clinical burnout scales. So that's going to be kind of where we're headed. And if you don't believe Emily is headed there on 11-hour workdays, then I don't know what your breaking point is.

Speaker1:
[3:30] And I'd bet almost nobody listening is surprised.

Speaker0:
[3:35] Yeah, if you're in the biz, then you know. If you know someone in the biz and you listen to them complain about work, then you know. And if you don't know, now you know. So yeah, that's kind of the point of what we're getting to is that we all feel this. And what we're going to do today is actually ground it in some data. So we have two studies. They're both in the adult clinical settings, so hospitals, SNFs, and talk about what is actually driving it. Because we hear a lot about like self-care, but that's not always what is happening, especially when we're hearing people are burning out and feel the need to leave their profession.

Speaker0:
[4:10] Anyways, on that cheery note, excited to get into it after this break.

Speaker1:
[4:18] So let's set up why this conversation matters specifically for those of us in skilled nursing facilities, hospitals, and outpatient clinics. We have caseload composition, payer pressure, documentation systems. The whole shape of the job is its own beast in adult medical practice.

Speaker0:
[4:38] Seriously, I feel like so much of what you learn in school is just all the clinical stuff. And then you get into the clinical space and they're like, how do you not know anything about like documentation requirements, productivity standards, like it's a whole retraining process. And as a result, we're going to be talking about stress. And what we're going to hear today is the mechanism of that stress, which is productivity standards. We have done a previous episode on productivity standards, but I really wanted to do a deep dive on how that actually correlates with burnout. So we have two studies on the topic in different ways they point at the central driver. One is a 2024 study out of a skilled nursing and assisted living facility, which looks at the relationship between productivity requirements and burnout. Nope. And the other is a 2023 study of SLPs working across hospitals and rehab centers, measuring their occupational stress directly.

Speaker1:
[5:39] Different settings, different countries, actually. But let's see if the pattern holds. Let's start with the SNF study, since I think it's most directly actionable

Speaker1:
[5:51] one for a lot of our listeners, at least.

Speaker0:
[5:54] Okay, let's dive in. Emily, tell us, what was our first study?

Speaker1:
[5:59] Okay, so up first, we have Coleman, McLaughlin, and Florin, published in the American Journal of Occupational Therapy in 2024. Title's a mouthful. Practitioner Burnout and Productivity Levels in Skilled Nursing and Assisted Living Facilities, Part 1, A Descriptive Quantitative Account.

Speaker0:
[6:21] I love that, Part 1. I think that may be our first title that's like over 10 words long. Well done. Well done, you guys. So something I want to flag right away is that this isn't SLP exclusive. It's for all of the rehab therapies and I think also with the assistance program. It's all in SNF and assisted living facilities across the U.S. 366 practitioners totaled and they were surveyed online. They just did a snapshot, not sort of an ongoing experience.

Speaker1:
[6:52] Why is a cross-discipline study still relevant for an SLP audience?

Speaker0:
[6:58] Well, I just think off the bat it's because we work with everybody. We are in there with the PTs, the OTs. We have the rehab therapists. We talk to the doctors, the nurse practitioners. Like, we talk to everybody. But more poignantly, we're all working on the same productivity requirements. It hits every rehab discipline. So it's not just a caseload composition or a diagnosis-specific thing that we may be working on versus our colleagues. But this is how we are all judged and determined.

Speaker1:
[7:31] So what did they actually measure?

Speaker0:
[7:34] Okay, they use this really interesting thing that I did not know about. It's called the Maslach Burnout Inventory. I don't know if I said that right.

Speaker1:
[7:44] Your whole Jewish thing came out.

Speaker0:
[7:48] I got my chuch in there. That's what that or it's like Maslach Burnout Inventory.

Speaker1:
[7:54] That's my Ohio accent, Maslach.

Speaker0:
[7:57] I'm going to start calling it the MBI. Okay. It is a gold standard burnout questionnaire, and it's the same ones used for a lot of physician and nurse burnout research. It looks at three main things. Emotional exhaustion, depersonalization, where you're kind of like feeling numb or checked out, and personal accomplishment, meaning whether you still feel like your work matters or if you're good at it. Okay. They look at those areas. Plus, it has a set of questions about productivity, the standards, and what they call ethical questionable behaviors, things that get pulled into the gray zone when a clinician is under pressure to hit a number.

Speaker1:
[8:36] Meaning decisions that get shaped by the productivity target rather than purely by clinical judgment.

Speaker0:
[8:42] Do you know those moments where you're like, I've got to meet productivity today, and I have to make a quick clinical judgment? What does that feel like?

Speaker1:
[8:52] It feels like all my goals are in a google doc because i don't have time to think clinically under pressure oh but that's

Speaker0:
[9:00] Like so spot on we all have goal banks right and if you're like me you may have bought those goal banks you didn't even write them initially, but i just wanted to bring us back to those three topics emotional exhaustion depersonalization and personal accomplishment, right? And I think those are all things we experience. Just the feeling tired, feeling like I'm not emotionally present at work. And finally, that last one, I feel like we hit a lot on this podcast, like, is what I'm doing even helping? Does it matter? You know, this almost like existential anxiety.

Speaker1:
[9:41] Yeah, we have to stop doing that.

Speaker0:
[9:43] Yeah, you know what? We're part of the problem.

Speaker1:
[9:47] We're like uh It's amplifying the problem. Everyone's going to have existential crises after listening to the podcast.

Speaker0:
[9:56] Hilariously, though, I think we got into this because we were trying to move away from that. We were like, we want people to feel positively about work. We want to help them find answers that they are not able to find on their own. We want to provide a supportive research space to, you know, help people feel valued. And we're like, what does anything mean?

Speaker1:
[10:17] I really like this inventory too, because all of these things are so, so heightened in the medical field, like way more so than, I don't know, working in construction maybe, right? Like emotional exhaustion, having to talk to people about their life moving forward after tricks or having to make really serious medical decisions because they've had strokes or doing the counseling, having to constantly be an ear to somebody new six times a day, always empathetic. Like that is hard or when you're when you're doing the same treatment back to back to back to back like that is numbing when you're just repeating the same things over and over it gets it's monotonous so you really don't feel like you're making a good impact you feel like a robot

Speaker0:
[11:20] It kind of reminds me what you're saying of like I used to just I remember one day it hit me in school that my teacher had just taught this lesson like four times in a row and I was like Dear God, how are they so pleasant? They've been teaching the same chapter to four different classes today. How are they not having their brain running out of their ears?

Speaker1:
[11:42] Right.

Speaker0:
[11:43] But to that point that you're saying with making sure you're there for people... And it is hard. I mean, I hold the hand of a crying person at minimum once a day. You know, people are going through something really difficult and, having to navigate that space where you are allowing them to have their feelings and also saying we got to keep our eye on the prize and trying to help them come out of that space and in towards a, productive therapy space without really doing any therapizing. Because we're not therapists, it's hard. We're constantly towing a line.

Speaker1:
[12:23] Right. Do you know how awkward it is to try and grab your book bag while somebody is crying to leave? Oh, God.

Speaker0:
[12:29] When somebody begins crying like three minutes before your session ends and you have to look at somebody and somehow go, I hear your feelings and they are valid and I need to leave you now.

Speaker1:
[12:49] It's so awkward. It's so awkward. Yeah. There's nothing to say. What can you say? Yeah.

Speaker0:
[12:56] Just, as you said, slowly pick up your bag and begin edging out of the door. And here's the headline finding. 25% of practitioners scored in the extreme range on all three parts of that burnout questionnaire.

Speaker1:
[13:11] Dude, that's rough. Being in the extreme range on all three of those at the same time, it just feels like... I don't know. In my personal experience, maybe one makes the other or they all kind of end up going hand in hand. So I guess I'm a little curious if it's all three because... It's all happening. Like, you can't really separate those. If you're making ethical, questionable behaviors, then you're probably feeling a little bit numb if you don't care about the ethics of your job anymore. And if you don't care about the ethics of your job, you're not going to feel any kind of personal accomplishment in what you're doing.

Speaker0:
[13:55] So I really think you hit on something, which is that one kind of probably goes with the others. For me, I know when I am exhausted, like literally like sleep deprived, it causes this whole cascade of other negative thoughts and feelings and I just have a harder time processing what's going on. And so I think that the first one being emotional exhaustion to me seems very reasonably related to depersonalization or your sense of accomplishment. And I think being that's really great for us to know that, you know, if you're feeling emotionally exhausted, like you have patients who are particularly difficult or you're dealing with too many patients at once and you're feeling exhausted as a result of that. You know, who knows what you can do about your schedule or your timing, but. Maybe somebody can help you out with it, or at least recognizing it gives you then the opportunity to try and balance it out by finding the space somewhere else to just decompress, get your hair pressed, get a back rub.

Speaker1:
[15:02] What was the productivity connection specifically?

Speaker0:
[15:06] Right, so this is the part I think is genuinely important for how we talk about this. The study found a real measurable link between productivity requirements and all three parts of burnout. The emotional exhaustion, depersonalization, and personal accomplishment. And that held up even after the researchers accounted for other factors that might otherwise explain it. And separately, productivity standards were clearly tied to five out of six of the ethically questionable behaviors they measured.

Speaker1:
[15:37] So the pressure to hit a number doesn't just make people tired, it's associated with them making choices that they wouldn't otherwise make.

Speaker0:
[15:45] Which I think is exactly what we talked about in our productivity episode, that people are put in positions of having to make decisions that they wouldn't normally have to make if they had more time.

Speaker1:
[15:57] Right.

Speaker0:
[15:58] So at least that's the implication. And I think that the piece that gets under discussed in most burnout conversations, this isn't just like, I'm tired, I need a nap. This is a study suggesting that productivity pressures create conditions where clinical integrity and burnout are entangled. Moral distress. I know we heard that one in our last episode. You know, essentially layering on top of that plain fatigue. Moral distress is a very deep and complex feeling and leaves you not feeling great.

Speaker1:
[16:32] Yeah, it definitely tracks with something I hear constantly from other skilled nursing-based SLPs, the guilt of feeling like you're choosing between hitting your number and doing what's clinically right for the patient in front of you. Yeah. I mean, it's constant. You're always asked to do things faster or to try and hit numbers quicker. Like, you want to hurry up and get them treated and off your caseload 30 minutes, but not if they're Medicaid.

Speaker0:
[17:07] And you and I have talked about this, that, like, sometimes you find your patients in a condition and you're like, dude, I just need to take care of you as a person right now. Like let's clean your fingernails let's get you up let's get you cleaned and that is literally not our job and so then it becomes like a question of well how am I supposed to get my work done because I, like as a person I just don't feel like I can leave my patient like this, on the other hand if I don't do my clinical work with them, then they're not going to make any progress and they won't get reimbursed. Like we may not get reimbursed, you know? So it's just, yeah, the time constraint is really hard.

Speaker1:
[17:51] It's truthfully not really about which building you end up working in either. Yeah.

Speaker0:
[17:57] Well, and to that end, the researchers looked at whether setting type, skilled nurses versus assisted living, skilled nurses, skilled nursing versus assisted living was actually driving productivity requirements. And it wasn't, at least not in any meaningful way. What did clearly drive productivity demands was a clinician's role. So whether you were an evaluating therapist or a therapy assistant.

Speaker1:
[18:22] That's interesting that the productivity demands were dependent on evaluator versus assistant. And I feel like that's

Speaker1:
[18:32] That's interesting, but not surprising because I do hear it. I hear it from mostly that I work with like three CODAs and they're always talking about not enough hours to go around, not enough hours to go around. And even the OT, they're like, well, now I have four evals or five evals and I don't get to see any of my treats and yada, yada, yada. So like her stress, like that evaluator stress seems different than her assistant stress or like the occupational therapy department's assistant stress because their stress is more hour based because they have to, they're only allowed to work within those specific times. But the role of the evaluator is maintaining a large enough schedule so that she can

Speaker1:
[19:25] Provide enough hours to have all of these people working in these buildings who are promised all of these hours so that they can be their family. So, but that is not our world, right? Our world, as far as the speech therapist in the skilled nursing setting, which is really different than the other disciplines, is that we are everything. We don't, like, I am your everything. If you need speech, voice, swallowing, I'm your girl. You want someone else? Too bad. Switch buildings because this is it. And I probably work in the building next door too

Speaker0:
[20:07] Well and to that point you know um, Across the U.S., there are SLPAs or slippers, but we mostly see them in schools. I've never worked at a building that ever had a speech assistant.

Speaker1:
[20:21] No.

Speaker0:
[20:21] Yeah, you wear all the hats. Right.

Speaker1:
[20:23] Even in, like, the teletherapy world, the schools provide people who don't have slippers. They have, like, a facilitator, like, just someone who's there helping. So it's, yeah, we don't have. And if we did have SLPAs, there would be no skilled nursing jobs for speech therapists. Yeah.

Speaker0:
[20:47] So I want to bring us back to kind of how we frame the conversation about stress and productivity. What the articles seem to be saying is that it's not really about where you are in the whole rigmarole of reimbursement. And it's not about picking the better company or picking a better setting, which I have definitely heard people are like, oh, don't work for that company. Don't work for that company. It's actually more about how we get paid for our work and how it's measured. Emily, you have worked in a lot of different settings. I have worked at one hospital and they are really good about giving us a lot of space. So for me, the pick a better setting has been.

Speaker0:
[21:30] I hate to say it a little bit true, you know, that they're way more strict. There's not the flexibility of skilled nursing. But at the same time, they, at least at this hospital, have really worked to build a culture of being like, we want our therapists to do well. We're going to give them lots of time to get their things done. And mostly that comes in the form of delegating. Like, I don't do scheduling stuff. I don't fix meal trays anymore. I don't do any of those other things. That is all handled by administrators. So I get a lot more time back in my day, because all I have to do is go into the room, see my patient and document. That's it. I don't have to fix any other broken problems. There's someone else for it. So, Emily, you have worked at more settings than I have, more buildings than I have. How do you feel like your SNF job compares to some of your other PRN work in terms of the amount you're expected to do and creating potential burnout?

Speaker1:
[22:27] I think that setting absolutely does play a big part in it. But I also think kind of along the lines of what you were saying, that culture makes the business. So it might not always be the general setting, like long-term acute, long-term care, residential, locked unit, memory care units. It might not be like those type of settings that make a huge difference, but the difference is in the culture of the workplace. So I would say that there are sometimes measurable differences and you can really tell that. Where people are cared for and where the employees are valued and cared for versus places where you're meant to make a number. And if you don't make that number, they'll find somebody else. Yeah.

Speaker0:
[23:30] Tough. That's like, them's the breaks. That's tough.

Speaker1:
[23:34] So what do the authors recommend?

Speaker0:
[23:36] Okay, so to kind of wrap up this conversation on burnout, I wanted to just take a look at three questions from the, and I'm probably going to say it funny again, Masla Burnout Inventory Questionnaire. And we're choosing these three questions because they were free. And the whole questionnaire is money.

Speaker1:
[24:05] That's typically how we choose our resources like do you want to pay seven dollars

Speaker0:
[24:10] Or the free version free yes well you pay 30 for this article for 24 hours no thank you i'm sure there's something else somewhere all right okay so the way these are laid out is it has a question and then there's like a little range of options at the bottom from like never, sometimes, never, rarely, sometimes, always is kind of the range. So first question, I feel emotionally drained from work, which I know we have all been there. Like you get home, you're like, wow, that was a lot. The next one is, I don't really care what happens to my patients. And I thought that was kind of a wild question.

Speaker1:
[24:53] Because who's going to admit

Speaker0:
[24:55] That?

Speaker1:
[24:57] Yeah, that is, that's crazy. I mean, if it's anonymous, like maybe somebody would be like, I don't care. Like at the end of the day, you could say I don't care. But like we are in a caregiving field. I think that none of us are actually answering.

Speaker0:
[25:13] Okay. I'll push back a little bit because the other day when I was at home with my kid and people are going to be like, you terrible mother. But like there was at some point my daughter just was constantly trying to like go off her like scooter over and over and over again. Eventually I was like, you know what, if you fall off the scooter, you fall off the scooter. Like I don't care anymore. And so in the sense that, like, I always care what happens to my child, but I was willing to, like, let a certain amount, let her experience a safe amount of harm. Yeah. I was like, I'm done. I am done telling you not to get on the scooter. I'm done telling you not to get on the scooter. And I kind of think about conversations that may not literally sound like that at work, because hopefully there's no scooters at work, but that have that kind of same tone. That they're like, Okay, like I went in and I did this, you know, therapy a hundred times, but nobody listened. I mean, how many times have we said that? It's like, there's nobody's doing our recommendations. Nobody's following our recommendations. Why should I do this anymore? Nobody's listening to my recommendations. It's like, oh, it's starting to sound like maybe I don't care, but I do, I do care.

Speaker1:
[26:28] Yeah I feel like we've talked about that before too like the the saying I don't care and it's like no I I say that because I'm trying to dissociate from how much I actually care about what's going on because it sucks to feel like what you're doing isn't matter like it doesn't matter yeah say that like I don't really care what happens to my patients like I don't think any of us could truthfully say that because why would we be doing this in the first place, right? Like we have a duty to the people that we work with to, to like hold some stock in the things that we're saying, the things that we're doing. So if we don't care what happens, like then you're really not doing anything.

Speaker0:
[27:13] Yeah. And I, I think to the point of like this research in this questionnaire, it's like, if you're starting to feel that way, then you really need to take a step back. Like you, to your point, it's like, then you are not caring what are the outcomes for your patients. That's not okay so if you're starting to get to the point where you feel like what i'm doing isn't helping or my patients don't uh you know for some reason you're feeling like you are emotionally disengaged, then like that's a time that like you need to go do some healing for yourself, have a margarita on the beach man like get out there leave the office but i think that transitions us really well to the third question and last free question, which is I have accomplished many worthwhile things from this job. And I don't know, I feel like that one kind of hits hard also from the always to never scale. It's like, yeah, some days you have those days where you're like, wow, I just like knocked it out of the ballpark. There was so much that I did that was, impactful and other days you're like nothing I did mattered.

Speaker1:
[28:26] I feel like that that word many holds a lot of weight in this sentence too like I I'm typically the one who's going to be over analyzing like I'll put myself on like uh what's that mild moderate scale like like half the time half of my treatment I'm like we're maybe a while like we're many we're over 75 percent of the things that I did today worthwhile. I don't know. Because it does. Sometimes it does feel very monotonous doing the same thing over and over and over again. Yeah.

Speaker0:
[29:03] But the flip side is like if you and I were on a phone call after work and you're like, dude, nothing I did today was worthwhile. I'd be like, every diet slip you wrote was relevant because it wasn't going to get done. That was just like a routine safety check for a bunch of people you did. Every documentation, a piece of documentation you did was important. Every time you brought someone a tray, you checked it to make sure it was right, was important. Every time you validated someone's experience, that was important. That was worthwhile. And it's like, I think because we do them every day, they can start to seem, less important or impactful. But it's kind of like when you're a tourist somewhere. It's like, whoa, this city is incredible. And then you get used to it and you're like, I live here now, whatever. It's the Eiffel Tower. Who cares? That's for if we lived in Paris, obviously.

Speaker0:
[29:58] But at some point you have to remember, dude, that's the Eiffel Tower. Doesn't matter if you live near it or not. It's pretty awesome. I guess all that is to say as clinicians out there, you all live in Paris and work in this metaphor. So I hope that if you are feeling any symptoms of burnout, just know that, you are not the only one, and that these are things that you can improve by being able to get some space and take care of yourself and just to recognize it when it happens. So until next week, we hope to hear from you guys again. I guess you're hearing from us again.

Speaker1:
[30:41] Thanks, guys. You've been listening to Speech Talk.

Speaker0:
[30:45] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker1:
[30:51] If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world because as podcasters, our love language is in positive affirmations.

Speaker0:
[31:02] And if you like listening to us, you may like more podcasts from our network, Human Content, like How to Be Patient, Bendy Bodies, Knock Knock High with the Glock and Fleckens, and Psychiatry Boot Camp. If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Speaker1:
[31:27] If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker0:
[31:39] We're your hosts, Eva Johnson and Emily Brady.

Speaker1:
[31:42] Our editor and engineer is Andrew Sims.

Speaker0:
[31:45] Our music is by Omar Benzvi.

Speaker1:
[31:47] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker0:
[31:52] To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers.

Speaker1:
[32:04] Speech Talk is a proud member of the Human Content Podcast Network. Humans are dead.