The following is the first in a series on self-care and preventing practitioner burnout from faculty member Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC. Jennafer is the co-author and co-instructor of the Boundaries, Self-Care, and Meditation course along with Nari Clemons, PT, PRPC.
“I just want you to fix me.” How many times have we heard this statement from our patients? And how do we respond? In my former life as a “rescuer” this statement would be a personal challenge. I wanted to be the fixer, find the solution and identify the thing that no one else had seen yet. Then, if I am being completely honest, bask in the glory of being the “miracle worker” and “never giving up” on my patient.
If you recognize that this attitude was going to run me into some problems, kudos to you. If you are thinking, “well of course, isn’t that your job as a pelvic floor physical therapist?” Please read on.
On my very first job performance review, when it came time to discuss my problem areas my supervisor relayed I was “too nice” and cited some examples: giving a patient a ride home after therapy (it was raining and she would have had to wait for the bus), coming in on Saturdays to care for patients (he was sick and couldn’t make it in during the week but was making really good progress). You get the picture. At the time, I didn’t understand how this could be something I needed to work on. I was going above and beyond and I got so much satisfaction from taking care of others!
Fast forward 10 years and add to my life a husband, two daughters, a teaching job, part time homeschooling, and writing course material. I was an emotional mess. Anxiety was my permanent state of mind. I gave my best to my patients while my family got my meager emotional leftovers. Something had to change and luckily it did. I got help and learned exactly what boundaries are and how to develop as well as enforce them.
There are several resources that discuss professional boundaries in health care, like this from Nursing Made Incredibly Easy. In this particular article, health care professionals are exhorted to stay in the “zone of helpfulness” and avoid becoming under involved or over involved with patients. Health care professionals are also urged to examine their own motivation. Am I using my relationship with my patient to fulfill my own needs? Am I over involved so that I can justify my own worth?
Here are some warning signs that you are straying away from healthy boundaries with patients and becoming over involved:
For some people, certain patients who push professional boundaries will cause the therapist to feel threatened and under activity is the result. This might result in talking badly about the patient to other staff, distancing ourselves, showing disinterest in their case, or failing to utilize best care practices for the patient.
Per Remshard 2012, “When you begin to feel a bit detached, stand back and evaluate your interactions. If you sense that boundaries are becoming blurred in any patient care situation, seek guidance from your supervisor. A sentinel question to ask is: ‘Will this intervention benefit the patient or does it satisfy some need in me?’”
Healthy professional boundaries are imperative for us and for our patients. Boundaries also help prevent burnout. Remshard delineates what healthy boundaries look like:
If you struggle with professional and personal boundaries, you are not alone and you can get support. Consider talking with your supervisor, a counselor, reading a good book on the subject or taking Boundaries, Self-Care, and Meditation, a course offering through Herman and Wallace that was designed to help pelvic health professionals stay healthy and inspired while equipping therapists with new tools to share with their patients.
We hope you will join us for Boundaries, Self-Care, and Meditation this November 9-11, 2019 in San Diego, CA.
Look forward to my next blog where The Rescuer (me) needs Rescuing and learn about the Drama Triangle.
Remshardt, Mary Ann EdD, MSN, RN "Do you know your professional boundaries?" Nursing Made Incredibly Easy!: January/February 2012 - Volume 10 - Issue 1 - p 5–6 doi: 10.1097/01.NME.0000406039.61410.a5
Tiffany Ellsworth Lee MA, OTR, BCB-PMD joined the Herman & Wallace faculty to teach a course on biofeedback along with Jane Kaufman, PT, M.Ed, BCB-PMD. The month of April is Occupational Therapy month, and we are celebrating by highlighting the role that Occupational Therapists play in pelvic floor rehabilitation. Tiffany founded a biofeedback program at Central Texas Medical Center in San Marcos in 2004, and currently runs her a pelvic rehab private practice .
Working in this area of biofeedback is extremely rewarding and fulfilling to help change peoples’ lives. I have a private practice now exclusively dedicated to treating patients with pelvic floor dysfunction. I became involved in working with patients with incontinence and pelvic floor disorders because of many opportunities along my career path. I have been an Occupational Therapist since 1994. Both of my parents are also OTs, so I think I was born to do this!
Erica Vitek, MOT, OTR, BCB-PMD, PRPC wrote a blog recently about the role of OTs in pelvic health. She writes:
“As we look closer at the framework and the definition of OT (Occupational Therapy Practice Framework: Domain and Process, 3rd edition 2014), there is clear evidence that the occupational therapist (OT) has a role in the treatment of pelvic health conditions. Importantly, occupations are defined by this document as ‘…various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living (ADL), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation.”
The clearest examples of the OT’s role in pelvic health occupations within this section include:
"We believe that the great patient need that exists can be better served by having trained OTs able to treat pelvic health conditions"
Occupational therapists wishing to pursue pelvic floor have a few options. The first thing is to find a pelvic floor clinical setting or work with their respective settings to check to see if they can start a women's health program with a strong focus on pelvic floor. OTs quite often do not start out in pelvic health directly after school and since this is a newer area as compared to other certifications such as the NDT and PNF it takes a little bit of research, time and effort to find one’s exact niche. To get started, an OT should seek out courses that teach the basics of bladder and bowel management. It is important to understand the anatomy and physiology of the bladder, bowel, and sexual systems.
Incontinence and pelvic floor disorders have a profound impact on occupation, the daily activities that give life meaning! OTs should have a larger role in treating this patient population. Offering hope to our patients is imperative when he/she is dealing with pelvic floor dysfunction!
Keep an eye out for an upcoming post from Tiffany with some inspiring clinical case studies. You can join Tiffany and Jane Kaufman in Biofeedback for Pelvic Muscle Dysfunction to get lots of hands-on time with surface eletromyography, and to work toward BCIA certification!
The Institute has welcomed occupational therapists since our founding in 2006. In addition, three OTs: Richard Sabel, MA, MPH, OTR, GCFP, Erica Vitek, MOT, OTR, BCB-PMD, PRPC, and Tiffany Ellsworth Lee MA, OTR, BCB-PMD all teach courses as members of our faculty. (Erica Vitek is also one of several OTs who holds certification as a Pelvic Rehabilitation Practitioner through H&W).
Recently, the Institute was contacted by an Occupational Therapist who has attended many of our courses, regarding a challenge she was experiencing obtaining CEUs in her state (Oregon) for courses on Pelvic Rehab and Biofeedback. In light of this, the Institute has been discussing with some of the occupational therapists on our faculty, as well as representatives of the BCIA and Marquette University, and how to spread awareness about and recognition of OT’s roles in pelvic rehab. Below, we’ve asked faculty member Erica to share a bit more about her journey and the role of the pelvic rehab occupational therapist.
As an OT student, I had a professor who brought in practicing clinicians to discuss their unique roles out in the field. Pelvic health happened to be one of the topics of the day. I was completely intrigued by the clinician, who had such passion about the role of OT in pelvic health. It became clear that helping people with impaired basic bodily functions was imperative to fulfilling life roles and participation; it was OT. I knew from that moment that I wanted to help people deal with these challenging, private issues.
In my journey, I did not immediately start out in pelvic health, but instead in an acute care hospital that had a women’s health program with a strong interest in pelvic health. A very experienced OT and her team of 2 additional OTs were doing great work in that department already. The window of opportunity opened for me to mentor with that group and I eventually was able to begin to get my own referrals and develop a robust hospital-based outpatient practice. At that time, ALL of my experience had been with OTs doing this work and I was naïve to the fact that outside of my world, most of the clinicians doing this type of work were physical therapists (PT). I asked to join a highly trained and skilled group within my health system of all women’s health PTs. Overtime, I was able to demonstrate my level of competency within the group of PTs and contribute valuable things to our organization. Herman and Wallace Rehabilitation Institute was instrumental in my quest to demonstrate competency as they allowed OTs a clear pathway for enrollment in their coursework and application for the Pelvic Rehabilitation Practitioner Certification examination. I can be proud to have those credentials to my name.
My challenges in the area of pelvic health practice have thankfully been minimal, nearly nonexistent, and it has come to my awareness in recent weeks that this is not the case for OTs around the country trying to develop themselves as pelvic health practitioners. My original OT mentors reassured me with the AOTA’s published document titled Occupational Therapy Practice Framework: Domain & Process, detailed a clear place in the role of pelvic health. This document has gone through 3 revisions over the course of its first publication in 2002. The 2nd edition was published in 2008 and the 3rd edition in 2014. I’d like to cite a few important areas of the document that I find to be helpful in an OT’s quest to demonstrate our role in pelvic health rehabilitation.
I’d first like to quote the definition occupational therapy according to the 3rd edition, “occupational therapy is defined as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings. Occupational therapy practitioners use their knowledge of the transactional relationship among the person, his or her engagement in valuable occupations, and the context to design occupation-based intervention plans that facilitate change or growth in client factors (body functions, body structures, values, beliefs, and spirituality) and skills (motor, process, and social interaction) needed for successful participation. Occupational therapy practitioners are concerned with the end result of participation and thus enable engagement through adaptations and modifications to the environment or objects within the environment when needed. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non-disability-related needs. These services include acquisition and preservation of occupational identity for those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. “
As we look closer at the framework and the definition of OT, there is clear evidence that the occupational therapist (OT) has a role in the treatment of pelvic health conditions. Importantly, occupations are defined by this document as “…various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living (ADL), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation.” The clearest examples of the OT’s role in pelvic health occupations within this section include: 1) ADL section: toileting and hygiene (continence needs, intentional control of bowel movements and urination) and sexual activity. 2) IADLs section: sleep participation (sustaining sleep without disruption, performing nighttime care of toileting needs). 3) Achieving full participation in work, play, leisure, and social activities, requires one to be able to maintain continence in a socially acceptable manner in which they can feel confident and comfortable to fulfill their roles and duties.
Client factors as defined in this document are “Specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occupations. Client factors include values, beliefs, and spirituality; body functions; and body structures.” Client factors are further identified as affecting the performance skills and participation of the clients we work with. OT’s role per definition is to “facilitate change and growth in client factors”. In order to fully enhance our client’s performance skills/participation related to change and growth in client factors, OT’s have to examine the whole person, including pelvic health impairments, which have a negative influence on performance. Within client factors, the document defines body structures as, “Anatomical parts of the body, such as organs, limbs, and their components that support body function.” Within this category, one can refer to multiple items named that relate to the care that OTs provide in pelvic health rehabilitation, including but not limited to, structures related to the digestive, metabolic, and endocrine systems and structures related to the genitourinary and reproductive systems.
Since the first email from this individual in Oregon, we have been reached by several other OTs asking about similar challenges and questions about scope of practice. Because of our commitment to honoring the AOTA’s Practice Framework, and because we believe that the great patient need that exists can be better served by having trained OTs able to treat pelvic health conditions, the Institute is working with members of our faculty and professional network to advocate for recognition of OTs in pelvic rehab and resolve confusion about scope of practice. For those interested in further resources, please check out:
American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68, S1-S48.
As someone who has spent nearly two decades marketing myself, my practice, or practices for employers, I have learned a lot of skills by trial and error. One of my favorite strategies to expand my professional network is to “Follow the Patient.” By this I mean to follow the patient to a specialist consult, to a procedure, or to a referral that you helped to coordinate. This must be done with the patient in mind, first and foremost, and then also the provider and their practice environment, so as not to have that practice shut the door on you in the future. Of course, this process can look different if you are in a health network because as an insider, you will likely be more welcome and have all the right credentials in order to simply attend a patient’s provider visit. If you are in a private practice, there are sometimes more hoops and permissions to negotiate. Following are some tips I have learned about this strategy of nurturing referral sources.
Offer the idea to the patient and see if they are open to it. It might sound like this: “If you are interested, I may be able to accompany you to your upcoming appointment. Does that interest you?” It’s very important that the patient is consenting to you being in attendance at their appointment, as the visit is for them. It may be best to not promise that you can clear your schedule, or coordinate the visit, but finding out if the patient is open to the idea is the first step.
2. Check in with the provider’s office. This can be accomplished by you or by the patient. This might sound like this: “I’d like to be sure that your provider would welcome me at your appointment. Would you prefer to contact the provider’s office or shall I?” In my experience, the provider’s office will say “if it’s ok with the patient, it’s fine with us!” Typically, a patient can bring whomever they like to an appointment, so that’s not much of an issue, unless there is close quarters or some other limiting scenario. The good thing about giving a heads up is it allows the provider’s office the opportunity to know that you may be joining your patient. I was able to follow a patient into a hernia repair surgery, and the nurses were so surprised that a physical therapist was in the prep room, they asked me “does the doctor know you are here?” in which case I was able to affirm that I indeed had permission from the surgeon.
3. When you attend the visit, allow the patient to introduce you or politely introduce yourself. Then listen. This is not the time to tell the medical provider all of the wonderful things you have been doing, or all of the things you have to offer their patients. Sometimes when reporting their history, the patient will look questioningly at me to recall details, and unless I am needed to give a brief response, I like to be quiet and stay out of the story until later. This is the time for the patient and the provider to get to know each other, establish rapport, and fewer interruptions are best.
4. Be prepared to summarize your thoughts when given the opportunity to share. Typically I have found that a medical provider will at some point turn and ask me a few questions, or simply state, “Do you have anything to add?” at which point I try to make concise yet thoughtful statements about the patient’s progress, continued challenges, and the reasoning behind the referral if I was the one to coordinate it. The summary might sound like this: “The original severe pain locations have eased, function has improved in this way, and the symptom or issue that is persisting is this. I was interested in knowing if there is potentially something else going on, or if you have a recommendation towards furthering their progress.” At this point, it’s best to not get too far ahead of yourself, or put expectations in front of the patient beyond a brief summary. In other words, don’t request specific imaging or suggest a particular procedure, as this may create an imbalance in the patient’s expectations and the reality of what takes place. If the provider wants more details or thoughts from you, they are likely to ask directly. (You can also send a progress report or summary letter prior to your visit if you have specific thoughts or concerns about what is going on.)
5. Allow the visit to unfold, listen carefully and take mental or written notes. I have often found that I recall details of anatomy, medications, or suggested interventions easily and the patient may ask about the details in a follow-up visit. This type of partnership allows the patient to have “another pair of ears” and can serve as a valuable part of the rehabilitation care planning. For example, perhaps the provider said, “Let’s try this imaging, if nothing of interest shows up, continue rehabilitation for 6 weeks. If no significant progress, I’d like to see you back here within a couple of months from today.” This allows the therapist to note that a provider visit was requested at 6 weeks following the appointment.
Marketing our services, in the long run, and especially in pelvic health, is critical in sharing awareness of the role of pelvic rehabilitation. Marketing is about relationships, and the easiest way to create a relationship is face to face. “Following” a patient along their healing journey, while it may take time out of the clinic for you, is a valuable way of engaging with providers and of being part of a collaborative process. When another provider or therapist requests that I see their patient to offer another view, I find it helpful to welcome the referring therapist to join the patient as well. This can lead to valuable discussions, sharing of information, and ultimately the patient may experience more efficient care that is directed to optimal strategies.