From decorative tissue boxes to puppies: first lessons from my OT fieldwork internship

It’s an exciting time in my life – in the last 3 months I finished the classroom portion of my Masters in occupational therapy, got married and went on a wonderful honeymoon, and started my first occupational therapy fieldwork internship.

After I finish two full time, three-month internships*, I will officially graduate with my Masters and be qualified to sit for the board exam. This is the last step before I can actually be an OT in the real world!

My Skilled Nursing Facility (SNF) houses mostly geriatric patients who are rehabilitating from a variety of physical ailments, from hip replacements to strokes.  The occupational therapist’s role in this setting is to help empower the patient to resume as much of their “prior level of function” (PLOF) as possible so they can return to their desired environment.

I feel so honored to be able to serve patients during a difficult time in their lives. I’ve learned so much already and would like to share just a few insights with you now – I can’t wait for more to come over the next 10 weeks!

1) Lesson #1: Sometimes, a decorative tissue box is not just a decorative tissue box (or, “forays into the art of observation”). 

Observation is at the heart of the occupational therapy practice. We are trained to acutely observe and break down every component of an activity, and observations help us determine which aspects of the person’s physical or psychological make-up contribute to their “performance deficits” (problems doing things that are important in their lives).   Our interventions target those areas that negatively affect their performance; our eyes, ears and hands (plus the cognitive tools of activity analysis) are the X-ray machines of our profession.

At some point, however, we must prioritize which elements are most important to attend to in the patient’s care. This can be a real struggle for students as initially it can appear that everything we’ve observed is important!  In just 2 weeks, however, I’ve learned that even the most seemingly frivolous things can actually illuminate important aspects of a patient’s needs, condition, and motivation.

Enter the decorative tissue box. I had a patient who, early on in her stay at the SNF, was very distressed that her caregiver had forgotten to bring her decorative tissue box to her room.

At first glance (and given this patient’s physical condition), one might think a tissue box was the most superfluous detail for me to attend to.  However, it ultimately ended up telling me a lot about this patient (details which I cannot publicly reveal due to privacy concerns).  In the big picture, this experience showed me the following:

1. Being surrounded by a sense of home and normalcy during a tumultuous time in one’s life can be very important for one’s attitude and healing;
2. It’s not always about the item itself that is important but whether the person feels like their desires are valued and respected (a medical staff person will, understandably, be focused on aspects of the patient’s rehabilitation other than their room decoration; this is where caregivers and family members can provide a helping hand);
3. At the end of the day, it was partly about the box itself, but more about control, which is important to remember if patients make seemingly “silly” requests.

There are so many things a patient recovery from a physical injury cannot control. The fact that this patient fought for her tissue box represented something potentially deeper about her; it told me that maybe she was not going to go down without a fight, and that she wasn’t ready to give up everything important to her just because she’d lost part of her health. If someone is willing to fight for a tissue box, it’s not too far a leap to presume that they would want to fight for their health and recovery as well.

At the most basic level, it taught me that I must not jump to quickly to cast off something seemingly superficial as unimportant. After this particular experience and upon hearing many other patients profess other very specific, aesthetic related desires, I’ve learned that it’s not my place to decide what is important and what is frivolous; it’s the patient’s, and my job is to listen 🙂

2) Never, ever underestimate the power of a puppy.

I had a patient who rated their pain at 10/10 even before we engaged in any activities.  I couldn’t begin to imagine the pain they were in, but I did my best to listen and determine what I could possibly do to help the patient achieve his goals despite the pain.

As we began some bedside exercises, his roommate’s family brought in a beautiful, serene, small dog.  I noticed a glimmer in my patient’s eyes and beckoned the family member to come over for a little visit.  The patient was able to gingerly lift his hand up to stroke the puppy’s soft ears, then he closed his eyes for a moment and said, “Wow. For just a moment there, my pain was down to a 6.”

It was a beautiful and humbling moment.  I may have an idea about what would be most effective for a patient, but it’s important to be flexible in the moment and remain open to the idea that something more effective might have just walked in the door.

3) Sometimes, a laugh is worth a thousand interventions.  

In school, our professors taught the importance of the “therapeutic use of self.” Simply put, the rapport we develop with our patients can facilitate healing, along with our official interventions.  Personally, I have struggled to determine how my “full of energy and laughter” personality can be best channeled into a professional demeanor that is authentically positive yet perceived as appropriate in a medical setting. One of my internship goals is to fine tune my professional persona so that it best serves my client’s needs.

In the last 2 weeks, I have been incredibly pleased to find that the SNF environment is often full of laughter!

One morning I observed in awe as my clinical advisor turned a patient’s tears into laughter within a mere minutes of walking into the room.  The patient was upset that she wasn’t getting better quicker, and the therapist was able to make a joke that revealed to the patient that perhaps her expectations had been unrealistic, and that she was doing very well all things considered.  Many physical and occupational therapists have counseled me that an extra 5-10 minutes of rapport building at the beginning of a session is often a wise investment for the remaining 30-80 minutes.

As Victor Frankl said about the role of humor in “Man’s Search for Meaning” (which details his experiences as a concentration camp victim in WWII), “Humor was another of the soul’s weapons in the fight for self-preservation. It is well known that humor, more than anything else in the human make-up, can afford an aloofness and an ability to rise above any situation, even if only for a few seconds.” These moments of transcendence are so important during the rehabilitation process; they may not always involve laughter, but I certainly have come to terms with the role humor can play in the healing process over the last 2 weeks!

4) The meaning of suffering…or the suffering of meaning.

Lest my puppy and laughter-filled stories give an unbalanced impression of the SNF environment, I must point out a basic reality: every single one of the patients I’ve seen is suffering, or has suffered, in some profound way.  As Frankl argued in Man’s Search for Meaning, suffering is like a gas; it fills whatever chamber it enters completely, no matter how big or small the chamber.

Yet as Frankl also argued, “I would say that our patients never really despair because of any suffering in itself! Instead, their despair stems in each instance from a doubt as to whether suffering is meaningful. Man is ready and willing to shoulder any suffering as soon as long as he can see a meaning in it.”

I would say that most patients need to see a meaning or purpose to their recovery, if not their suffering itself. The meaning could be as simple as, “I need to get better to take care of my husband” or “to see my grandkids again.” It could be more complicated, as in, “I need to get better so I can prove that I can live safely on my own, without anyone’s help.”

Many of the patients who struggle the most with the rehabilitation process don’t see any purpose or meaning in it.  They may not understand the purpose of the specific exercises (“Why do I have to do this silly obstacle course around the therapy gym?”), or they may not see the big picture purpose of their recovery (“Why should I try to get better if I’m just going to get sick again?”).

I’ve noticed that occupational and physical therapists are, on the whole, somewhat biased towards recovery; of course, recovery is the purpose of our professions.  However, I believe it’s important for us to consider the depth to which some patients don’t understand the meaning or purpose of recovery.  Nearing the end of life, some patients do not wish to improve on their conditions and prefer to be “left alone,” as one patient vehemently told me one afternoon.  In this case, our job is not just to provide an environment where they will “get better,” but to help the patient understand why getting better will help them.

You may think this is self evident; better is better, shouldn’t that be enough?  The problem is, getting better involves pain, exertion, embarrassment, and many other uncomfortable emotions for many patients. In the short term, it is almost always more comfortable for a patient to just stay in bed.  As Nietzche said, “He who has a why to live for can bear almost any how.”

I knew going into this profession that occupational therapy involves deeply personal, psychological and physiological issues; what I did not fully recognize until now was how deeply philosophical it also is.  I hope that in the coming weeks I can impress upon a patient not only the “how” and the “what” of their rehabilitation process, but also the “why.”

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*The fieldwork experiences are designed to help advance the student from academic to clinical competency. Each student is paired with a clinical instructor who’s a full time occupational therapist with at least 3 years of experience. After shadowing that instructor and learning the ropes, the student takes on a progressively larger portion of their instructor’s caseload, with their close supervision and guidance.  They become a member of the treatment team for 12 weeks and are given constant feedback and guidance. It’s a wonderful model for learning!