Q&A: Briana Ralph, CCC-SLP with a Small Community Hospital in West Virginia

Briana Ralph does it all as a clinically focused speech-language pathologist—in-patient, outpatient, nursing home, and home health care are all part of her professional portfolio.

For Briana, the job never gets old because there’s a new experience every day:  helping a patient regain the ability to swallow following a stroke, teaching a laryngeal cancer survivor how to use an augmentative communication device, or focusing on a speech delay with one of her youngest patients.

We sat down for a conversation with Briana about what it’s like working with patients that run the gamut from toddlers with swallowing disorders to elderly adults coping with the affects of a stroke or Parkinson’s Disease.

Briana opened up about what she loves about the job, and wasn’t shy when it came to voicing her frustrations either.

Q: How long have you been a speech-language pathologist?

Briana: Seven years. My first job was at a nursing home at a skilled nursing facility that I worked at for about 6 or 7 months.

Q: What is your educational background?

Briana: I have a masters from West Virginia University and my bachelor’s from West Liberty University.

Q: And are they both in speech-language pathology?

Briana: Yes.

Q: And where you able to specialize at all in your master’s degree or is that not an option?

Briana: I don’t think you can specialize in your masters, but you can specialize later on… I know that there’s things through ASHA like augmentative communication that you could focus on.

Q: What made you decide to go into the clinical area versus education?

Briana: Right out of school, I wanted to try to stay clinical and use as many skills as I learned. Plus, the money is better. And then I thought I would go into the schools later on because I don’t want to say it’s easier, but it’s less of a broad range in the schools.

The hospital where I am has an outpatient clinic and inpatient clinic, and we have a lot of contracts. I do both, and I go into people’s houses for early intervention. We also have a home health agency. I have some personal contracts, so I have experience with IEPs already. A lot of what I do is coaching parents in the home for birth to age three. I got trained doing assessments with children with autism, diagnosing them, and I do home health inpatient and outpatient. I also do swallow studies at the hospital—pretty much everything I was taught to do I use.

Q: So, essentially, you could make the transition rather easily into education if you decided?

Briana: Probably, yes, because it’s about half what I do now.

Q: So, clearly, you’re moving and going to different places. Do you like that?

Briana: I do because it doesn’t really get stale, and I can choose to do things if I want a break or if I want something different. For example, this summer, the therapist who did most of the home health work was super busy, so I took two of the home health referrals that we got, so I had two adults for a while.

Q: What are the typical services for adults? Are they mostly post-stroke?

Briana: Yeah, and usually people with Parkinson’s. Sometimes we get ALS, but that’s usually focused on getting them a device.

Q: Which explains why you’re interested in augmentative communication.

Briana: Yes, I like that. It’s mostly strokes with adults or traumatic brain injury, and we’ve had so many people with a brain injury of some sort.

Q: So, are these services very short-term?

Briana: It all depends on how much progress they make. Usually the most progress is made in the six months after, but some continue to make progress after, so they receive [services] for a while. We’ve had people who have had another, so they come back if they’ve had more than one.

Q: Tell me what your day is like working with the preschool age? And tell me again, birth to three?

Briana: Yes; right now, I try to fit two visits in in the morning. I go to someone’s home, and we usually talk about how things have been going for the last couple weeks since I haven’t been there, and then they tell me what’s good or bad or what is new, and then what they’re currently working on or what’s difficult in their day. I’m used to giving them strategies to use throughout the day because the parents are with the kids way more than I am as a therapist. So, we work on things that they can do throughout their days and what they can do to work on their child’s speech. And then at the end, we review the plan and what’s going to happen in the next couple weeks.

Typically, the parents are my barrier; whether they want to participate…you know, it’s hard to get people on board and sometimes you have to make it seem like it’s their idea to do things. I don’t want us to just come in there and tell them what to do. I want us to talk about it and come up with things together, like what’s going to make sense for them to do, and I’m always telling them that I want you to feel like I’m [giving you] things you can do any time of the day.

Q: Is the [program] based off an IEP? Do you do the same type of things with short-term and long-term goals?

Briana: We have a birth to three state program. We don’t go off an IEP but an IFSP—Individualized Family Service Plan. The program is free and voluntary for the program’s parents to sign up for development assessment on the child. So, the parents come up with the goals for that child; it’s not me coming up with the goals for their child. The parents come up with an area they’re lacking, and this is what we need to work on.

So, typically, the most common goal is using more words, so we look at their routines and work on it that way. So, if it’s mostly that the parents want their child to tell them what they want to eat or drink, it’s coming up with things to work on that.

Q: Do you work a lot with developmental delays? What are your typical patients?

Briana: Technically, it’s a diagnosis of speech delay. We get some kids with Down Syndrome and cerebral palsy. I also get feeding issues at this age. Babies who were premature or neonatal abstinence, prenatal drug use, type of stuff. So, some is in foster care.

We also get a lot of rare disorders. I have a patient with Miller-Dieker syndrome, one with Smith-Lemli-Opitz syndrome. When I get these kids, I have to research them!

Q: Do you have to be licensed?

Briana: I have to have a state license, and I have my certificate of clinical competence (CCC). I have to maintain the CCC-SLP, so I complete continuing education hours every two years for my license and every two years for my ASHA certification.

Q: Let’s go back to your school for a second. Did you know by the time you hit your graduate program that you wanted to focus on the clinical area?

Briana: No, I thought I wanted to work in the schools. I think everybody had an idea where they wanted to work and then they didn’t end up there. I didn’t think that I would end up working in a nursing home, and I ended up loving nursing home work. I like it a lot more than I thought I would.

You think it’s going to be sad and depressing, but it’s very rewarding. If you [are able to] upgrade someone’s diet and they are very happy because they don’t have to have food thinner at all their meals and they get to look at real food again.

I also have really nice families who were very appreciative.

Q: So, what was it like working in the nursing home environment?

Briana: At nursing homes, it’s usually a contract company providing the services… I was happy there. I don’t know if I would have wanted to do it forever; the medical and billing and things are hard because of the productivity rate you have to match or meet. So much of your day has to be one-on-one patient time, which makes you feel like you’re scrambling all day. Documentation time doesn’t count.

The legal and administrative stuff was a turn-off because the productivity in some places was worse. I was only 75%, but in some places, it’s 90%, which is impossible when you have to document and go to the bathroom and walk down the hall! Any time I would spend talking to nurses and talking to family didn’t count. Even the times when I would go to the patient’s room and see what they wanted to eat and then go down to the kitchen and get it and take it back to then would take 20 minutes of my time.

Q: Do you feel that your job is very collaborative? For example, in the nursing home, everybody had to be on board for the patient’s plan. Is that a little different now that you do home home?

Briana: Collaboration now is PT and OT being involved…physical and occupational therapy working with me. At my other job I felt like I had to fight for patients. Like a PT would have my patient, and then I would say, ‘Can I have them a minute?’ But in an outpatient setting, we work a lot with PT and OT. We have a lot of kids come in and have all three disciplines, so sometimes we co-treat. If there’s a feeding issue, PT works on positioning them, OT works with hand-to-mouth, and I’m working on feeding.

Q: How do you collaborate and come together to have a plan for the patient?

Briana: We usually just talk about it in the office, and it usually comes down to the needs of the child. Sometimes it ends up being the child’s participation level because if you have three disciplines and the child is going to be there for an hour and a half, some kids just completely max out after an hour and then the third person gets nothing. So, sometimes we talk about what’s appropriate to treat together. Like if it’s a feeding situation, we all have similar goals and we work together. Some of the kids with developmental delays who won’t sit up, PT can work on things while I work with them, too.

Q: So, you’re literally working with the patient at the same time?

Briana: Oh, yeah. It’s usually me and a PT vs. an OT. If I’m playing with toys, I can entice them to crawl or walk toward me while I work on language and the PT is working on balancing.

Q: So, you’ve worked with the oldest population and now you’re working with the youngest population. What do you prefer? And why?

Briana: It’s hard because it depends on the patient. I do like both, but I probably prefer working with kids because I have more fun. And it depends on the kid; sometimes I might be having fun, but they might scream and run to the other room. Sometimes they’re done with me. (she laughs) I’ve also had adults that were really fulfilling and really sweet.

Q: So, you don’t see leaving this area anytime soon?

Briana:  I think about when I have kids I might want to work in the school. But I like the setting that I’m in because I get to do so many different things. I feel like I won’t lose things that I’ve learned because I’m using it all the time.

Q: What’s the best part of your job?

Briana: Probably when I do something that we’ve been working… and working… and working out for a while and then all of a sudden, they do it and then I flip out and I’m all excited!

And the kids look at me like I’m a crazy lady. (she laughs) But most of the time they get excited too because they’re like, ‘Yeah, I did it!’ And then I tell the parent about it and they’re excited.

Q: What’s the most frustrating part of your job?

Briana: Paperwork and parenting probably.

Q: So, you really feel like parents are one of your biggest barriers?

Briana: It depends on what their understanding is of what we’re trying to do. Sometimes, when it comes to behavior…if we come up with something to work on with behavior and their parents don’t do it at home, it’s not going to work, it’s not going to get better.

When I go to a house for a follow-up visit and I ask how it’s been going and I ask, ‘Have you tried this?’ and it’s, ‘No we didn’t get to it, or no, I didn’t try this.’ Or I ask, ‘Did you use the picture cards?’ And they say they lost them or whatever, and here we go again.

Q: What was your most rewarding patient that you can think of, and why?

Briana: I guess what I can talk about was a guy who had a stroke and all he could say was ‘wow’ and ‘yeah.’ Sometimes so he would have a whole sentence conversation using just ‘wow.’

I got him a device and he could use it. And he would use it to tell me things. And it was exciting. And he could tell me what he wanted to eat, and he was pretty proud of himself when he realized he could use that. And he could tell his wife his clothes were uncomfortable or whatever it was.

And then the other thing I can think of is augmentative also. In grad school, I did assessments for augmentative communication. And in the State of West Virginia, we were the only ones who did that, so people would come from all around because it was free…

 And we had a woman who had laryngeal cancer, and she had her larynx and her tongue removed. So, she couldn’t make sounds at all, and she couldn’t even use one of the artificial larynxes because she didn’t have a tongue to articulate. And she babysat for her little grandchildren and she had no way to make sounds, which was terrifying because if something happened she couldn’t call anybody. And we just gave her a keyboard to type and we had a device like that and she would type it and hit enter. And she was talking to us and typing something funny about her husband, who was behind her, and he laughed. And she cried because she said something, and he heard her. It was so sweet, it was the best thing.

Q: If someone came to you for advice and said I’m thinking about going into speech language pathology, what would you tell them? What words of advice would you give?

Briana: It [speech-language pathology] is rewarding, and I do love it. What I like about the field is that you could do so many different things. I mean you can do research if you don’t want to work with patients. You can do it at a school. Then there’s also a hospital or voice clinic, where you work with an ENT and work specifically on voice.

Q: What made you decide to go into the field?

Briana: Well, I was going for English and dreading the next four years, and I was in a linguistics class with some speech pathology majors and I didn’t even know what it was, and they told me what they were doing. Then I went back to my dorm and researched it and said, ‘That sounds more like me!’ I’ve always noticed how people talk if they do something weird with their mouths or if somebody has a lisp, I always noticed it. And I didn’t want to teach a whole classroom full of people. With this, I take two kids at a time. I don’t want to be in a room full of people.

Q: What are the most important traits a speech pathologist should have?

Being flexible and personable. Be able to work with stubborn kids and cranky adults, and just roll with it.