Experiencing occupations with chronic hand disability: narratives of hand-injured adults

Abstract

Introduction

Hand injuries commonly account for a fifth of all emergencies presenting to emergencydepartments of most hospitals in Europe. One-third of these injuries lead to chronic hand disability thatentails economical, psychological, physical and social implications on the wellbeing of hand-injured adultswith longterm consequences. However, knowledge about the impact of chronic hand disability onoccupations in the long term is limited.

Methods

The purpose of this narrative study was to understand how adults after a hand injury experience theimpact of chronic hand disability on their occupations over time. Participants were selected through purposive sampling. Two narrative interviews were conducted with each participant and analysed usingnarrative and structural analysis.

Results

All participants experienced the challenge of occupational disruption. They faced occupationallimitations with the consequence of changed occupational patterns, and later strived for normality. In the end, all participants still needed to get accustomed to occupational changes.

Conclusion

The findings indicate that this process of occupational adaptation continues on for at least one year after the hand injury. They further highlight the importance to support the clients through engagement in occupation during the therapy process.

Keywords

Chronic hand disability occupations adults qualitative research narratives

Introduction

Hand injuries commonly account for a fifth of all cases presenting to emergency departments of most hospitals in Europe.¹ One-third of these injuries lead to chronic hand disability that entails economical, psychological, physical and social implications on the wellbeing of hand-injured adults with longterm consequences.^2–8 According to Townsend and Polatajko,⁹ a traumatic hand injury can heavily influence a person's occupational and social life, especially when chronic hand disability is delineated. By definition, a chronic condition is one lasting three months or longer,¹⁰ implying that people with chronic hand injuries are not able to do daily occupations independently for a long period of time. For example, they may not feel that they can adequately carry out the responsibilities of parenting children and need help from others. They further may experience difficulties in going back to work, wondering if they will be able to do these occupations again independently and if they will have problems in being able to support the family as a wage earner.¹¹ Performing daily occupations is further influenced by the person's condition, environmental demands and resources and the complexity of an activity task. These factors interact and make occupational performance possible or not.¹² Therefore, the ability to participate in occupations has a direct link to health¹³ and is an important issue for hand injured people.

During the hand therapy treatment, clients often fear not being able to engage in meaningful occupations anymore due to the injured hand. Most clients explain during therapy that they experience difficulties in performing everyday activities at home. Although there is a slow shift towards a biopsychosocial viewpoint in the field of hand therapy,¹⁴ current treatment is still generally focused on functional outcomes. Often hand rehabilitation consists of intensive outpatient service and a recommended home programme of exercises.¹⁵ It involves comprehensive services for physiological impairments, activity difficulties and limitations in roles of occupations.^16,17 Within an individual hand therapy session, the hand therapist usually addresses physiological issues (e.g. tissue healing, scarring, oedema, pain) using physical agent modalities such as splinting or manual techniques.¹⁸ Although it is known that engagement in occupation is supportive for health and well-being,^9,13 occupations are not often used as means or goals in hand rehabilitation.¹⁶ Knowing that there is this relationship, it is interesting to know how people with chronic hand injuries experience their participation in occupation after their injury.

An extensive literature review demonstrated that few qualitative studies have been performed exploring the consequences of a traumatic hand injury or hand disease from a client's point of view. Jerosch-Herold et al.¹⁹ and Pratt and Byrne²⁰ described the patients’ experiences of living with carpal tunnel syndrome (CTS) and Dupuytren's disease respectively using a phenomeno-logical approach. They found out that many participants experienced problems with functional aspects of their daily life due to difficulties with dexterous tasks requiring fine manipulation. People with CTS further expected that symptomatic relief would enable them to resume activities important to them, allowing a return to some normality. This suggests that aspects of living with hand deformity experienced by those with hand injuries⁷ were also encountered by people with CTS and Dupuytren's disease.

Fitzpatrick²¹ used a phenomenological approach to study the experience of patients during a rehabilitation programme following a flexor tendon injury to their hand. He interviewed five patients at the point of discharge. All participants experienced that minimizing the impact of the injury, struggling and coping, trying to elicit help from others and feelings of dependency were themes during the time of therapy. However, how these themes developed over time when hand therapy has been finished a long time ago was not addressed in this study.

Another qualitative investigation into the rehabilitation experience of patients following wrist fracture explored the impact the wrist fracture had on their lives as well as the role that hand therapy played in the rehabilitation process.²² As in the study by Fitzpatrick,²¹ the participants experienced dependence on others. They further highlighted that early and continued patient education should be provided by therapists to address lack of information concerning the rehabilitation programme. Making treatment and assessment relevant to their activities of daily living was essential to ensure the participants were motivated for therapy.

This topic was taken up by Bialocerkowski.²³ In her descriptive study, she identified that all individuals used compensatory mechanisms such as using the other hand or using other parts of the body to lift or grasp objects.

Cederlund et al.¹² also investigated in exploring compensatory mechanisms through identifying coping strategies in daily occupations among Swedes three months after a severe or major hand injury. Six groups of strategies were identified, such as ‘changing occupational patterns’ or ‘keeping up a social network’. However, the study concentrated on the early stage of the hand injury and thereby did not describe which coping strategies patients used to perform daily occupations at a later stage.

Chan and Schier¹¹ examined the impact of hand injury on life roles in a longitudinal case-study. They described a psychological dimension to hand injury that can lead to feelings of insecurity, incompetence and dependency of the clients. This can affect the way people with chronic hand injuries experience life roles and change or reverse them. However, as the information provided in this study was in response to standardized interview questions, more detailed responses to questions involving specific effects of hand injury on one's ability to perform occupations were not examined.

Chan and Spencer²⁴ demonstrated that adaptation to hand injury is an evolving process. The data showed that through participation in everyday activities over time, the interviewees came to the realization that they had chronic limitations in the use of their hands. However, knowledge about the longterm impact of chronic hand disability on the daily life of the hand-injured adults was missing.

To summarize the literature review, most previous studies focused on the psychological, physical and social consequences following traumatic hand injury. Studies paying attention to the experienced consequences of a hand disability for the daily occupations of the affected persons mainly focused on the early stage of recovery. To date, little is known about personal disability experiences from a client's perspective, a longterm view of outcomes or the significance of the hand injury on the clients’ daily life over time. Therefore, the present study aimed to understand how adults with chronic hand disability experience the impact of their disability on their occupations over time, at least one year after the hand accident.

Methods

Design

Representing a constructivist–interpretivist philosophical position, a naturalistic or qualitative methodology was chosen for this study to examine the experiential life of people. Methodology is the theory and analysis of how research should proceed.²⁵ Qualitative research occurs in the field, thus the phenomena under study occur or are embedded in a context or natural setting. The purpose is to observe, understand and come to know the phenomenon under study.²⁶

Human beings organize their experiences of the world into narratives. The stories that are told depend on the individual's past and present experiences, her or his values, the people the stories are told to, and when and where they are told.²⁷ Thus, human experience is always narrated. When we are thinking narratively, we are trying to understand the particular case, specifically a particular person's experience. According to Mattingly,²⁸ narrative thinking is our primary way of making sense of human experience, and narratives give people meaning to their occupational experiences over time.^29,30 Therefore, a narrative design was adopted as theoretical perspective to conduct this study. The type of narrative used in this study was a first-order, biographical personal experience story.^31,32 In first-order narratives, individuals tell stories about themselves and their own experiences. In a biographical study the researcher writes and records the experiences of another person's life. A personal experience story portrays an individual's personal experience found in single or multiple episodes, private situations or communal folklore.³²

Participant recruitment

Three outpatient hand clinics were contacted by telephone and email, requesting participation in the study. The researcher provided exact admission criteria. After the clinician–gatekeepers performed their preselection, the researcher chose which potential participants with whom to proceed, and the hand clinics mailed the participation letter to the selected potential participants to ensure that the prospective participants satisfied the admission requirements, while simultaneously ensuring their data privacy. This letter informed them of the project and invited them to contact the researcher if they were interested in participating in the study or if they wished further information about the project. User involvement enhanced the recruitment process; the email was read by hand therapists from the researcher's workplace and hand-injured clients the researcher knew read the participation information sheet. Their feedback improved the comprehensibility and integrity of the recruitment letters.

All potential participants contacting the researcher for participation in the study were selected through a purposive sampling technique seeking to document diverse stories.³³ Four participants out of 14 invited responded. All four were included in the study. Inclusion criteria were a chronic hand disability due to an accident that happened at least one year ago, above 18 years of age and the ability to understand Swiss German. A chronic condition is defined as a condition lasting three months or more.¹⁰

Informed consent was obtained from all participants. Pseudonyms were used to guarantee anonymity. Participation was voluntary and could be terminated at any time during the study without further explanation. One participant declined further participation after the initial interview due to his poor health condition. The research protocol was approved by the Bern Ethical Commission (September 2009) and strictly complied with the principles and ethical regulations of the participating clinics.

Data collection

Data were collected by means of two narrative interviews per participant, based on the Biographic-Narrative Interpretive Method (BNIM) by Wengraf.³⁰ BNIM, through its focus on eliciting narratives of experience rather than just explicit statements of position, facilitates the expression and detection of implicit and often suppressed perspectives in the present as well as earlier perspectives in the past. The BNIM method of narrative interviewing is one which provides a relatively coherent ‘whole story’ or ‘long narration’, thus rich material for any method of narrative interpretation.

According to BNIM, the interview guide has three subsessions: firstly a non-interrupted initial narrative, secondly the internal questioning of points raised in the initial narrative, and third – as a follow-up interview – all further questions relevant to the study focus. Demographic information was obtained from the participants (Table 1). Each interview lasted between 45 and 65 minutes, with a time span of 2–3 weeks between the initial and follow-up interview. With permission from the interviewees, the interviews were audiotape recorded and transcribed verbatim.

Table 1

Demographic data of participants

Participant (sex)	Age	Social status	Job/leisure time activities	Time since hand accident	Hand disability	Affected hand
Lillian (f)	49 years	Married, 2 children (14 and 15), dog	Housewife and mother/ painting, cycling, gardening	Ski accident 14 months ago	Comminuted wrist fracture, proximal phalangeal fracture small finger, algodystrophy	Left non-dominant
Ursula (f)	66 years	Married, 2 adult sons	Retired/producing jewellery, gardening	Lawnmower accident 2.9 years ago	Complex pluridigital injury (partial loss of thumb and amputation of ring finger)	Right dominant
Martin (m)	48 years	Divorced, one son, in a relationship	Self-employed metalworker/ skiing	Angle grinder accident at work 1 7 months ago	Angle grinder injury left volar lower arm (severed flexor tendons, dissected nerves and veins)	Left non-dominant

Data analysis

As this research project was a narrative enquiry, the collected data were required to be analysed for the story the participants had to tell, a chronology of unfolding events as it is recommended by Molineux,³⁴ and turning points or epiphanies. Each participant's personal experience story was ‘restoryed’ individually.³² The narrative analysis of the interviews therefore mainly followed the five stages by Molineux and Rickard³⁴: •

Step 1 (determining the boundaries). This step was done before data collection started.

•

Step 2 (ordering the events chronologically). This step was conducted as a preliminary analysis to prepare the follow-up interview, and was completed after the interviews were finished.

•

Step 3 (establishing the plot). Labov's structural analysis was adopted as a microanalysis-structure.³⁵ It helped to further analyse the narrative structure of the text, paying attention to how stories were told. The three resulting condensed core stories were sent to the participants for verification.³⁶ All suggested changes by the participants were included in their stories.

•

Step 4 (determining contributors to the story). This step commenced with reducing the core stories to ‘emplotted whole narratives’.³⁶ This process of narrative smoothing³³ meant to exclude events that did not contribute to the story end.

•

Step 5 (writing the narratives). This step implicated ‘restorying’ each participant's personal experience story individually.³²

•

Step 6 (identifying similarities and differences among the stories). This final step was added in order to find a general narrative line among the stories. This step was done to synthesize the three individual narratives into a general narrative, serving as a structure to present the findings.²⁹

Trustworthiness

To enhance credibility of the findings, a member check was done during the follow-up interview, confirming the truth value or accuracy of the investigator's observations and interpretations as they emerged.²⁶ Furthermore, the three core stories were returned to the participants for verification.³⁶ One participant answered by email and two provided feedback by telephone. The researcher joined peer debriefings to discuss the procedural steps throughout the research project. To ensure transferability, the sampling procedures were described in detail. The demographic data from the participants were presented in the article, using pseudonyms to preserve confidentiality.

Reflexivity was addressed by describing the researcher's philosophical position. Furthermore, taking field notes, analytical memos and keeping a reflective journal helped the researcher to distinguish personal reasoning from the stories being told by the participants. To ensure dependability, the process of the study and the interactions between the researcher and the participants were described in detail.

Results

In general, the participants all experienced a similar development of recovery after their hand accident. All participants were healthy people leading an active life, until the hand accident disrupted their occupational lives. The first common turining point for all participants was coming home from the safe hospital environment. They all described feelings of helplessness when trying to do daily occupations single-handedly at home. Another common turning point in time for the participants was the removal of the splint and the therewith hope for better occupational performance. This hope was soon overshadowed by patients facing occupational limitations despite having two hands. From then on, all participants individually recaptured their occupational life at their own pace, all striving for normality as fast as possible. In the end, they were still getting used to occupational changes as part of their life. The individual narratives of Lillian, Ursula and Martin (Table 1) are presented in one story following the general narrative line (Figure 1). The major turning points - ‘coming home’ and ‘removal of the hand splint’ - indicate the start of a new stage of life, emphasized through the participants using words such as ‘in the beginning’, ‘later’ and ‘today’. The latter was changed into ‘in the end’ by the researcher to represent the time up to the present day when the follow-up interview took place.

Figure 1

General narrative line with stages of life (indicated by →) and major turning points (indicated by )

In the beginning: the challenge of occupational disruption

Coming home after surgery, the injured hand covered in a splint was a challenging experience for the participants, because they did not feel the supporting environment of the hospital anymore. It was not until then when the difficulties started for real. Not being able to do most occupations independently due to their single-handedness started to temper their mood. They felt frustrated about having difficulties with ordinary daily occupations. Lillian described it as follows:

You cannot dress yourself, you cannot scratch yourself, you cannot move as before. I did everything I was able to do with one hand. But this was not much. Because what can you do with one hand? Open and close a curtain, close a window, pick up some things with one hand, clothes for example, but to make the beds was not possible.

They described requiring additional time for all activities, which was an incisive and disillusioning experience for them.

In the beginning, it was drastic! It started when I came home and intended to fasten my trousers. It took me 10 minutes, maybe 15, until I had closed them the first time! (Martin).

The participants’ strategies to solve this challenge of occupational disruption were three-fold. They tried to accomplish occupations with one hand, asked for help or just avoided doing certain tasks during that time, such as ironing. Ursula and Lillian introduced a kind of ‘task-sharing-system’ with their husbands for certain activities, such as preparing a meal, which they appreciated and still adopted in the end. Nevertheless, asking for help was not easy for Ursula and Martin, because they expressed having difficulties in being dependent on others. Both turned down help quite often because they wanted to try it themselves. Martin experienced it as follows:

I finally did most of the tasks on my own – single-handed! One marvels at how much one finally can do single-handed, just more arduously. However, my son helped me more than usual. He for example fastened my shoes, and it is sometimes still like that today.

Ursula explained:

What I hardly could bear was the dependence while eating, that I could not cut anything. That I simply had to send across my plate to my husband and say: 'Would you please cut it for me?

In the beginning, all participants connected their experience of occupational disruption with their single-handedness. Therefore, the moment when the splint was removed was described as a special moment that was filled with hope for better occupational performance and the connected hope for normality.

From then on it was a relief to me not always having the feeling of damaging something while using my hands. From the point when I had the ‘go’ it was already better (Martin).

On the other hand, they had nothing left to protect their injured hand. Especially Lillian initially was afraid of using her left hand for daily occupations when the splint was gone: ‘I had to force myself to do something. To do the things I actually could do.’

However, their early optimism and hopefulness declined quite quickly when they started to use the injured hand for two-handed occupations. There, they started to realize that they could not do everything as before, which was not easy.

It was frustrating not being able to do certain things. Like peeling vegetables, or holding something. It didn't work out the same way with the left hand as it did with the right one. No matter what you did – it was not that easy to do with the left one. I then realized that I cannot do everything as before (Lillian).

I have re-started my office work, but I was astonished as to how one can get stuck there. One can't say: ‘Office job only!’ Typing doesn't work, opening a letter doesn't work, there are many things that don't work (Martin).

Being confronted with those unexpected difficulties made them sad and angry, but also stimulated their ambitions to find devices and tricks to solve those practical problems. Martin for example changed the original buttons with press buttons on his shirts.

Later: striving for ‘normality’

Struggling with occupational disruption for longer than expected evoked a strong will to strive for normality in all participants.

It was simply like this for me; I wanted to be as I always used to be. I really wanted to! (Ursula).

All participants considered being allowed to drive an important step back to normality, experiencing being mobile as a return to ‘normal independence’.

I was not allowed to drive, until I was able to close my fingers enough to grip the steering wheel. Then, almost everything was good again. Well, I couldn't do many things yet, but driving a car was very important to me then (Lillian).

However, many occupations still took longer than usual to complete. As a consequence, the participants still delegated many tasks to others. Ursula shared tasks with her husband she usually would have done alone:

While peeling a carrot, this is – when you hold it and you cannot – and then it just takes 20 minutes to peel one carrot. Then you prefer to ask: ‘Can you do this? I can't’ (Ursula).

Lilian was thankful for the support she received from her social environment, especially from her family:

I would not have been able to cook or peel vegetables in the beginning. Well, somebody who does not get any help – I don't know, how he would get along with one hand in such a situation! A solitary person… I couldn't imagine this. They [her family] took over everything. I was thankful for that. Yes.

Martin had to delegate the fine motor tasks to his employee at work. As a consequence, Martin does not like to visit customers alone anymore:

We [the employee and Martin] usually worked together before the accident. Maybe we more often said: ‘One person can go and do it!’ But only – there is not much I can do. Imagine me going to a customer and then I have to say: ‘I cannot do this.’ I don't let it come that far! This is actually my handicap I have, which is painstaking. And it almost affects my self-confidence and is a drastic change for me, that you just don't dare doing certain things anymore. This is not a problem for me when I am at home. But in public or in front of a customer it is different. Where I have to say: ‘No, I do not dismantle this.’ I fear of not being able to compose it again, but not because of not knowing it, but because it may not work due to my hand skills. This is where I sometimes feel awkward.

Nevertheless, all participants described how they slowly but steadily made progress in performing occupations independently and two-handedly, everybody in their own time. The first occupation Ursula still remembered was putting on some body lotion two-handed, which was a great experience for her. She also tried to drive a car again, which she managed successfully. Lillian described how she went cycling and gardening again.

I can remember when I went cycling for the first time. I thought: ‘How do I clutch there with my left hand? And what when I fall?’ and then I thought: ‘Nuts! I do not think of anything, I just cycle.’ And I just had the better grip with my right hand, or safer, and the left hand was added slowly, because this was still during therapy time. But this automatized itself. You forget it, and you do more and more.

To realize that she was able to perform those leisure time activities independently again made her proud and encouraged her to try out other activities.

In the end: strategies and occupational changes are part of my life

In the end, the participants all experienced a kind of rethinking due to their hand accident. This caused a change in their occupational patterns, which meant a reorganization of their lives by setting different priorities.

A lot happened in my mind, like my attitude towards everything and setting priorities. I have to admit that a lot really changed. The accident… this caused a rethinking: Not always running around and ‘gee up!’ But maybe once: ‘Now we leave it like that. I take that day off.’ From that point of view it kind of did me good (Martin).

Another change in occupational patterns they discussed was avoiding certain occupations. This was still present at least one year after the hand accident and was experienced as normal because it became habitual for them, such as avoiding ironing for Martin, skiing for Lillian or mowing the lawn for Ursula.

All the participants still needed time to get accustomed to occupational changes, thus accepting occupational adaptations, such as typing-single handed for Martin. For certain tasks, he had to adopt devices, such as changing the original buttons with press buttons on his shirts. He got used to his new life situation:

Those occupations that don't work anymore I arranged myself, like the shoes or the buttons…It could be much worse. As such… yes, it is like that now, and I live with it.

For him, small changes were easier to make the more automated the occupations were:

I gained routine… Things that you adopted and changed go quicker and easier now. But only in the new way, no more like it was in the past. It's not the same anymore (Martin).

The participants reported they were still experiencing occupational limitations, to which they either became accustomed to, or still struggled with.

There are the small things today that make me angry sometimes. When you for example want to change a light bulb, where you need two hands, and it does not work. This is very limiting for me (Martin).

As an adaptation strategy to those occupational limitations, all participants adopted an adapted ‘occupation-sharing-system’ they had introduced since the time after the accident. For Martin, it was mainly at work where he got into the habit of submitting the finishing touch of his work to his employee. In the end, Lillian and Ursula did not experience it anymore as being dependent on their husbands. It rather became normal to share occupations with their husbands.

What has changed since is that I cannot do certain things that well anymore. When I want to prepare a pumpkin soup for example, and there is a huge pumpkin in front of me – hard as stone – then I cannot cut it. Then I call my husband (Ursula).

Discussion

This study adds to the existing although limited body of qualitative evidence in hand therapy. The findings revealed that experiencing severe hand injury caused the feeling of occupational disruption, negatively affecting the participants’ moods. Occupational disruption is a temporary state that, given supportive conditions, can be resolved.³⁷ The participants experienced changes in performing daily occupations due to the splint and the resulting temporary single-handedness. Strategies to cope with this challenge of occupational disruption were threefold: They tried to accomplish occupations with one hand, asked for help or just avoided doing certain tasks during that time. In the literature there is a general agreement that changing the performance of daily occupations is common after a hand injury.^6,24 These studies identified coping strategies during the early stage of recovery, such as ‘changing occupational patterns’ or ‘keeping up a social network’, emphasizing that patients with few coping strategies should be recognized in order to give adequate psychosocial support. The present study deepens knowledge about experiences with altered occupational performance at a later stage. For example, soon after the removal of the splint participants realized that their hand disability would not be temporary, but would rather permanently change their occupational life. This finding parallels other research that documented the realization of limits to recovery from hand injury after early optimism.^24,38

The findings indicate that the participants had an inner drive to strive for normality after this disillusioning experience of recapturing two-handedness. Facing those occupational challenges evoked a strong desire to participate in daily occupations. This desire was the intrinsic motivational force that led to occupational adaptation.³⁹ This demand for mastery motivated the participants to find strategies to perform occupations at the highest achievable level, accompanied by a strong will for self-dependence despite the chronic hand disability. Not only changes in the performance of daily occupations were a consequence of the hand disability, but also changes in occupational patterns were a common experience. An occupational pattern is the ‘regular and predictable way of doing; occurs when human beings organize activities and occupations’⁴⁰ (p. 4). Through occupations, people organize time into patterns.⁹ Due to the hand injury, all participants used considerably more time for all occupations, especially during the early stage of recovery. These findings are supported by earlier studies,^12,41 which have reported that the consequences and adaptation in daily life after hand injury entailed changed occupational patterns. Using more time to manage daily occupations was a frequent statement confirmed by their participants. Some accepted the need for more time whereas others were frustrated by this.

At least 14 months after the hand injury, the impact of the disability on the participants’ occupations had decreased but was still present. As ‘man is a creature of habit’ (Martin), the participants were still getting adjusted to their changed performance of daily occupations and occupational patterns. They adopted new occupational patterns to perform their everyday lives with their disabled hands. Clark⁴² observed that routines provide a structure that serves to organize and maintain individual lives. All three participants managed to reorganize their lives individually after the hand accident. They for example adopted an ‘occupation-sharing-system’ with their social environment for occupations which they could no longer perform individually, such as preparing pumpkins for Ursula. This ‘doing-together’ has been documented in the literature,⁴³ but not in connection with hand-injured people. Finally, the findings show that activity continued to provide the desire for leading a valued life for all participants. They further showed that doing valued occupations led to positive changes over time. Those findings are in line with previous literature.⁴⁴

Limitations of the study

In narrative research, the sample size is always small, unless it is used to develop a collective story.³² As the aim of this study was to understand the personal experiences of the individual, a small sample size is justified. Nevertheless, there was more than one participant designated for this study, as a set of case studies topically related provide greater insight and understanding of the topic than any single vignette.²⁹ The choice of engaging gatekeepers was done out of practical and ethical reasons, being aware of the potential pitfalls that can be included when hiring other people than the researcher to recruit participants. Finally, the meaning of the presented statements out of the interviews may have been altered through translation from Swiss German into English.

Conclusion

This study aimed to understand how adults with a chronic hand disability experience the impact of a disability on their occupations over time, at least one year after the hand accident. The findings of this study showed that a chronic hand disability can have different meanings for the individual's occupational life, although there was a common pattern in how all participants experienced similar feelings and turning points. All participants felt the disillusioning and frustrating experience of occupational disruption due to the hand accident. They all experienced changes in performing daily occupations and occupational patterns over time. All participants received assistance from their social environment. Furthermore, the findings showed that all participants were still getting accustomed to the perceived occupational changes. This indicates that this process of adaptation is still going on at least one year after the hand accident.

Implications for hand therapy practice

This qualitative study demonstrated that a hand injury is far more than just a biomedical problem for the affected people. Instead, there are various life areas of occupation affected, such as work, leisure or social participation, interwoven with changed performance patterns and skills.⁴⁵ Therefore, it is important for hand therapists to address this issue already during the early stage of recovery after a traumatic hand injury. Potential difficulties in doing occupations at home the client talks about during hand therapy should be assessed. Furthermore, listening to the story the clients have to tell provides great insight into their personal disability experiences, allowing hand therapists to learn from them and to improve their treatment. Occupations as a means of therapy should be implemented wherever possible in hand rehabilitation. This allows the therapist to observe potential difficulties and to discuss and train them with the client in the safe environment of the therapy setting. The findings can further be used to support other clients early in hand rehabilitation to show them how other affected people felt when coping with this disability experience, using Figure 1 as a tool to illustrate the occupational adaptation process. Special attention should be paid to the two turning points the participants had experienced in this study – thus the moment when they are discharged from hospital and the moment when the splint is removed. Pointing out those turning points might allow the clients to be better prepared to face occupational limitations and dependence from others during the hand rehabilitation process.

Further research is necessary to strengthen the present findings, for example by applying a prospective/longitudinal narrative study together with field observations. Through this additional data collection method, tri-angulation would be considered. Furthermore, participants who have difficulty in expressing changes in occupations verbally could perform them instead of only talking about them.

Competing interests: None declared.

Footnotes

Acknowledgements

The author is deeply grateful to the participants of this study for their willingness to share their experiences and their time. Further thanks goes to peer students for their inspiring discussions, to the three outpatient hand clinics (Handtherapie Inselspital Bern, Ergotherapie Seeland and Ergotherapie Spiez) for their help in recruiting the participants, and to Kirsten Clift from the Schulthess Klinik, Zurich, for her editing of the article. This study was completed as partial fulfillment of the European Master of Science degree in Occupational Therapy.

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