Novice therapists in a developing context: Extending the reach of hand rehabilitation

Abstract

Introduction

Hand rehabilitation needs in some parts of the world extend beyond the impact of specialised hand therapists. This study aimed to establish what hand rehabilitation services novice occupational therapists in South Africa were providing; the supports and barriers for such services; and, therapists’ perceptions of being equipped for hand rehabilitation.

Methods

A descriptive cross-sectional study was conducted, and an online questionnaire was sent to all occupational therapists in their first year of practice (n = 240). Data were analysed with Stata 12 and IBM SPSS Statistics, version 21.0. Responses to open ended questions were post-coded.

Results

A 43.3% response rate was obtained. Participants (n = 104) treated an average of 20 clients requiring hand rehabilitation per month often without adequate equipment (73%). Central nervous system (91.3%), bone and joint (72.8%) and arthritic conditions (72.4%) were treated most frequently. Most participants felt confident (64%) and competent (79%) in hand rehabilitation.

Conclusion

Participants were undertaking hand rehabilitation that in other contexts is considered to require specialised skills. To ensure quality rehabilitation, supervision and mentoring of novice therapists and appropriate professional development opportunities are required.

Keywords

Community service developing country hand rehabilitation novice therapist Occupational therapy

Introduction

Determining the incidence, prevalence and nature of hand injuries and conditions in many developing countries is a challenge due to limited statistics. A picture of the problem thus needs to be approximated from available evidence. Hand injuries constitute 20% of all injuries presenting at hospital emergency units.¹ Considering the link between injuries, and deprivation and poverty,² developing countries such as South Africa, are likely to experience even higher numbers of hand injuries considering their high poverty rates.

More than half of South Africans (53.8%) live in poverty,³ and interpersonal violence and road accidents far exceed global rates. Furthermore, South Africa has an injury rate of 158 per 100,000 and in 2000, 6.5% (1,000,000) of all Disability Adjusted Life Years (DALYs) resulted from interpersonal violence with road accidents accounting for around 3% (500,000) of DALYs.⁴ Limited hand injury statistics are available for South Africa. A study at a tertiary hospital identified a high incidence of violence-related injuries, many complex in nature, with knife injuries accounting for the greatest number of assault-related injuries and motor vehicle accidents for non-assault based injuries.⁵ One-third of cases sustained flexor tendon injuries with 12% classified as complex. South Africa has a large manual labourer population⁶ and carries a high rate of workplace injuries and illnesses, although the extent of the problem is concealed by poor statistics and underreporting.⁷ The hand is the body part most commonly injured at work.⁸ One study revealed finger injuries as the most reported work accident injury (24%), of which a substantial number led to permanent disability (57% of cases).⁶ Another study found that 24% of a sample of employees (n = 15,664), experienced discomfort or stiffness in the hands, wrists, forearms and elbows ‘sometimes’ or ‘frequently’.⁹ Within occupational therapy, nerve injuries, tendon injuries, fractures, arthritis, brachial plexus injuries and burns have been reported as the conditions treated most frequently.¹⁰ Although difficult to quantify, the impact of interpersonal violence, road accidents and work-related injuries on hand conditions appears significant.

Understanding health services for clients with hand injuries is also important. The South African health system has a complex history that has been shaped by discrimination, high levels of violence, the destruction of family life, income inequality, migrant labour and other factors.¹¹ This has contributed to health care that remains characterised by extreme inequality despite government attempts to effect change.^11,12 Although South Africa spends 8.5% of its gross domestic product on health care, more than half (4.4%) is spent on 16% of the population.¹³ The country has a public and a private health system; the latter being accessed mainly by those with medical insurance which represents around 17.6% of the population. The skewed distribution of health professionals towards the private sector, urban areas and better resourced geographic areas¹³ applies to services for hand conditions as verified by a record review of members of the South African hand therapy and hand surgery societies.¹⁴ Many therapists (67%) and surgeons (80%) were located in the two most urban provinces, and although a small number worked across sectors, most worked in the private sector (75% of therapists and 85.7% of surgeons). This is noteworthy considering that 83% of the population rely largely on public health services.¹⁵ Although there may have been other hand practitioners in the public sector who were not members of these societies, De Klerk found that more than 90% of experienced (≥5 years) South African therapists treating hand clients worked in the private sector.¹⁶

It was within the context of extreme health care inequality that the South African government introduced a year of compulsory community service (CS) for graduating health professionals with the aim of improving the provision of health care to all South Africans¹⁷ particularly those in rural and under-served areas.¹⁸ Graduates apply for placements at hospitals or community health facilities of their choice but can essentially be allocated anywhere in the country. Although therapists are posted at a health facility, they often deliver outreach services to multiple clinics or community-based services in the area. CS occupational therapists may be sole practitioners or part of a rehabilitation team. Some join well-established clinical departments while others are required to establish or re-establish departments.¹⁹ No formal mentorship is provided as the National Department of Health considers practitioners to be qualified to practise independently.¹⁹ CS occupational therapists commonly receive diverse referrals across a range of practice areas,²⁰ and predominant services relate to wheelchairs (51.2%), child development needs (49.5%), adult neurology (39.8%), disability grant assessment (36.9%) and upper limb injuries and conditions (30.1%).²⁰

Although compulsory CS has significantly increased the number of clinicians practising in the public sector²¹ and has extended access to health services, the continued skewing of resources perpetuates difficulties in access to health and rehabilitation services. Where rehabilitation is available, expertise and resources are often lacking.²² The high levels of disability related to hand injuries⁶ supports the importance of rehabilitation services, and the complexity of many of these injuries suggests that some expertise is required to treat them. Inadequate treatment of hand injuries results in increased costs, both direct and indirect, and higher disability rates.¹ Sound clinical reasoning and competence in implementing decisions is therefore critical in providing quality, cost-effective services.¹

Basic hand rehabilitation is included in all occupational therapy undergraduate programmes in South Africa, but the content varies substantially.²⁰ A survey of the eight programmes revealed a median of 30 h (range 12–96) for teaching upper limb assessment and treatment with a median of 22 h spent on splinting (range 8–42). On average, 70% (range 8.5–100) of students had a practice learning placement involving upper limb rehabilitation (including upper motor neuron injuries).²⁰ Graduate therapists thus enter CS with varying degrees of knowledge and skills, and limited experience. Although literature suggests a substantial need for hand rehabilitation in South Africa, there is no information to verify this, particularly regarding services CS occupational therapists provide to this group of clients or their preparedness to do so. This study therefore addressed the following questions:

What services do CS occupational therapists provide to clients with hand conditions?

What are the supports and barriers to hand rehabilitation services?

How equipped do these therapists perceive themselves to be for treating clients with hand conditions?

Methods

Design

A descriptive cross-sectional survey design was chosen for its flexibility and versatility.²³ A survey allowed questions to be asked across a variety of areas to provide the range of data required to answer the research questions.

Sampling

The research population constituted all occupational therapists allocated CS placements for 2013 (n = 241). One potential participant who was not completing CS in 2013 was excluded. To capture a broad spectrum of experience the entire population (n = 240) were included.

Questionnaire

In the absence of previous studies and therefore no appropriate measurement instruments, a self-administered survey was designed and created with Fluidsurvey software.²⁴ A review of the literature guided the development of the survey, which constituted two sections: Section A contained demographic and general practice information and Section B related to hand rehabilitation practice. In Section A, published reports of novice therapists’ experiences of practice were used to compile a list of experience descriptors.^25–33 Participants selected as many of the descriptors they felt captured their experience. Spaces were provided to allow participants to add other descriptors and make comments if they wished. The development of Section B was informed by a hand therapy practice analysis compiled by the American Hand Therapy Certification Commission.³⁴ Questions about contextual barriers and facilitators that impacted participants’ feelings of being equipped were included. Similar to the experience descriptors in Section A, a question in Section B presented a list of experiences reported by novice therapists working in hand rehabilitation. Participants selected the descriptors they identified with and could explain their choice. Response formats included numerical items, yes/no responses, multiple response items, linear numeric scales and open-ended questions. In keeping with the focus of this article, relevant demographic and practice information (Section A) and findings related to hand rehabilitation practice (Section B) are reported.

Piloting the questionnaire

The draft questionnaire was piloted in September and October 2013 with three groups of occupational therapists to establish content validity, face validity and utility. The first group, hand rehabilitation experts with post-graduate qualifications in hand therapy (n = 5), answered questions about the adequacy of the survey in interrogating all necessary knowledge, skill and behaviour components of practice. They were also asked to suggest additions and comment on the structure and format. Feedback resulted in adding some items. This questionnaire was also piloted with fourth year occupational therapy students (n = 5) who commented on the ease of understanding the questionnaire and aspects that were difficult to understand or confusing. The time taken to complete the survey was recorded and used in the instructions on the expected time for questionnaire completion. The last pilot group was therapists who had previously completed CS (n = 7). After completing the hardcopy questionnaire, six of these therapists attended a meeting where each question was examined and discussed and feedback noted on the content, format, item scaling, errors, omissions and ambiguity. Feedback highlighted the need to define some terms, improve the clarity of questions and rephrase some items. Once the questionnaire was finalised and developed on Fluidsurvey, one further therapist who had completed CS completed the questionnaire to identify any further clarification, formatting or editing required. The questionnaire is available from the first author on request.

Participant recruitment

A list of CS occupational therapists with their placements and available contact details was obtained from the National Department of Health. Participants were recruited in multiple ways (telephone, text messages, post, email and Facebook) to maximise the response rate. As the CS service period usually extends from January to December, data collection took place between November 2013 and January 2014 to allow responses to be based on at least 10 months of the 12-month contract. Questionnaires were completed online where possible and hard copies were posted to participants without telephone or email contact details. An emailed reminder inviting participation was sent. Participants received a discount voucher for splinting material on completion of the questionnaire and were entered into a draw for a hand rehabilitation textbook. Participants who completed their questionnaire before a stipulated date were also entered into a draw and the winner received a gift pack from a splinting material company. Incentives were small and did not lead to undue inducement.

Data management and analysis

Data were stored using Fluidsurvey software. Manually completed and emailed questionnaires were entered into Fluidsurvey and checked by a research assistant. IBM SPSS Statistics³⁵ and Stata 12³⁶ were used for analysis. Frequencies and proportions were established for categorical data. Non-parametric statistics were used throughout. Pearson’s χ² test of association and odds ratios were used to explore associations between variables. Variables that were potential predictors for a confident and competent therapist (25 participant and environment-related variables) were tested against perceived competence and confidence levels within hand rehabilitation. The five categories were collapsed for this analysis (competent/confident and incompetent/not confident). Variables that demonstrated statistically significant univariate association (P ≤ 0.1) with competence and confidence were included in a logistic regression model to develop a profile of perceived competent and confident therapists. Responses to open-ended questions were post-coded and grouped into categories and themes by the first author, and checked for consistency by the second author.

Ethical considerations

Ethical approval was obtained from the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee (HREC approval number: 551/2013). Informed consent was obtained from all participants. Although participants provided their names to ensure that multiple responses from a single participant were not received, names were removed and replaced with numbers once this was confirmed.

Results

A 43.3% (n = 104) response rate was achieved. One response was excluded as no questions were completed.

Participant and general practice profile

Participants’ median age was 23 years and most were female (n = 100; 97.1%). Responses varied per province (range 1%–26.2%) and per university (range 33.3%–52.4%). Close to half (n = 46; 44.7%) were placed rurally and many spent at least some time working at primary levels of care (n = 53; 51.5%). Participants provided services at a median of three sites (range 0–26) and worked with a median of three occupational therapists, two physiotherapists and no other rehabilitation personnel. Although most had a supervisor (n = 86; 89.6%) and received a median of 1 hour of supervision per month (range 0–20), many (n = 60; 65.9%, missing responses = 12) were dissatisfied with supervision pertaining to their practice in general. A high proportion reported difficulty communicating with clients (n = 68; 73.9%) predominantly due to language discordance or because attempts to overcome language barriers were insufficient.

Descriptors selected most frequently to describe participants’ experiences were satisfaction from interacting with clients (n = 72; 75.0%), proud to be an occupational therapist (n = 64; 66.7%), occupational therapy is poorly recognised (n = 61; 63.5%), frustrated (n = 56; 58.3%) and challenged (n = 52; 54.2%). The challenge one participant experienced is evident in this quote:

Hand injuries was thus far the most challenging field to work in as I never had any (fieldwork) blocks as a student to assist me with any physical injuries. All my blocks were related to psych.

Many participants’ related their choice of descriptors directly to hand rehabilitation with some (n = 42; 43.8%) indicating a need for specific knowledge in assessment and treatment ‘beyond the basic’, for ‘higher-grade injuries’, or where contextual challenges create a demand for this:

In terms of hands, I would like more knowledge on treatment protocols in a setting where most hand injuries present very late, and surgery is usually not a realistic option.

One participant who [felt] ‘like I am consolidating my skills’ (n = 30; 31.3%) explained it was ‘Particularly in splinting which I was very anxious about on arrival.’ Feeling frustrated was common (n = 56; 58.3%) and sometimes related to issues beyond the participant’s control:

…the lack of specialists in the province is a big frustration which causes our orthopaedic patients to wait months to see an orthopaedic surgeon and sometimes they are never operated. This is very frustrating with hand injuries as hand function is lost just because the patient was not operated in time or never operated at all.

Of the participants describing themselves as anxious (n = 24; 25.0%), one explained it was ‘Especially in the first month and with hand patients as I don’t feel equipped to assess and treat.’ Similarly, feeling apprehensive (n = 12; 12.5%) was linked to uncertainty about standard procedures following surgical repair:

I have the basic knowledge, but in some cases where there is a tendon and nerve injury – what protocol do you follow?

Of the participants that felt inadequate (n = 20; 20.8%), two related this to treating clients with hand injuries. Positive experiences were also linked to hand rehabilitation, for example, a participant who described herself as thriving (n = 15; 15.6%) stated:

Every time I spend time with my patients, especially people with cerebral palsy, Down syndrome or hand conditions, I feel like I am flourishing. I know that I’m exactly where I’m meant to be.

Hand rehabilitation practice profile

Participants (n = 86, missing responses = 17) treated a median of 20 hand rehabilitation clients per month (range 0–225). Central nervous system disorders (n = 83; 91.3%), bone and joint conditions (n = 64%; 72.8%) arthritic conditions (n = 63; 72.4%), thermal injuries (n = 53; 58.9%), tendon injuries (n = 51; 58.0%) and complex injuries (n = 45; 51.1%) were treated at least monthly^a

Daily, weekly and monthly categories combined.

by more than half of participants (Supplementary file I).

Modalities used most regularly in treatment included home programs (n = 74; 84.1%), manual therapy (n = 72; 81.8%), exercise (n = 70; 80.4%), activity as a means/end (n = 71; 79.8%), activities of daily living training (n = 70; 78.6%), strengthening (n = 67; 76.2%) and education (n = 64; 71.9%) (Supplementary file II).

In terms of resources to support hand rehabilitation practice, most participants indicated having sufficient support at work (n = 62; 71.3%), but many felt they had insufficient supervision from experienced colleagues (n = 60; 67.4%) and lacked a mentor to guide professional development within hand rehabilitation practice (n = 52; 59.8%). A majority were not members of a professional organisation (n = 56; 62.9%). A substantial number did not have adequate equipment to treat clients with hand conditions (n = 65; 73.0%), around one-third (n = 31; 34.8%) felt they lacked an appropriate work area to treat these clients and more than two-thirds (69.7%) did not have access to the internet at work (Table 1).

Table 1.

Resources available to support hand rehabilitation.

Resources available	Yes No. (%)	No No. (%)	Total no. of responses (no. of missing responses)
Access to a computer at work	62 (70.5)	26 (29.5)	88 (15)
Access to a telephone/fax at work	68 (76.4)	21 (23.6)	89 (14)
Access to the internet at work	27 (30.3)	62 (69.7)	89 (14)
Adequate equipment	24 (27.0)	65 (73.0)	89 (14)
Appropriate work area	58 (65.2)	31 (34.8)	89 (14)
Access to research/literature/evidence	39 (44.8)	48 (55.2)	87 (16)
Member of professional association	33 (37.1)	56 (62.9)	89 (14)
Mentor to guide professional development	35 (40.2)	52 (59.8)	87 (16)
Professional development opportunities	59 (66.3)	30 (33.7)	89 (14)
Sufficient undergraduate preparation	41 (47.1)	46 (52.9)	87 (16)
Sufficient supervision	29 (32.6)	60 (67.4)	89 (14)
Sufficient support at work	62 (71.3)	25 (28.7)	87 (16)

The most desired resources to support hand rehabilitation practice were continuing professional development (CPD) courses (93.4%), access to guidelines and protocols (86.8%), regular support and supervision from an experienced colleague (83.5%) and improved undergraduate practical exposure (80.2%) (Table 2).

Table 2.

Desired resources to support hand rehabilitation practice (n = 91).¹

Desired resources to support hand rehabilitation practice	Participants No. (%)
Continuous professional development courses	85 (93.4)
Access to clinical guidelines and protocols	79 (86.8)
Regular supervision/support by experienced therapist	76 (83.5)
Improved undergraduate practical exposure	73 (80.2)
In-service training at work	71 (78.0)
Hand rehabilitation mentor	68 (74.7)
Online resources, e.g. electronic databases	67 (73.6)
Up-to-date hand textbooks	66 (72.5)
Online courses	60 (65.9)
Smartphone or iPad/tablet application	48 (52.7)
Adapted undergraduate theoretical curriculum	46 (50.5)
Online support forums	37 (40.7)

Twelve missing responses.

Perceptions of hand rehabilitation

Descriptors reflecting participants’ experiences of hand rehabilitation (Table 3) showed that 64.8% (n = 59) felt it is a specialised area of practice. Some felt overwhelmed by hand rehabilitation (40.7%), although many reported being enthusiastic (48.4%) about the area. Many feared harming clients (41.8%) due to the potential adverse effects of their intervention (n = 10), the complexity of the field and their uncertainty and inexperience. This led to some practising with extreme diligence. Although a substantial group (n = 70; 76.9%) reported needing to ‘learn by doing’, some felt their hand rehabilitation experience was more ‘trial and error’.

Table 3.

Frequency of hand rehabilitation descriptors selected by participants.

Descriptors	No. (%)
Fearful of harming my patient	38 (41.8)
Upper limb rehabilitation is a specialised area	59 (64.8)
I need to learn by doing	70 (76.9)
I am not confident	33 (36.3)
A heightened sense of responsibility	40 (44.0)
Overwhelmed	37 (40.7)
Enthusiastic	44 (48.4)

Other perceptions participants held of their hand rehabilitation practice are contained in Figure 1. Approximately half felt they had sufficient knowledge (n = 44; 49.4%) and skill (n = 44; 49.4%), many felt their clinical reasoning was sufficient (n = 62; 71.3%) and that they were able to relate to clients’ beliefs and values (n = 68; 76.4%).

Figure 1.

Participants’ perceptions of hand rehabilitation practice.

Less than half the participants had access to up-to-date evidence (n = 39; 44.8%) to support hand rehabilitation practice and relied largely on knowledge from undergraduate education (n = 85; 93.4%), textbooks (n = 75; 82.4%), personal clinical experience (n = 72; 79.1%), internet searches (n = 69; 75.8%) and advice from colleagues (n = 63; 69.2%) to support their practice (Supplementary file III).

Participant’s ratings of their preparedness within 50 competency areas of hand rehabilitation practice generally indicated high levels of preparedness with the majority feeling at least somewhat equipped or prepared for all competencies (Supplementary file IV).

Most participants (n = 71; 78.9%) perceived themselves to have some level of competence with 21.1% (n = 19) feeling incompetent to varying degrees (Figure 2).

Figure 2.

Perceived competence in hand rehabilitation.

Similarly 64.4% (n = 58) felt some level of confidence while 35.5% (n = 32) felt unconfident (Figure 3).

Figure 3.

Perceived confidence in hand rehabilitation.

The regression analysis identified that participants reporting a level of competence were more likely to enjoy treating clients with hand conditions (Adjusted Odds Ratio (AOR): 85.94, 95% CI: 4.72–1564.58, p = 0.003) and to have had a hand rehabilitation practice learning placement during their undergraduate education (AOR: 265.73, 95% CI: 1.23–57548.30, p = 0.042). Confidence was similarly associated with enjoying treating clients with hand conditions (AOR: 28.21, 95% CI: 2.47–322.74, p = 0.007) and perceptions that their practical skills were adequate (AOR: 7.86, 95% CI: 1.63–37.82, p = 0.010).

Discussion

The study provides evidence of the demand placed on CS occupational therapists to provide hand rehabilitation. The high frequency of treating central nervous system disorders (86% of participants) and provision of activities of daily living training supports a previous study that reported a high number of rural South African stroke survivors requiring assistance with activities of daily living.³⁷ As stroke significantly affects the young adult population in South Africa, it is likely to form a substantial proportion of the rehabilitation case load.³⁸ The relatively high percentage (51%) of complex hand trauma treated ‘at least monthly’ confirms reports of the prevalence of these injuries.⁵ This is noteworthy considering that participants were in their first year of independent practice and thus treating with limited experience. The limited hand rehabilitation experience of therapists working in rural and remote areas has been reported previously,³⁹ and has implications for achieving optimal treatment outcomes. Similar to the current study, de Klerk found the hand conditions treated most frequently by a sample of South African occupational therapists were nerve injuries, tendon injuries, fractures, arthritis, brachial plexus injuries and burns.¹⁶ Many of these, and those treated frequently by participants in the current study, are due to accidents or injury implying a need to reorientate and develop services towards prevention of hand injury and promotion of hand health.

Supports and barriers to service provision

Hand rehabilitation services were provided in less than optimal conditions. Most participants lacked equipment (73%) echoing previous reports by CS occupational therapists,^40–46 and a sizable group lacked an appropriate work area for treating hand clients (34.8%). Although health facility development and improvement has been a priority in South Africa for 20 years²¹ and substantial gains have been made, anecdotal evidence indicates that a consultation room, adequate space, appropriate furniture and a reliable water and power supply may not be guaranteed for occupational therapy services.

The high number of participants reporting communication difficulties (64.0%) is not surprising given the 44 living languages in South Africa, 11 of which are official.⁴⁷ The fact that English is the preferred language of health care providers in South Africa, resulting in around 80% of communication taking place across communication barriers,⁴⁸ poses a considerable challenge to hand rehabilitation⁴⁹ due to communication being central to client-centred and holistic practice. A substantial majority (76.4%) felt able to relate to the beliefs, values and traditions of their clients, which is considered key to communication and collaboration with hand injured clients in rural and underserved communities.³⁹

The lack of supervision (67.4%) and mentoring to guide professional development (59.8%) reiterates Kingston et al.’s recommendation that therapists with limited hand rehabilitation skill servicing rural or remote areas should seek the support and mentorship of an experienced colleague.³⁹ It is therefore not surprising that a high percentage of participants indicated that regular supervision by an experienced colleague (83.5%) and hand rehabilitation mentor (74.7%) were resources that would support their practice.

Although professional development opportunities were available but under-utilised may be due to accessibility issues given participants’ rural locations and the fact that most hand rehabilitation courses are offered in or around three of the major cities.⁵⁰ CPD courses were considered by almost all (93.4%) to be a necessary support for their hand rehabilitation practice. While a substantial proportion perceived online courses as desirable (65.9%), this would have to rely largely on personal internet access given that few had internet access at their workplace. Access to up-to-date evidence was limited (55.2%) and, similar to other studies,^51–54 the sources of evidence used most frequently tended to be less robust and more susceptible to becoming outdated. MacDermid⁵⁵ identified the importance of integrating evidence into hand rehabilitation; access to this evidence is thus key, particularly where knowledge and skills are limited. It is, however important to note that appropriate evidence may not always be available⁵⁵, and that the knowledge and skill required of a novice therapist in a rural or underserved area may need to be informed by multiple sources of evidence to ensure contextually responsive therapy.^56,57

Equipped for hand rehabilitation?

Therapy for clients with hand conditions is considered a specialist area of practice requiring advanced post-graduate education, experience and complex integration of knowledge.⁵⁸ As a result, formal accreditation processes are common worldwide.⁵⁹ This study showed a demand for novice occupational therapists to provide hand rehabilitation. Despite contextual barriers and the specialist skills this work may require, a surprising number of participants felt confident (64%) and competent (79%) although the high proportion feeling they possessed sufficient knowledge and skill for hand rehabilitation practice (49%) may represent an over-estimation of competence as discussed later.

Self-assessments of competence have been shown to be inaccurate compared with external, objective observations.⁶⁰ It is not uncommon for novice therapists or those new to hand rehabilitation to over-estimate their abilities. For example, a United States study found that therapists new to hand therapy reported acquiring knowledge and skill earlier than those with more experience.⁶¹ This phenomenon may reflect unconscious incompetence (first stage of the model of skill development)⁶² where insight into incompetence is lacking. Experienced hand therapists have demonstrated that awareness of what was not known could only be generated in hindsight as an awareness of what needs to be known is developed.⁶¹ Conscious incompetence (stage two) only emerges as the outcomes of action are evaluated or feedback is received from others, resulting in the learner realising their incompetence.⁶² Elements of conscious incompetence were evident in participants expressing their need for supported learning. If, in the case of many of the participants, supervision or other clinical feedback is lacking, the therapist must rely on personal reflection to progress in skill development and clinical decision-making.⁶³ Where this is absent, a therapist who has not moved beyond the first level of skill acquisition, but acts with increasing confidence, may cause harm with potentially concerning implications for clients.

In Dreyfus and Dreyfus’ five phase process of skill acquisition,⁶⁴ the novice (first) phase involves an ability to recognise elements of a skill and rules guiding its use, but with little attention to the context. This stage thus has no experiential background and has been approximated to the early stages of undergraduate education within nursing.⁶⁵ As advocated by Benner,⁶⁵ many participants in this study may be considered advanced beginners. In this second phase performance may only just be considered acceptable and is attained with extensive exposure to real clinical situations.⁶⁴

Although over 75% of participants felt ‘competent’, considering their limited practice experience, it would be surprising if they were operating at this level of skill. The competent practitioner (phase three)⁶⁴ is able to perceive and process a vast amount of information from the environment which requires far more than a procedural approach. Benner⁶⁵ suggests that becoming competent depends on the variety and complexity of a practitioner’s patient population and that competence may develop unevenly across practice areas depending on exposure and the quality of education. This intimates that exposure to clients with hand conditions, despite limited prior experience, facilitates the progression to competence. This deduction is supported by the many participants who reported needing to ‘learn by doing’ (76.9%). For some however, developing competence appeared to be necessitated by their practice conditions reiterating the need for support and continuing education opportunities.

Strengths and limitations

This study is the first to report the demand on CS occupational therapists to deliver hand rehabilitation services in South Africa and their perceptions of being equipped for hand rehabilitation. Several study limitations are acknowledged. Firstly, the use of self-report may have motivated respondents to respond overly positively⁶⁶ thus providing an over-estimation of the actual situation.⁶⁷ While a self-report questionnaire was suited to the research questions, it was not an objective measure and could not assess the quality of the services provided. Secondly, as the study investigated treatment of hand conditions, implying predominantly curative and rehabilitative care, the questionnaire is likely to have under-captured preventive and promotive approaches. Thirdly, because the study focused on being equipped for hand rehabilitation, it is possible that those who felt less equipped chose not to participate which may have introduced non-response bias. Fourthly, the formatting of the online questionnaire precluded making questions compulsory which introduced item non-response. Some responses may therefore have been under-captured leading to a skewing in the findings. Lastly, the study was underpowered due to a substantially higher percentage of participants indicating their competence and confidence in hand rehabilitation than the estimates used to calculate the sample size. As a result, generalising the study findings to the 2013 CS occupational therapy population, other CS occupational therapy groups and novice occupational therapists in other countries needs to be done with caution.

Implications

The study suggests that novice therapists providing hand rehabilitation services, particularly in rural and underserved communities, require experienced supervision, mentorship and CPD opportunities to support practice. These needs could be met by mobilising therapists with appropriate expertise, which could involve collaborations facilitated by international and regional hand therapy societies and associations.⁶⁸ Mentors and supervisors should receive training directed at appreciating the realities of working in underserved contexts and equipping them with tools and methods to provide support (e.g. Smartphone chat groups, telephonic support, support and supervision contact/video-chat sessions). As an incentive, supervisors and mentors could receive CPD points for attending training and for submitting a record of their supervision and mentorship. Furthermore, hand therapy societies should ensure that appropriate and accessible CPD courses are available, and professional organisations should lobby for access to appropriate evidence to support practice, particularly in rural and underserved communities where such resources are often lacking. As an objective measure was not used, further research should be undertaken to evaluate the quality of the interventions provided.

Long-term strategic planning involving key stake holders should focus on developing quality hand-care^b

The comprehensive management of hand conditions at all levels of care, from basic principles of practice within primary settings to advanced surgery and therapy at the end of the referral pathway.

for all; such a plan may assist novice therapists to prioritise how hand services are developed and may also earmark where human resources need to be deployed to support hand rehabilitation practice. Although the South African hand surgery⁶⁹ and hand therapy⁷⁰ societies’ visions do not currently demonstrate an orientation towards increasing access to quality hand care, it is argued that a strategic plan to improve the hand health of the population, may be critical in directing research, infrastructure improvement and education, all of which are essential for developing hand care services.⁶⁸

Conclusion

The demand placed on this group of novice occupational therapists illustrates a need for hand rehabilitation services that extends beyond the impact of therapists with specialist training. Although service quality was not assessed, the conditions under which services were delivered and the specialist skills required suggest that, in contexts where hand rehabilitation services are by necessity provided by novice therapists, appropriate training, supervision and mentorship should be in place to support the provision of quality basic hand rehabilitation.

Footnotes

Acknowledgements

We would like to thank the study participants and the occupational therapists who assisted in refining the questionnaire.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the KW Johnstone Award, the University Research Committee at the University of Cape Town and the Postgraduate Publication Incentive Fund, University of Cape Town.

Ethical approval

Ethical approval for this study was obtained from the Human Research Ethics Committee, University of Cape Town (HREC approval number: 551/2014).

Guarantor

KvS.

Contributorship

KvS researched literature. KvS and HB conceived the study and were both involved in protocol development. KvS gained ethical approval and recruited participants. KvS conducted data analysis with guidance from HB. KvS wrote the first draft of the manuscript. Both authors reviewed and edited the manuscript and approved the final version of the manuscript

Informed consent

Written informed consent was obtained from all participants before the study.

Supplementary material

Supplementary material for this paper can be found at

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