Research question

What are the perceptions of OT students on undergraduate splinting as a part of hand rehabilitation at the University of KwaZulu-Natal?

Aim:

The study aimed to investigate the perceptions held by undergraduate OT students regarding splinting in hand rehabilitation at the University of KwaZulu-Natal.

Objectives

1. i. To explore the OT students’ perceptions of their readiness and preparedness for splinting in clinical fieldwork.
2. ii. To identify students’ recommended strategies for addressing deficiencies in the UKZN OT hand rehabilitation section, specifically splinting.

Hand rehabilitation in KwaZulu-Natal

The scope of hand rehabilitation in KwaZulu-Natal (KZN), South Africa, is marked by significant challenges, including a shortage of OTs in the public sector, limited studies on rehabilitation outcomes, and budget constraints [8]. The prevalence of hand injuries in KZN is substantial, with a need for comprehensive data on hand rehabilitation in the South African context.

South Africa’s healthcare landscape faces several challenges, including the distribution of OTs, accessibility to rehabilitation services, research gaps in service outcomes, and budgetary constraints [9]. In 2022, South Africa’s population was just over 62 million [10], with a significant portion (71%) relying on the public health sector for their healthcare needs [11]. In 2018, there were 5180 OTs in South Africa [9]. In KZN, there were 75 OTs spread across 45 district hospitals and 14 regional hospitals, serving a population of over 11 million.

More than 90% of OTs with over five years of experience in hand rehabilitation tend to move into the private sector due to barriers such as limited access to resources, physical environment, client follow-up up and high caseloads [8]. This trend has significant implications for rural areas in South Africa, where access to hand rehabilitation services within the public health sector is limited. In 2018, a shortage of OTs was evident in KZN, where the division needed 19 OTs but had at most six positions filled across various public healthcare sectors. This shortage harms the delivery of OT services within the public health sector. According to Ghela et al. (2022) [8], the uneven distribution of OTs is attributed to the limited number of studies conducted on the outcomes of rehabilitation services provided at various levels of the public health service system. This makes it challenging to assess the effectiveness of rehabilitation efforts and pinpoint areas that require improvement. Ghela et al. (2022) [8] added that government budget constraints pose a significant challenge, affecting therapists’ ability to utilise specific treatments, such as hand splinting, due to the high cost of required materials.

Human hands are highly complex structures as they are made up of numerous bones, joints, tendons, ligaments, muscles, nerves and blood vessels, as well as sensory receptors, that all work in a coordinated way to produce precise, controlled movements that allow individuals to function and complete a variety of daily tasks [4,12]. Hand rehabilitation is a multifaceted process that requires a multidisciplinary approach to provide holistic treatment and optimal recovery and function. Although many professionals form part of the multidisciplinary team (MDT) for hand therapy, this has been an area of speciality for OTs since the 1940s [12]. Hand surgeons, nurses, and physiotherapists form part of the MDT to help maximise the outcomes. OT hand rehabilitation starts with a referral, evaluation, intervention, and follow-up with the client [13]. OTs address physiological issues using modalities such as splinting, manual techniques, and occupation-based activities, which are tailored to the client’s goals [4,14].

Splinting as a part of hand rehabilitation within OT intervention addresses the biomechanical, functional and psychological complications related to hand injuries [4,14]. Hand rehabilitation aims to restore functional use by applying knowledge from physiology, anatomy, and psychology [4,14]. While physiology and anatomy guide the physical restoration of structures, psychology plays a critical role in addressing the emotional, cognitive, and behavioural factors that influence recovery. Following a hand injury, individuals may experience a wide range of emotional distress, including anxiety, depression, frustration, fear, and guilt [15]. The loss of hand function can also lead to feelings of insecurity, dependency, and perceived incompetence, further contributing to psychological strain [16]. Studies on work-related hand injuries have shown high incidences of stress-related conditions such as anxiety disorders, major depression, and post-traumatic stress disorder [17,18]. These psychological factors can negatively impact motivation, pain perception, coping ability, and ultimately, engagement and outcomes in therapy.

Traumatic hand injuries remain a significant global health concern [19], while just above 30% of traumatic injuries are hand-related in South Africa [20]. [13] However, comprehensive data regarding the prevalence of hand injuries in South Africa remains limited. Naidoo et al. (2021) [13] noted that the most frequently treated injuries and conditions included bone and joint conditions, arthritic conditions, tendon injuries, peripheral nerve injuries, complex injuries, thermal injuries, and infections, many of which resulted from accidents or other traumatic events. Among these, the most common traumatic hand injuries managed by OTs were flexor tendon injuries (88%), fractures (83%), extensor tendon injuries (73%), and combined hand injuries (73%). Vascular injuries were the least severe condition managed by OTs, accounting for only 17% of cases that year [13].

To address the issues highlighted above, it is crucial to invest in OT training and encourage the deployment of OTs within the public health sector. Strengthening the OT workforce will enhance healthcare access, improve rehabilitation outcomes, and ultimately, promote the well-being of South Africa’s diverse population.

Undergraduate occupational therapy training in hand rehabilitation

In South Africa, eight universities offer undergraduate programs in OT. In the province of KZN, UKZN at the Westville Campus is the sole institution offering this degree. The Health Professions Council of South Africa (HPCSA) mandates that the OT curriculum at each university should encompass various components, such as, but not limited to, 10% on understanding human structures and functions (anatomy and physiology), 10% on understanding diseases, disorders, and trauma (physiology and clinical sciences), 35% on occupation and OT, 10% on primary health care, promotion, community or social development, and social determinants of health [6]. The comprehensive OT curricula in South African universities provide a solid foundation for students to acquire the knowledge and skills necessary for effective patient care, including hand rehabilitation, and prepare them for professional practice.

This comprehensive knowledge base is crucial for students as it forms the foundation for their practical application during clinical fieldwork. UKZN’s curriculum is designed to build upon this knowledge each year. For instance, students learn about anatomy and physiology in their first and second years. These two subjects expose students to the fundamental knowledge about the structure and function of the hand. Their OT-specific sections begin in the second year, where students are introduced to various hand conditions and learn how to assess and conduct essential treatments. Different tools and materials are used for hand-related teaching, encompassing traditional lectures with slides, demonstration videos, recommended textbooks, and recent, contextually relevant published articles. The in-class hand lectures duration ranges from half a day (5 hours) to three full days (8 hours per day). In their 3^rd and 4^th year, the focus delves into splinting as an intervention modality, specifically learning about splinting and how to make splints. A splint is “a rigid or flexible material used to protect, immobilise, or restrict motion in a part” [21], p98. During the practical training sessions, students develop their clinical skills by fabricating hard and soft splints for adult and paediatric clients, practising on classmates’ typical, uninjured hands.

This is an essential part of the learning process, as by practising on a typical, uninjured hand, students can build their confidence, become familiar with the tools and materials used and develop techniques without having the added complexity of an injury. Some splints that are explored and/or made are forearm-based splints, such as wrist extension splints, resting splints, and dynamic extension splints. Other splints introduced at the undergraduate level include hand-based splints, such as finger splints, thumb splints, and buddy strapping [22].

To enhance their skills, students are expected to attend clinical fieldwork and utilise opportunities, such as working in an MDT for applied learning at various fieldwork sites, including Substance Abuse Rehabilitation Centres, Sheltered Workshops, Old Age Homes, Chronic Care Facilities, Public Hospitals, Rehabilitation Centres, Community-based Centres, Special Needs Schools and other relevant settings. The four-year Occupational Therapy programme at UKZN structures its clinical fieldwork as ‘blocks’ – i.e., periods of supervised practice that begin in the second year and are progressively scaffolded through to the fourth year. These blocks expose students to various fields of occupational therapy, including occupational therapy applied to physical conditions. The overall structure is as follows:

• 2^nd year: Students attend clinical settings once a week for 8 weeks (no splint-making, as splint training begins in the third year).
• 3^rd year: Students attend three times per week for 8 weeks and start fabricating splints.
• 4^th year: Students attend clinical settings daily for 6 weeks.

Researchers emphasise the importance of applied learning for developing professional competence, suggesting that clinical exposure, rather than classroom instruction, plays a more pivotal role in student development [7,23]. This relationship has profound implications for curriculum design.

De Witt et al. (2019) [24] found that international studies emphasise the importance of such clinical or hands-on exposure in fostering both clinical competence and professional identity in OT students. These practical learning environments develop students’ ability to adapt to real-world clinical complexities, improving their problem-solving and therapeutic reasoning skills. For instance, splinting, a core skill for treating various hand injuries, requires both technical proficiency and adaptability to patient-specific conditions [14]. Integrating hands-on experiences into undergraduate training is crucial, and the current focus on clinical fieldwork as part of applied learning reinforces this need. This literature suggests that improving access to resources and providing comprehensive practical opportunities could help bridge the gap between theory and practice. Ultimately, strengthening undergraduate OT training at UKZN—particularly through practical experiences such as splinting—will help produce more competent graduates who are better equipped to serve in the public health sector. This can enhance access to rehabilitation services for underserved populations in KZN province and improve the well-being of individuals affected by hand injuries in these communities. However, several challenges hinder the effective implementation of practical learning experiences, including difficulties in finding suitable clinical fieldwork placements and supervisors [25]. These have a negative impact on students’ exposure to specific OT fields, such as splinting as part of hand rehabilitation and their overall experience levels. Such placements have an impact that extends beyond the South African setting, as it is noted that a lack of supervision, limited access to clinical sites, and high academic pressure contribute to students’ feelings of being underprepared and stressed internationally [24].

While the value of clinical preparedness is well documented, there is a scarcity of research that contextualises this within South African OT programs, specifically those operating in resource-constrained provinces like KZN. Furthermore, few studies have explored how undergraduate students perceive their readiness for splinting as a specific skill within hand rehabilitation. Given the high burden of hand injuries in KZN and the uneven distribution of therapists across the public and private sectors, this study is crucial for understanding how current training methods affect students’ competence and long-term workforce readiness. The section below focuses on Kolb’s Experiential Learning Theory in relation to this study.

Kolb’s experiential learning theory

Widely recognised and applied since its inception [23,26], Kolb’s Experiential Learning comprises four stages of learning: concrete experience, reflective observation, abstract conceptualisation and active experimentation [7,23]. Despite its prominence, Morris (2020) [26] critiques it for lacking robust theoretical support and clarity in its components. Morris (2020) [26] argues that the theory should be more contextually responsive, emphasising contextual richness, context-specific and practical experiences to enhance active experimentation. In essence, Morris (2020) [26] suggests that the model should incorporate contextual considerations to be more responsive, a finding that aligns with this study’s results.

This study advocates for integrated educational models that blend theory with experiential learning, as supported by researchers [23,26]. Kolb’s Experiential Learning Theory [7,23] contextualises this study’s findings, highlighting the limitations of curriculum structures that prioritise theory over practical training, which may hinder procedural skill consolidation. The findings underscore an urgent need for curriculum developers to integrate deliberate and structured clinical exposure into the OT program at UKZN. This need arises in the context of the unequal distribution of therapists between South Africa’s private and public sectors, requiring a curriculum that equips students with adaptability and resourcefulness for diverse, often resource-constrained environments. Contextually relevant training [26] could better prepare students to serve South Africa’s diverse populations. The aim and objectives of this research were achieved as outlined in the conclusion section below.

Study design

A qualitative study design was employed to gain an in-depth understanding of undergraduate OT students’ perceptions of their training. This approach is particularly suited for capturing students’ complex and subjective perspectives, which cannot be adequately represented through quantitative methods. The Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups was followed to ensure that all method-related items were adhered to [31].

Population

The study was conducted at the UKZN, Westville campus. The targeted student cohort, comprising just under 70 registered combined 3^rd and 4^th year Bachelor of Occupational Therapy students in the College of Health Sciences, was selected. A purposive sampling strategy was used to select participants who had been exposed to splinting theory and practice, which was introduced in the 3^rd year of study. This method was chosen to ensure the inclusion of students with relevant knowledge and experience related to the research topic. Purposive sampling was chosen because it enabled the intentional selection of individuals most likely to provide rich, in-depth, and context-specific data, which would not have been possible with random sampling [27].

Inclusion and exclusion criteria

The inclusion criteria comprised 3^rd and 4^th year OT students from UKZN with physical fieldwork experience and exposure to hand rehabilitation, particularly splinting. First and second year students, as well as those without prior physical fieldwork experience or exposure, were excluded from this research because they had not yet covered splinting in their curriculum.

Data collection process

The data collection process commenced following ethical clearance from the UKZN Biomedical Research Ethics Committee (BREC). Class representatives of 3^rd and 4^th year OT students were contacted via WhatsApp and requested to distribute an information sheet along with a Google form. This form was used to collect (prospective) participants’ contact information, level of study, and sex, which enabled the researchers to identify them and obtain informed consent. The information sheet outlined the study’s purpose, explained that participation was entirely voluntary, and stated that participants could withdraw at any stage without consequences or penalties. It also detailed any potential benefits of participation. It included contact information for the researchers, which allowed participants to ask questions or seek further clarification in accordance with UKZN’s ethics policy [22].

Individual, once-off semi-structured interviews were conducted using the Zoom platform. Each researcher selected participants who consented. A literature-informed interview guide was used to ensure consistency. This guide was piloted with recent OT graduates and refined to improve clarity. Recruitment and data collection spanned from 22 July to 12 September 2024. Additionally, peer debriefing and member checking were used where necessary to validate interpretations and ensure the credibility of the findings. The researchers aimed for data saturation and sufficient depth of perspective to provide a meaningful understanding of participants’ experiences, thereby strengthening the reliability of the study [28]. Data saturation was achieved when the researchers had collected sufficient data to draw the necessary conclusions, and further data collection yielded no additional insights of value into the study. Trustworthiness and accuracy of the data were ensured through several strategies grounded in credible qualitative research practices. Participation in the study was voluntary, and to promote anonymity and honest responses, participants were asked to refer to themselves as “Participant” during online Zoom interviews. All interviews were audio-recorded with participant consent and later transcribed verbatim (using Microsoft Word Online) to maintain the accuracy and integrity of the data. Coding was conducted by two researchers and verified by the other two researchers to enhance reliability. Intercoder agreement was assessed using a consensus, where discrepancies in coding were discussed and resolved collaboratively by all researchers to ensure consistency and rigour in theme development. The research team consisted of four student researchers, supervised by an experienced academic.

Reflexivity, which entails continuously critiquing one’s own beliefs, subjectivity, and their influence on the research process [29], was maintained throughout the study to minimise bias. A transparent decision-making process and regular collaborative discussions with the research team supported this. Data triangulation among the research team further strengthened the credibility of the findings. A clear audit trail was kept, and all data were securely stored on a restricted-access online platform. All raw data files are available from the Open Science Framework (OSF). The complete reference is as follows: UKZN undergraduate research Raw Data. OSF; 2024. Available from: https://osf.io/yvd7r under file: https://osf.io/yvd7r/files/osfstorage. Contact the corresponding author for further details.

Data analysis

A hybrid approach was employed during the thematic analysis, as it allows for both inductive and deductive methods [30]. While Braun and Clarke’s six-step process, namely familiarising with the data, data coding, identifying themes, reviewing themes, defining and naming themes and producing the report [31], guided the analysis, some themes emerged inductively from the data. Others were informed deductively through existing literature and research objectives that aligned with the study’s focus, e.g., ‘explore the OT students’ perceptions of their readiness and preparedness’. To safeguard the inductive component, initial codes were generated directly from participants’ words and independently reviewed by other researchers before being examined alongside deductive expectations, allowing unexpected insights to be retained. Four themes, each with corresponding subthemes, emerged, supported by quotes from participants.

Ethical considerations

The study adhered to the World Medical Association’s Declaration of Helsinki, ensuring informed consent, privacy, non-maleficence, beneficence, and confidentiality [32]. The UKZN Biomedical Research Ethics Committee (BREC) reviewed the research proposal and granted both gatekeeper permission and ethical clearance, ethics number BREC/007090/2024. Written and witnessed informed consent was obtained from all participants.

Demographic profile of the participants

This research consisted of 16 participants: n = 5 males and n = 11 females undergraduate OT students at UKZN, of whom six were in their 3^rd year, and 10 were in their 4^th year. The number of physical blocks completed by the participants ranged from two to three. The number of splints made during clinical fieldwork showed that two participants made no splints, seven made between one and three splints, and seven made four or more. Refer to Table 1 for details.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Demographics of Participants.

https://doi.org/10.1371/journal.pone.0343017.t001

Themes

Four themes and corresponding subthemes emerged in this research, summarised in Table 2 below. The four themes are student readiness and preparedness, challenges in splinting, comparison of readiness in the 3^rd year and 4^th year, and suggested solutions to bridge the gaps. The themes are explored using verbatim quotes to capture and represent the participants’ perspectives authentically.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Themes and Subthemes.

https://doi.org/10.1371/journal.pone.0343017.t002

Theme one: Student readiness and preparedness

Theme two: Challenges in splinting in hand rehabilitation at UKZN

Theme three: Comparison of readiness in 3^rd year and 4^th year

Theme four: Suggested solutions to bridge the gaps

Student readiness and preparedness

The findings from this study highlight a notable discrepancy between students’ theoretical knowledge and their perceived readiness to apply splinting techniques in clinical settings. Despite increased exposure to theoretical content in the 3^rd and 4^th years, students consistently reported feeling underprepared, uncertain, and low in confidence in their splinting abilities. These concerns are similar to those raised by Ghela et al. (2022) [8], who identified a critical shortage of OTs specialising in hand rehabilitation in KZN, thereby limiting opportunities for supervised clinical practice in this area. This pattern suggests that both exposure and its sequencing influence confidence. This study highlights the need to balance classroom teaching with hands-on [23,33] clinical fieldwork to enhance students’ readiness for splinting techniques in OT training, thereby reducing the risk of patients receiving incompatible splints that could endanger their health. Students value classroom learning for its structured, often ungraded setting, which builds confidence. However, limited access to practical experience in hand rehabilitation hinders their skill development, as shown by this study and supported by Ghela et al. [8]. These findings are supported by Kolb’s Experiential Learning Theory [7].

The above findings support and expand upon available global [19] and South African [20] research, which suggests a growing demand for therapists skilled in managing traumatic hand injuries. Students’ confidence appeared to fluctuate between teaching and clinical periods, suggesting that irregular exposure may disrupt continuity in their learning. This highlights the value of practice that is revisited and reinforced over time rather than delivered in isolated blocks. The students’ anxiety around preparedness may affect workforce development, as some may be discouraged from specialising in hand rehabilitation. This concern is supported by Ned et al. (2020) [9], who reported that most experienced hand therapists work in the private sector, worsening access to care in the public health system.

Interestingly, despite the challenges, a few students showed interest in specialising in hand rehabilitation. This may suggest that their motivation offsets perceived skill deficits, aligning with self-efficacy theory, which emphasises the role of confidence in forming one’s identity [34,35]. However, the overall trend of low confidence signals a disconnect between curriculum structure and clinical readiness, warranting urgent curricular reform. Emphasis on experiential learning could assist in this regard [7]. Consistent with the literature [22,23], this study reinforces the value of experiential learning in closing the gap between theory and practice. Although students acquire substantial theoretical knowledge, their ability to apply it in practice is hindered by limited hands-on opportunities. Kolb’s Experiential Learning Theory supports this, asserting that concrete experience and active experimentation are crucial for skill development [23].

This study also reveals inconsistencies in clinical training. While some students had meaningful hands-on exposure, others were confined to observational roles. These inconsistencies likely reflect broader systemic issues such as placement shortages, limited supervisory capacity, and resource constraints, as noted by Naidoo (2013) [25]. These factors may be beyond the control of UKZN and the clinical fieldwork sites hosting their students. These variations risk producing uneven graduate competence and, ultimately, affecting the quality of care delivered. Students with greater hands-on clinical exposure in hand rehabilitation gained a significant learning advantage, as supported by Wijnen (2022) [23], Morris (2020) [26] and Kolb (1984) [7]. However, those restricted to observational roles in the OT program’s hand rehabilitation section reported frustration with repetitive, limited training experiences, mirroring the systemic placement and supervision constraints identified by Naidoo (2013) [25] and evidenced in this study.

Student-proposed solutions for enhancing splinting training

Students’ recommendations to increase practical training time, introduce splinting earlier in the curriculum, and diversify clinical placements directly respond to the challenges identified in both this study and the literature. These recommendations align with Van Stormbroek and Buchanan (2018) [22], who advocate for curricula that reflect common clinical presentations and emphasise iterative skill practice. Moreover, these findings draw on Kolb’s Experiential Learning Theory, which spans concrete to active experimentation [7,26]. Specifically, students could transition from learning splinting patterns in class to applying abstract problem-solving skills to fabricate suitable splints tailored to diverse patient conditions or injuries. The proposal to introduce splinting earlier aligns well with scaffolding learning principles [36], which advocate introducing foundational skills early and building on them systematically to foster competence and confidence. These patterns indicate that confidence develops gradually and is strengthened through repeated reinforcement, offering a broader understanding of why students consistently request more opportunities to practise. For instance, introducing basic splinting techniques and materials at a junior level could enhance students’ preparedness. By providing more time to practice and refine skills, this scaffolding approach could mitigate the confidence deficit observed in clinical practice. Furthermore, students’ calls for diversified fieldwork placements address healthcare access disparities and uneven therapist distribution, as noted by Ghela et al. (2022) [8]. Expanding clinical placement opportunities, particularly in underserved areas, can enrich student experiences while addressing workforce inequities. However, achieving these outcomes requires enhanced institutional partnerships with the public health sector, improved supervisory capacity, and strategic curriculum reform, which may take some time. In the interim, minor adjustments, such as those outlined above, can be implemented immediately to enhance learning in line with Kolb’s Experiential Learning Theory.

In closing, the above discussion suggests that students in this research move through only part of Kolb’s Experiential Learning Cycle, gaining reflective observation and abstract conceptualisation through theory-based teaching, but with sparse concrete experience and structured, consistent opportunities to foster active experimentation. This incomplete movement through the learning cycle may explain why additional exposure on its own does not necessarily build confidence or a sense of readiness.

Strength

This research contributes to the knowledge base of a previously underexplored area. The research employed a rigorous methodology, and ultimately, the findings can inform student training, yield better-prepared graduates and contribute to enhanced patient care, improved patient outcomes, and an overall better quality of life. Moreover, although the study focused on a single institution in South Africa, the findings hold relevance for institutions worldwide. These results could be shared at international platforms such as the World Federation of Occupational Therapists conference, potentially sparking discussions on standardised approaches that would benefit training globally.

Limitations

This study encountered several limitations that could impact the depth of the outcomes and generalisability of the findings. The limitations are summed up as follows:

• One significant limitation was the inability to conduct focus groups due to scheduling conflicts, which limited the depth of data that could have been gathered through group discussions.
• Furthermore, a low response rate resulted in a small sample size, a characteristic of qualitative research.
• There are limited international studies that focus on OT students’ preparedness in providing intervention, particularly hand rehabilitation.
• The institution-specific sample may not reflect hand rehabilitation practices or challenges faced by other universities in South Africa and internationally
• To address the limitations of this study, future studies should consider flexible scheduling or virtual platforms to facilitate focus groups, thereby enriching the depth of the data. Increasing the response rate can be achieved through follow-up reminders, simplifying data collection tools, and emphasising the value of participation. Expanding the sample size by including students from different year levels and even alumni can improve representation. Broader literature searches and collaboration with other institutions can provide more comprehensive and generalisable findings.