Maximum variation sampling (Given 2008) was used to select a wide diverse study sample. In this study, participants were purposefully and maximally different from each other by race, experience, job title (e.g. manager, clinical practitioner) and location or site (e.g. province). Race and gender were considered because these are significant social and political identities that interact with professional practices (Abrahams et al. 2019).

Prior to recruitment, a human research ethics committee clearance was obtained from the review board of the University of Cape Town (REF:569/2021). A recruitment letter was circulated to the National Public Sector Rehabilitation Forum to all occupational therapists, speech-language therapists, physiotherapists and audiologists, describing the study and asking volunteers to contact the principal investigator. Eligibility was determined by the research team, consent was obtained, and participants were enrolled in the study.

The inclusion criteria for rehabilitation practitioners were those: (1) whose primary practice site is in the public sector in clinical and/or managerial (service) positions; (2) who have practised with/for COVID-19 patients; and (3) who self-declared their willingness and ability to participate in a critical conversation.

The study sample included 12 participants with 4 being in management positions. The professional breakdown included four occupational therapists, three physiotherapists, three speech-language therapists and two audiologists. Of these, three were male and nine were female. Four participants were from Gauteng, three from Mpumalanga, two from the Western Cape, two from Kwa-Zulu Natal, and one from North West province. Three rehabilitation practitioners had 5 and less years of experience, two had between 6 and 10 years and four had between 16 and 20 years of experience.

Twelve individual critical conversations were conducted which took an average of an hour each. At the time of each critical conversation, participants received both oral and written information about the study, including their right to withdraw their participation at any point without consequences. Written informed consent was obtained from all the participants. The conversations were conducted via Zoom by an individual who was not a member of the rehabilitation professions, and who is a natural disruptor, which is required to facilitate critical conversations and to develop an emic-etic balance in the methodological processes typical of critical conversations (Lambert, Glacken & McCarron 2011; Macnamara 2021; Olive 2014). Emic and etic perspectives are important in ethnographic research so that it captures the interaction between the interviewer and participants to explore multiple perspectives (Macnamara 2021; Olive 2014).

Twelve participants were asked to share their experiences, based on their unique perspectives and, as these were critical conversations, specific, structured questions were not predetermined. The questions differed based on the information obtained during each conversation which ranged from 50 to 60 min. A short introduction was provided by the lead conversation partner to situate the study and to position their role as a health activist and journalist who was not trained in any of the rehabilitation professions. At the end of the conversation, participants were provided the opportunity to correct misunderstandings or add additional information. Conversations were audio-recorded using Zoom online meeting software, and transcribed verbatim using Otter.ai, a speech-to-text transcription software that uses artificial intelligence (AI). Zoom allows for the safe protection of data for research because of its ability to securely record and store sessions for the purpose of collaboration (Archibald et al. 2019). Transcriptions were then rechecked for syntactic and content accuracy by the researchers shortly after each critical conversation. Interviewee transcript review (Hagens, Dobrow & Chafe et al. 2009) was utilised where participants were provided with their verbatim transcripts to verify for accuracy and correct any errors. The audio recordings were stored in a password-protected file on the lead researchers’ computer and managed in accordance with University of Cape Town’s data management policy. Each participant’s audio-recording and transcript were de-identified and labelled with a code (numerical) to maintain confidentiality, and only the primary investigator had knowledge of the participants’ code.

Data were analysed after all critical conversations were completed, and a thematic analysis was conducted using steps described by Braun and Clark (2019). All data obtained were initially read to provide a holistic view of the reported lived experience. Data were coded (substantive and axial coding) resulting in an extensive list of codes; the codes were categorised, clustered into concepts, and finally formulated into three themes. Researchers then subsequently discussed, critiqued, collaborated and concluded on any divergent opinions concerning the categorisation and themes.

This reflection allowed the researchers to evaluate their subjectivity, belief systems and underlying biases which contributed to the overall trustworthiness of the study (Delve & Limpaecher 2022; Olmos-Vega et al. 2023).

The fragility of healthcare systems and its leadership was exposed by the COVID-19 pandemic, which included the lack of leadership, limited guidance and poor communication from top management. While there is no playbook for leadership in a pandemic, positive and collective leadership that is ‘authentic, aware, adaptive, flexible, as well as trusted, engaged and compassionate’ is crucial (Anjara et al. 2021; Hill et al. 2020). Collective leadership is displayed by joint participation in decision-making by all team members who complete tasks that were reserved for a hierarchical leader (Anjara et al. 2021; Edwards & Bolden 2023).

In this study, top management’s response was described as a ‘fragmented, reactive response to COVID-19’. The anger of rehabilitation practitioners is exemplified in the responses of Participants 5 and 6:

Mather (2020) states that leaders need to act with urgency, take responsibility by responding to mistakes, adapt and constantly update, communicate with clarity and transparency, and think outside silos. Managers who were interviewed highlighted these behaviours as they reported that they led their teams with the sense of urgency that was required. They achieved this by initiating collaboration with other health care workers in the wards and by developing systems within their departments to address workload and well-being challenges. Transparency and communication were the key strategies utilised by managers. Other strategies included daily meetings to touch base and share any new information received, developing protocols, establishing clear and accessible communication channels, and responding from a point of ‘humanity’. This example of leadership exemplifies some of the characteristics as described by Mather (2020) earlier:

One of the managers stated that there was a lot of resentment directed towards them; however, they did not receive much guidance from their hospital management or province as validated by a provincial manager in the quotation below:

The lack of collective leadership and barriers to service delivery led to ‘inverted decision-making’ by rehabilitation practitioners; that is, the traditional hierarchical approach to decision-making was flipped. Collective leadership refers to an approach that allows us to understand power relations within the rehabilitation context, as discussed below by a variety of practitioners such as clinical leaders or their managers towards transforming healthcare services in the future. Frontline rehabilitation practitioners initiated collaborative team decision-making to find solutions to service delivery challenges, thereby deviating from ‘the traditional command and control’ leadership style (Anjara et al. 2021:2).

Work model rotations, the practice of alternating schedules, shifts and working hours, were instituted within some rehabilitation teams, and were later adopted by management using a consultative decision-making model. This response was used so that rehabilitation practitioners could ensure that service delivery continued, despite changing and uncertain circumstances. ‘Risk rating with a heart’ was implemented to safeguard team members with comorbidities. This implies that a decision-making process was used that not only considered objective risk assessments but also considered the well-being and needs of the individual involved. This model was unfortunately not carried over at all levels of service delivery, highlighting the siloed response in leadership. Rehabilitation practitioners felt pressured to continue providing services to all citizens at all levels of healthcare as the struggling healthcare system was crippled further by the COVID-19 pandemic (McKinney, McKinney & Swartz 2021; Uys et al. 2021). While there was an international call for rehabilitation to be included in disaster management planning (Amatya & Khan 2020b), rehabilitation practitioners across disciplines in this study reported that rehabilitation services were ‘at the bottom of the food chain’. The statements in Figure 1 highlight the emotions and frustrations felt because of rehabilitation outpatient services being stopped, and inpatients being prematurely discharged because of COVID-19.

While the directive was to stop services, there was a commitment to finding alternate ways of reaching patients (Ilyas et al. 2021). Participants also expressed their concern about the socioeconomic impact of this exclusion and its disproportionate effects on people with disabilities living in poverty (Banks et al. 2021). This concern was highlighted by Participant 10:

Many participants commented that they experienced an identity crisis related to their role within the healthcare system during COVID-19. There was a general sense of underappreciation of the role of rehabilitation as part of the health care systems response to COVID-19. Participants expressed that their voices were not heard and that they were often not consulted when decisions were made:

Participants further highlighted a sense of being forgotten, when they shared examples of their difficulty trying to access PPE. Participant 8 expressed their disappointment when describing their experience during the first wave:

A study conducted at a tertiary hospital in South Africa also found that health care workers reported psychological distress related to the perceived barriers to infection control practices (Lee et al. 2022). This feeling of being undervalued and underappreciated had a negative impact on the well-being of many rehabilitation practitioners.

Rehabilitation practitioners, like all other health workers, were expected to ‘step up, be brave, and provide care and comfort’ (Iheduru-Anderson 2020) to those affected by COVID-19 while faced with the challenge of managing their personal/human response to the pandemic.

Participants in this study stated that the critical conversations provided a debriefing session for them. Participant 2 summarised the sentiment of most participants when stating that:

Like Chersich et al. (2020) and Dawood, Tomita and Ramlall (2022), we also noted participants reporting difficulties coping with stress, anxiety and the psycho-emotional impact that the pandemic has had on them.

In Figure 2, participants’ expressed responses across the spectrum of emotions referencing paranoia, feelings of anxiety, anger, frustration, exhaustion, stress, and burnout. Some mentioned developing a blunted affect alongside COVID fatigue, expressing that they were ‘tired of being resilient’ which concur with findings in a study conducted by Jow et al. (2022). Participants stated that their feeling of anxiety was initially related to the lack of PPE, dealing with the uncertainty of COVID-19 on individuals, and its impact on the profession.

Rehabilitation practitioners enacted personal or human responses across their professional and home lives, as evidenced by three significant issues: management of work and family responsibilities, protecting families against possible exposure, and having to make the rules about the safety of family members within the home context. Rehabilitation practitioners, who are predominantly female, reported the added burden of having to continue with their responsibilities at home in addition to online learning for their children. Saragih et al. (2021) found that women healthcare workers faced an increased caregiving burden during the pandemic which impacted their health and well-being. This is highlighted by Participant 7:

The fear of infecting family members at home increased the fear and anxiety experienced by participants at work. One participant mentioned that they avoided any contact with their family after they had contracted COVID-19. The lack of understanding at community level further isolated rehabilitation practitioners from visiting family. The added responsibility of keeping families safe and making rules within families to ensure that everyone stayed safe was an additional burden on rehabilitation practitioners. The line between home and work became blurry as COVID-19 was not just something being experienced by the patients they treated at work but was something that affected their families.

The impact of people’s loss was not limited to work, as many had to deal with loss of family members and return to work and continue to function within a highly stressful and demanding setting. This was expressed by Participant 1:

Undoubtedly the pandemic was scary, an event guaranteed to evoke a range of emotions, particularly fear and anxiety as displayed by the participants responses:

The notion of rehabilitation practitioners not displaying their vulnerability was quickly discarded as many created healing and holding spaces for their colleagues. Rehabilitation practitioners shared their own COVID-19 stories; the aims for this were multifold. Some saw it as a means to break the stigma of being COVID-19 positive, especially during the early stages when even health care workers were unsure how to respond. Storytelling was used to establish a broader sense of belonging and healing. This ‘unmasking of emotions’ represents a significant shift in how rehabilitation practitioners overtly engage their own humanity in relation to their personal health risks, the Loss or death of family and loved ones. Practices, mediated by anxiety, fear, self-advocacy and suchlike created a humanising professional development experience and highlighted the spirit of ubuntu. The following responses from participants display how ubuntu was ignited within healthcare settings. Rehabilitation practitioners also reached out to one another and offered support; many online platforms and resources were also shared.

The importance of putting patients’ rights first (Uys et al. 2021) was emphasised by participants and in some places, patients were provided with varied options in terms of service preference and attendance. Rehabilitation practitioners had to find new ways of practice. Telerehabilitation is an effective method to reduce the financial burden and improve access to healthcare services for patients and their families in low socio-economic settings (WHO 2021). In this study, rehabilitation practitioners reported that the initial lockdown period provided them with the opportunity to investigate telerehabilitation practices and how it could improve access to healthcare services:

The telerehabilitation practices utilised included both synchronous (video calls) and asynchronous (pre-recorded videos and WhatsApp groups) methods. Rehabilitation practitioners reported that they effectively reached treatment aims through the distribution of pre-recorded videos which assisted patients with activities like dressing and completing exercises within their home environment. Pre-recorded videos were also used to train caregivers and family members of patients who were unable to enter health facilities for essential practical training such as wheelchair transfers and home exercises. WhatsApp groups were created to maintain communication and support as another asynchronous method of service delivery.

The socio-economic status of rehabilitation practitioners determined whether they were able to personally access the technology required. Some were able to use their own technology like cellular phones, tablets and their own data to provide telerehabilitation, as resources were unavailable at institutions. Rehabilitation practitioners at one site approached cellular network providers for assistance and funding to ensure telerehabilitation services were available for themselves and for their patients. The need for equitable access to resources for telehealth was highlighted by Participant 6:

To date, there are no published guidelines on telerehabilitation by the National Department of Health to guide practitioners and managers (Govender et al. 2022). The need for these guidelines were expressed by Participant 1:

In the context of South Africa’s history, race and racism have deeply influenced all parts of society, including healthcare and rehabilitation workers. While the discussions with participants didn’t always directly highlight the role of race in rehabilitation, the conversations did emphasise the significance of race-related issues in South Africa, such as economic disparities and unequal healthcare services.

However, participants’ understanding of their social and professional identities, including factors like race and gender, had an indirect influence on how they saw their role as practitioners. For example, Participant 2 mentioned that therapists from different backgrounds might have varying levels of exposure to different environments, impacting their ability to relate to patients’ challenges, like lack of access to healthcare because of financial constraints and transportation issues.

Interestingly, one participant noted that factors like race, gender and age weren’t as crucial as the amount of clinical experience they had. This viewpoint contrasts with a previous argument by Pillay and Pillay (2021) that highlighted the role of race and social identities in rehabilitation practice, particularly in cases like dysphagia rehabilitation in South Africa.

Nonetheless, further investigation is needed to fully establish the significance of race and racism as key factors in how practitioners responded during the pandemic.

This study presents a cross-professional examination of rehabilitation practices during the pandemic, highlighting the growing relevance beyond traditional healthcare domains such as medical and nursing services. By doing so, it sheds light on the distinct contextual challenges faced by rehabilitation practitioners in South Africa. It should be noted that this study provides a comprehensive portrayal of rehabilitation practitioners, predominantly from therapeutic disciplines, while excluding input from stakeholders in fields like psychology, social work and other healthcare professions. This study’s scope does not encompass a specific geographical or socio-economic context. However, it offers valuable insights as a representative voice from the public rehabilitation service sector, which has been the primary resource for many South Africans with disabilities during the pandemic. The experiences recounted by South African rehabilitation practitioners in this study could potentially resonate with those of professionals in similar settings across the globe, particularly in low-to-middle-income countries.

Methodologically, the inclusion of a non-rehabilitation partner, in this case a journalist, for critical discussions is noteworthy. This study provides, via the use of critical conversations, a robust approach to studying the experiences of rehabilitation practitioners. When synthesising the interview data, it was noted that there was potential for uncovering valuable insights into the diverse and challenging landscape of rehabilitation practice in South Africa. As a method ‘critical conversation’ may benefit from more explicit review of how, more specifically its techniques and methods may be used to foreground social, economic and political issues associated with rehabilitation practice in South Africa. Its integration within a phenomenological approach allowed for nuanced revelations on social and cultural influences on rehabilitation practitioners. This innovative approach not only introduces external perspectives but also brings essential critical perspectives to the forefront. Moreover, it holds the promise of generating fresh insights into the societal, cultural and political dimensions of rehabilitation practice.