Rehabilitation following a spinal cord injury (SCI) addresses the resulting physical impairments and functional limitations, which can lead to poor quality of life (QoL) (Cheng et al. 2017) and an increased burden of care (Turner-Stokes et al. 2016). According to the World Health Organization (WHO), rehabilitation should be guided by the categories highlighted in the International Classification of Functioning, Health and Disability (ICF), namely health condition, body functions, activity limitations, participation restrictions, environmental factors and personal factors. The use of these categories as guidelines for care by an interdisciplinary team should aimed at optimising functioning within the person’s environment while keeping the individual’s goals, preferences and circumstances at the centre, with the ultimate goal of enabling people with SCI to return to productive life and to self-manage as far as possible (Du Plessis et al. 2018; Pefile, Mothabeng & Naidoo 2019).

The WHO has put forward a global action initiative to strengthen rehabilitation care by 2030 (WHO 2017). This initiative states that rehabilitation care should be accessible and available at all levels of care to all people with disabilities to allow them to participate in home and community life (WHO 2017). Currently, there is no one SCI care model that is universally used (Ho et al. 2021). In addition, most of the evidence on SCI rehabilitation has been conducted in high-income countries, such as Australia, the United States and Canada (Ho et al. 2021). In low- and middle-income countries such as South Africa, however, contextual evidence on SCI rehabilitation is limited.

In South Africa, rehabilitation care for people with disabilities, including SCI, is not prioritised and needs strengthening (Morris et al. 2021). With the impending reform to a National Health Insurance (NHI) system and limited guidelines on rehabilitation in South Africa, there is a need to understand the current state of rehabilitation services (Louw et al. 2023). There are myriad challenges facing rehabilitation in South Africa, including limited services at primary healthcare levels, inadequately skilled healthcare workers, a lack of specialised services for long-term care and inadequate referral systems (Louw et al. 2023).

These challenges can impact long-term care outcomes for people with SCI. For example, Madasa found that the mortality rate 4 years after injury was 24% in patients with traumatic SCI (Madasa et al. 2020). People with SCI also experience secondary health complications, including pressure sores, urinary tract infections and pain, which increase readmission rates and negatively impact QoL (Kashif et al. 2019; Madasa et al. 2020; Mashola et al. 2019). In addition to the health complications, SCI can also limit participation in community activities (Kashif et al. 2019). These activities include sustaining employment and education, and participating in social activities, the lack of which can lead to financial insecurity, isolation (Tsai et al. 2017), and poor QoL (Smith, Sakakibara & Miller 2014). Although the national policy on rehabilitation recognises the importance of community reintegration, most rehabilitation services in South Africa do not progress beyond the achievement of basic mobility and self-care (Nizeyimana, Louw & Joseph 2025). Combined with the environmental, psychological and social barriers that people with SCI face, this situation emphasises the need to understand the experiences, and more importantly, the gaps in existing inpatient rehabilitation services.

The objectives of our study were to explore the experiences of inpatient rehabilitation among people with SCI, to explore how the experience influenced their transition out of inpatient rehabilitation, and to identify the needs of people with SCI when transitioning out of inpatient rehabilitation. To the authors’ knowledge, there is no other study in South Africa exploring the experiences of inpatient rehabilitation and their influence on the readiness to transition home in SCI.

The sample in our study included 11 patients with SCI. Most of the participants were men (81.8%) and had traumatic injuries (72.7%). Most of the participants’ injuries were thoracic (54.5%) and incomplete (81.8%). Table 1 and Table 2 show the demographic and SCI profile of the participants.

The themes which emerged were: ‘overall rehabilitation experience’, ‘factors influencing rehabilitation experience and their influence on readiness to transition out of rehab’, and ‘needs of people with SCI when transitioning out of inpatient rehabilitation’. Table 3 shows the themes, categories and subcategories that emerged from the data analysis. Appendix 1 Table 1-A2 shows the distribution of participant responses across themes and subthemes identified in the qualitative analysis (n = 11).

Our study aimed to explore the experiences of inpatient rehabilitation among people with SCI, how this affects their transition out of rehabilitation, and to identify needs to assist in this process. This is the first study to explore the experience of home transition for people with SCI in South Africa. Three themes emerged: (1) overall rehabilitation experience, (2) factors influencing rehabilitation experience and their influence on readiness to transition out of rehab and (3) needs of people with SCI when transitioning out of inpatient rehabilitation. The findings of our study show that, while most participants generally found their time in rehabilitation to be beneficial and positive, several factors shaped their experiences. This result was in alignment with previous studies (Mothabeng et al. 2007; Samuel et al. 2007). Key areas for improvement were identified, highlighting opportunities to bridge the gaps within the rehabilitation process, as well as in the transition out of rehabilitation to home.

The approach to care was a key factor influencing the rehabilitation experience, particularly in relation to staff attitudes and knowledge, communication and participants’ involvement in decision-making. The attitudes and expertise of healthcare workers play a crucial role in shaping patients’ experiences and readiness for transition (Conti et al. 2020; Moran, Barclay & Lannin 2022; Pryor, Haylen & Fisher 2021). In our study, while most healthcare professionals were described as helpful, friendly, and knowledgeable, some demonstrated gaps in attitude, knowledge, or skills, which negatively affected participants. Previous research supports this observation, showing that staff attitudes impact patients’ ability to achieve self-management goals and their sense of control (Bourke et al. 2014).

Additionally, communication and shared decision-making about their care impacted participants’ experiences.

Some patients felt excluded from decision-making about discharge plans, medical care, and scheduling, highlighting the need for greater autonomy and involvement. Patients with SCI often experience a diminished capacity to engage in decision-making during the early stages of rehabilitation as a result of physical, psychological, and environmental factors (Scheel-Sailer et al. 2017). This finding emphasises the importance of receiving adequate, personalised information to regain their decision-making capacity.

A patient-centred approach was one of the recommendations that participants made to assist patients’ transition from inpatient rehabilitation to home. A patient-centred approach prioritises listening to patients, incorporating their preferences, empowering individuals in their recovery and promoting self-management (Bourke et al. 2014; Lindberg et al. 2013).

The participants with SCI recommended three essential elements: the need for specialised SCI care, meaningful involvement in decision-making, and positive staff attitudes. Specifically, some participants identified a critical gap between skills learnt in structured therapy sessions and opportunities to practise these skills in the ward. This recognition, combined with feeling excluded from decision-making processes regarding their medical care, resulted in insufficient preparation for discharge, particularly concerning essential self-management skills such as bowel and bladder management. Effective communication, provision of information, and fostering an open atmosphere are essential for patient involvement (Melin et al. 2018). When nursing staff engage with patients on a personal level, they become more attuned to the patients’ situations, fostering closer relationships and improving the overall rehabilitation experience for patients with SCI (Steensgaard, Kolbaek & Angel 2022).

Specialised SCI care also extends beyond technical knowledge; such care includes ensuring that all rehabilitation staff clearly understand their roles and possess the skills to sensitively engage with patients undergoing profound life changes. Ongoing professional development programmes are therefore recommended, with particular attention to patient-centred care, self-management strategies, and effective communication (Krysa et al. 2022). Training initiatives focused on enhancing staff communication skills and promoting shared decision-making can directly address these identified gaps, ultimately fostering a supportive rehabilitation environment that prioritises patient autonomy and preparedness (Bourke et al. 2014; Lindberg et al. 2013). In low- and middle-income countries like South Africa, where resources are often constrained, cost-effective strategies such as modular training programmes, mentorship programmes, and integration of patient-centred care principles into existing national rehabilitation policies can help bridge these gaps. Practical steps include regular in-service training, incorporating patient-centred care modules into undergraduate and postgraduate health professional curricula, and developing locally relevant guidelines and checklists to standardise care practices within the appropriate context. Even within busy, under-resourced settings, regular, structured training for all staff can ensure that the priorities are patient autonomy, shared decision-making, and holistic preparedness for life after discharge.

The physical environment played a significant role in shaping the rehabilitation experience, consistent with findings from previous studies (Bourke et al. 2014; Colley, Zeeman & Kendall 2018; Nunnerley & Dean 2013; Simpson, Villeneuve & Clifton 2020). While participants generally appreciated the ward’s space and cleanliness, some found the main ward noisy and noted that bathroom equipment was occasionally unavailable or not in working order. The most notable concern was that the rehabilitation environment did not closely simulate their home settings, making it difficult to fully prepare for the transition. Many participants felt adequately prepared only after completing home visits or weekend trials. Previous research emphasises the importance of rehabilitation spaces that mirror real-life environments to facilitate a smoother transition to home (Bourke et al. 2014; Moran et al. 2022; Nunnerley & Dean 2013). While hospital safety and accessibility are essential, integrating elements that reflect the actual living conditions of the patients can better prepare them for home trials and promote greater independence upon discharge. However, implementing this approach may be challenging in the South African context, particularly in the public health sector, because of significant disparities in housing conditions across socio-economic groups (Mathee et al. 2021). Rehabilitation hospitals must consider adapting their hospital environment to more closely simulate real home environments to facilitate recovery and prepare for home transitions.

Being among other individuals with SCI during rehabilitation fostered belonging and reduced feelings of isolation. Participants described how peers with SCI offered encouragement and provided perspective by demonstrating that independence was possible, supporting findings by Machida, Irwin and Feltz (2013). These findings also align with research showing that peer connection supports adjustment by offering hope, normalising experiences, and reducing loneliness (Sweet et al. 2021). However, some participants anticipated difficulty adjusting once this natural peer network was no longer present at home, highlighting the value of structured peer mentorship to extend these benefits beyond hospital discharge (Sweet et al. 2021).

Similar to previous studies, patients’ mental health can affect the rehabilitation experience and outcomes (Mothabeng et al. 2007). Psychosocial factors such as patients’ emotions, dependence on health professionals, and insight into health conditions play a large part in the rehabilitation experience (Samuel et al. 2007).

Although those studies were conducted almost 2 decades ago, our current study echoes their findings. People with SCI, including those in our present study, experience trauma, confusion, grief, and distress in the acute and subacute phases following their injuries (Bender & Burgess 2020; Bourke et al. 2014; Clifton 2014; Joseph et al. 2016; Machida et al. 2013; Nunnerley & Dean 2013).

While participants in our present study felt encouraged and supported by various staff members at the rehabilitation hospital, some did not feel that their psychological needs were adequately met. Many felt that this support lacked structure, individualisation, and consistency during rehabilitation. In addition, some participants felt that, while they were physically prepared for discharge, they were not psychologically prepared for returning home or to the community with their disabilities. Many participants planned to continue with physical rehabilitation after discharge, but only two expressed an intention to seek psychological support. Bourke et al. (2014) also highlight this gap in psychological support around navigating community members’ attitudes. Some participants expressed mixed feelings about discharge: they were eager to return home, but apprehensive about reintegrating into their communities. Mpho’s concern about the attitudes towards him in the township reflects the anticipated stigma or judgement based on his disability. Recent research shows that stigma after SCI often persists beyond the hospital stay and can significantly impact QoL and social participation (Budd, Gater & Channell 2022; Ownsworth et al. 2024). In southern Africa, a study from Namibia found that lack of community acceptance was a source of distress for individuals with SCI (Ashipala & Langendorf 2022). These findings highlight that successful community reintegration depends on more than physical readiness. It requires meaningful social acceptance and opportunities for participation. This conclusion aligns with global recommendations, which advocate for interventions targeting both individual coping strategies and broader societal attitudes (Budd et al. 2022). Addressing stigma within rehabilitation planning may therefore be critical to improving long-term outcomes for individuals with SCI in South Africa.

The psychological state of the person with SCI can have an impact on their choices to participate in social or community activities (Joseph et al. 2016). Clifton (2014:1825), in his autoethnographic paper following his own SCI, describes SCI as a ‘body/mind separation’ and a deeply personal loss. Joseph et al. (2016:1376) also found that people with SCI needed to learn to deal with their ‘new self’. This skill requires psychological interventions which help people with SCI rebuild their personal and new life narratives (Clifton 2014). These findings underscore the critical need for a structured, formalised, and individualised approach to psychological support, both during rehabilitation and beyond, to better equip people with SCI for their transition and long-term well-being.

The findings of our study highlight possible gaps in SCI rehabilitation in South Africa, which mirror the systemic challenges, including limited access to specialised services, inadequately trained staff, and weak referral systems (Louw et al. 2023). As South Africa moves towards the implementation of the NHI, there is an opportunity to address these issues and bolster rehabilitation care for people with SCI. Integrating specialised SCI rehabilitation into the NHI framework could help standardise care and ensure that all patients have access to comprehensive services. Priority actions include developing national rehabilitation guidelines, strengthening referral pathways, and implementing systems to monitor outcomes. Workforce reinforcement is also essential, focusing on recruiting and retaining skilled rehabilitation professionals. Aligning these strategies with NHI reforms could promote successful community reintegration and a better QoL for people with SCI.

Our study provided valuable insights into the rehabilitation experiences of people with SCI in South Africa and identified critical needs impacting their readiness to transition home, including a specialised and patient-centred approach to care (including staff attitudes and knowledge, communication, and involvement in decision-making), bridging the gap between hospital and home physical environments, and more structured and individualised psychological support. With no contextual SCI model of care, future research across diverse healthcare settings is required to inform structured rehabilitation systems in favour of promoting QoL, reintegration, and participation upon discharge.