Survival Is Just the Beginning of Recovery: A Qualitative Study of Survivors’ Experiences after Severe Injury

Abstract

Purpose

Patients experience severe physical trauma every year. However, studies on survivors’ experiences after severe injury are limited. Previous studies have mainly focused on time spans of trauma treatment. This study aimed to comprehensively explore survivors’ experiences to improve the current quality of trauma treatment and highlight the importance of patient-centered care.

Materials and Methods

Structured, face-to-face interviews with six domains were conducted on survivors aged ≥18 years who were previously hospitalized in an intensive care unit due to traumatic injuries. Self-reported questionnaires were administered for a multidimensional assessment of participants’ conditions. Transcripts of each narrative were analyzed per grounded theory.

Results

Fourteen participants were assessed. The median injury severity score was 25.5. The median elapsed time from injury to interview was 17.3 months. The physical and psychiatric difficulties of the participants remained unresolved even after completing rehabilitation. The main theme derived from the narratives were struggle with injury, consequences, and contributing factors, with the following subthemes: 1) suffering from injury and treatment, 2) psychological adaptation to the changed self and life after the accident, 3) significant family support, 4) gratitude to medical staff despite inadequacies in the healthcare system, and 5) legal and economic issues that impede recovery.

Conclusion

Increased efforts focusing on enabling survivors of severe injury to return to society and improve their quality of life are needed, including the establishment of patient-centered care in the trauma field, extended care for the survivors’ families, multidisciplinary treatment, and the collection of quantitative post-discharge data.

Graphical Abstract

INTRODUCTION

As in several countries,¹ severe injuries are a common cause of death in South Korea, where the number of trauma patients has gradually increased annually.² In 2010, 3.39 million people were injured, and 1.10 million of them were hospitalized. In 2019, these numbers increased to 3.71 million and 1.19 million, respectively.² In 2021, 193921 cases of severe injury were reported to the National Emergency Department Information System.³ Among the severely injured patients, 27.1% were admitted to intensive care units (ICUs), according to the Korean Trauma Database.⁴ As of 2020, young patients (aged <65 years) accounted for 56.6% of severely injured patients, which is a significant proportion compared with that for other diseases.³ The socioeconomic cost of injury was estimated to be 21 trillion KRW in 2015.²

To reduce trauma mortality, the Korean government has established regional trauma centers for severely injured patients since 2014. As a result of this effort, the domestic mortality rate of preventable traumas (ratio of patients who have died from injuries that they could have survived had they received appropriate treatment after being quickly transported to suitable hospitals within acceptable time frames)⁵ dropped from 35.2% in 2010 to 15.7% in 2019.⁶ Currently, trauma patients who previously could not have been saved are more likely to survive, and the number of survivors is accumulating in South Korea. Despite recent advances in acute care for traumatic injury, the long-term recovery of patients after survival has not yet been adequately addressed. The increasing number of severely injured patients and trauma survivors motivated us to examine their experiences throughout all the phases of treatment and recovery.

Few studies have addressed the experiences of survivors after severe injury.¹,⁷ Despite the paucity of literature, previous studies have investigated survivors’ satisfaction with healthcare services, physical and psychological well-being, and ways to improve the quality of trauma care from diverse angles, including the prehospital system,⁸ resuscitation process,¹,⁹ discharge process,¹⁰,¹¹ and burden of pain.¹² According to these studies, a patient’s involvement in decision-making; the coordination of care; healthcare professionals’ demeanor, competency, clear clinical communication, and reassurance; and physical/emotional comfort,¹,⁹,¹⁰,¹¹ contribute the most to the feelings of security and satisfaction with the quality of care among patients.¹⁰ Another crucial factor in a trauma patient’s experience is pain, which is reported by most patients even at the time of hospital discharge. Pain intensity is associated with low self-efficacy, low satisfaction with care, and depression.¹² Additionally, previous studies have noted a discontinuity in trauma care in which the discharge process does not transition smoothly to post-discharge care.¹¹ Some qualitative studies have elicited themes of “a detour in life,”⁷ post-traumatic concerns,¹³ patients’ perceptions of repair, rehabilitation and recovery,¹⁴ the experience and understanding of pain management,¹⁵ social support in adjustment, ¹⁶ and the impact on intimate relationships.¹⁷ However, previous studies have mainly focused on the specific time span of trauma treatment.

This study aimed to provide an overall picture of the survivors’ experiences from the prehospital phase to the ICU and the post-rehabilitation period, including their concerns and the support they need. Drawing upon previous literature, this study comprehensively explored the experiences of survivors of severe trauma from the trauma treatment stage to the outpatient rehabilitation and treatment completion stage using structured interviews. Our findings will contribute to the improvement of the quality of trauma treatment and highlight the importance of patient-centered care from a long-term perspective, which is paramount for enhancing patient outcomes and prognosis.

MATERIALS AND METHODS

Study design

This study adopted a qualitative research method, which is particularly useful to present the complex context and nuanced nature of the phenomenon by the participants’ perspectives and narratives, to investigate the experience of patients with severe trauma during and after treatment. We interviewed survivors (aged ≥18 years) who had been hospitalized in ICUs due to accidental injuries that occurred at least 6 months prior. Individuals with no sequelae of head injury and those who are able to communicate clearly in Korean were also set as inclusion criteria. Based on previous research results,¹³ the interview questions (Table 1) comprised six domains (physical health, psychological health, work and finance, social and medical support, and legal issues), and a group of seven multidisciplinary trauma treatment experts reviewed the validity of the interview questions. Structured interviews were conducted; while transcribing the interviews, the personal narrative of each study participant was retained as much as possible.

Table 1. Examples of Interview Questions.

Physical health	What was the most physically challenging experience after the accident? Compared to before the accident, how much do you feel that your physical function has recovered?
Psychological health	What was mentally difficult for you after the accident? Have you ever received psychiatric treatment or psychological counseling after the accident?
Social support	How did your family and friends react after the accident? How is your current relationship with family and friends?
Work and finance	Do you have any difficulties with work/economic activities after the accident? Has your income level changed after the accident?
Legal issue	What were the legal issues related to the accident, if any?
Medical support	How was the medical service you received during the treatment process? How was your relationship with the medical staff?

At the end of the interviews, self-reported questionnaires were administered for a multidimensional assessment of participants’ sociodemographic and clinical characteristics. The questionnaire included the following scales to assess major mental health problems: Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5)¹⁸; Patient Health Questionnaire-9 (PHQ-9), which measures depression severity¹⁹; the Generalized Anxiety Disorder-7 (GAD-7) scale, which measures the level of generalized anxiety²⁰; and the Korean version of Mini International Neuropsychiatric Interview-Plus (MINI-Plus) for suicidality to assess suicidal risk.²¹

Recruitment and data collection

Participants were recruited by their treating physicians between November and December 2021 from four trauma centers and one rehabilitation center located in Seoul, Gyeonggi-do, Chungcheong-do, and Ulsan, provided they met the inclusion criteria. Face-to-face interviews, which took 1 h to 2 h each, were conducted by JUH, who has extensive experience in psychiatry. To enhance the reliability of the interview data, the interviews were recorded with the participants’ approval and transcribed into an MS Word file. After conducting interviews with 14 participants, no new codes occurred in the interview data, and the saturation was achieved.²²

Analysis

In accordance with the grounded theoretical methodology²³,²⁴ the analysis was conducted using MAXQDA as follows: in the open coding stage, YRC and YJ, who practiced as a trauma surgeon and nurse, thus possessing a profound comprehension of the trauma treatment process, and underwent training to proficiently conduct qualitative research, read the transcripts and memos repeatedly and created the codes. During this process, the full audio recording was consulted to understand the circumstantial context that was not captured in the written transcript. YRC and YJ independently coded the transcripts and cross-reviewed the codes. An experienced ethnographic researcher with a robust background in qualitative research (JK) reviewed the transcripts and the generated code structure. The research team identified the themes and sub-themes and continuously revised them until a consensus was reached by all team members. After seven rounds of discussion, the final comprehensive code structure was approved. All study processes were reviewed using the items of the COnsolidated criteria for REporting Qualitative research.²⁵

Ethics statement

This study was approved by the Institutional Review Board of the Seoul National University Hospital (Approval No. 2112-119-1284). All participants were informed of the purpose and method of the study before enrollment, voluntarily decided to participate in the study, and granted written consent.

RESULTS

Demographics

Fourteen individuals (six women and eight men) participated in the study. Participants were conveyed to nine trauma centers and received their first trauma treatments; 11 were injured in traffic accidents, two were hit by objects, and one was injured by violence. The median treatment period of hospitalization for trauma treatment was 92.0 days. The median Injury Severity Score,²⁶ which is the most commonly used anatomical scoring system to assess trauma severity, was 25.5, and seven participants were diagnosed with disabilities. Participants suffered from severe pain caused by trauma or medical interventions and were in states of deterioration or loss of various functions and physical disability. All the participants were treated in ICUs, and seven were treated at specialized rehabilitation institutions. At the time of the interviews, five participants were hospitalized in rehabilitation hospitals, and eight were receiving outpatient rehabilitation treatment. The median elapsed time from the injury to the interview was 17.3 months (Table 2).

Table 2. Demographics of Study Participants.

Characteristics	Participant No.
	1	2	3	4	5	6	7	8	9	10	11	12	13	14
Age group	60	50	60	60	20	30	40	30	80	50	20	60	60	50
Sex	M	M	M	F	F	F	F	M	M	F	M	F	M	M
Occupation at the time of injury	Retired	Self-employed	Transportation	Factory worker	Office worker	Office worker	Public officer	Office worker	Farming	Self-employed	Office worker	Restaurant business	Livestock	Transportation
Cause of injury	In car TA	In car TA	In car TA	Hit by an object	In car TA	Pedestrian TA	Pedestrian TA	Motorbike TA	Pedestrian TA	In car TA	In car TA	Stab injury	Hit by object	Motorbike TA
Injury site	A, C, E, Sp	A, Sp, P	A	A, Sk	A, E, Nk	E, Nv, P, Sk	A, Nv, P, Sk, Sp	A, C, E, P, Sp	H, C, E, Sp, P	E, Nv, Sk, Sp	A, C, E, Nv, Sk	Nk	C, E	A
ISS	29	35	26	16	17	30	34	25	33	33	22	10	25	25
LI, days	13	5	5	8	2	15	150	58	30	15	4	10	2	4
LT, days	115	78	35	90	12	94	112	114	95	23	146	20	33	100
Location after trauma treatment	Private clinic	Private clinic	Private clinic	Residence	Residence	Specialized RH	Specialized RH	Specialized RH	Specialized RH	Specialized RH	Specialized RH	Residence	Specialized RH	Residence
LR, months	0	0	0	0	0	7*	4*	7*	5*	15	6*	0	8	0
Diagnosed with disability	No	No	No	No	No	Yes	Yes	Yes	No	Yes	Yes	No	Yes	Yes
Current medication	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Time from injury to interview, months	44	20	39	41	28	13	15	10	9	19	12	12	15	24
Insurance type	AutoIn	AutoIn.	InduAcIn	InduAcIn	AutoIn	AutoIn	AutoIn	AutoIn	AutoIn	AutoIn	InduAcIn	Government support	Health insurance	InduAcIn
Who pays for the cost of care expenses	Paid by self, cared by family	Cared by family	Insurance, cared by family	Cared by family	Cared by family	Cared by family†	Paid by self	Cared by family†	Paid by self	Paid by self	Cared by family	Cared by family	Cared by family	Paid by self
Who pays for the cost of rehabilitation	Paid by self	AutoIn	InduAcIn	RT not received	RT not received	AutoIn	AutoIn	InduAcIn	AutoIn	Paid by self, AutoIn	InduAcIn	RT not received	Paid by self	RT not received
Return to economic activity	No	Yes	No	No	Yes	No	No	No	No	No	No	No	Yes	No
Current income, compared with that before the accident, %	20	60–70	20	70	100	0	100	20	0	0	70	0	100	0
Legal issues	Yes	No	Yes	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No
Psychological function recovery, %	60–70	50–55	80	60–70	100	50	98	40	70	50–60	90	50	50	unknown
Most mentally challenging time	Immediately after return of consciousness	When returning to ICU	8 months after the accident	1–2 years, after discharge	Immediately after discharge	6 months, during rehabilitation	When making important treatment decision	Upon first seeing amputated leg	Right now	Oral rehabilitation period	Immediately after the accident	Few months after the accident	Not particularly	Right now
Psychiatric treatment	Yes	Yes	Yes	No	No	Yes	No	Yes	No	Yes	Yes	Yes	Yes	No
Psychiatric medication	Yes	Yes	Yes	No	No	Yes	No	Yes	No	Yes	No	Yes	Yes	No
PCL-5	35	44	24	36	8	27	11	35	29	23	53	40	0	40
PHQ-9	12	13	7	16	5	3	2	12	11	8	17	6	1	11
GAD-7	7	7	6	7	5	5	2	8	6	3	11	4	0	7
MINI-Suicidality	9	9	17	1	0	7	1	0	3	0	0	7	0	9

A, abdomen; AutoIn, automobile insurance; C, chest; E, extremities; F, female; H, head; InduAcIn, industrial accident insurance; ICU, intensive care unit; ISS, injury severity score; LI, length of stay in intensive care unit; LR, length of hospitalization for rehabilitation; LS, length of stay; LT, length of hospitalization for trauma treatment; M, male; Nk, neck; Nv, nerve; P, pelvis; RH, rehabilitation hospital; RT, rehabilitation treatment; Sk, skin; Sp, spine; TA, traffic accident; PCL-5, Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition; PHQ-9, Patient Health Questionnaire-9; GAD-7, Generalized Anxiety Disorder-7.

^*Currently hospitalized; ^†Litigation for insurance settlement.

Main themes and sub-themes

In this study, the struggle with injury, its consequences, and contributing factors was derived as the main theme. The sub-themes were 1) suffering from injury and treatment, 2) psychological adaptation to the changed self and life after the accident, 3) significant family support, 4) gratitude for medical staff despite inadequacies in the healthcare system, and 5) legal and economic issues that impede recovery. The following sections present these five subthemes.

Suffering from injury and treatment

With respect to injury and treatment, we divided the codes along with the standard treatment sequences, starting from trauma treatment, to inpatient rehabilitation, and to outpatient rehabilitation. The codes in each stage were grouped according to functional and emotional aspects (Table 3 and Supplementary Table 1, only online).

Table 3. Experience of Study Participants in Each Treatment Stage.

Category	Details (participant no.)
	Trauma treatment stage		Inpatient rehabilitation stage		Outpatient treatment and after completion of treatment stage
Functional aspect	Physical aspect		Lack and delay of recovery		Lack and delay of recovery
		Experienced severe pain (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)		Still need to take the medication (1, 2, 3, 6, 7, 8, 9, 10, 11, 13)		Inadequate recovery of physical function (1, 2, 3, 4, 5, 10, 12, 13, 14)
		Unable to move body (1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14)		Inadequate recovery of physical function (1, 2, 3, 6, 7, 8, 9, 10, 11, 13)		Persistent pain (1, 2, 3, 4, 5, 10, 12, 13)
		Loss of bowel and bladder control (3, 5, 6, 8, 11)		Persistent pain (1, 2, 3, 6, 9, 10, 11, 13)		Inadequate recovery of mental function (1, 2, 3, 4, 10, 12, 13)
		Decreased digestive ability (2, 4, 10, 14)		Inadequate recovery of mental function (1, 2, 3, 4, 8, 9, 10, 13)		Still need to take medication (1, 3, 4, 10, 14)
		Unable to communicate (8, 12)		Persistent difficulty with bowel and bladder control (6, 8, 9)		Sleep disturbance (3, 10, 14)
		Amputation of parts of the body (8, 13)		Sleep disturbance (6, 9, 11)		Persistent difficulty with bowel and bladder control (10, 14)
		Decrease or loss of sensation (6, 12)	Difficulty in daily life			Decreased body weight and strength (14)
	Psychiatric aspect			Diagnosed with disability (6, 7, 8, 11)	Difficulty in daily life
		Loss of memory immediately after the accident (1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)		Experience difficulty in daily life (7, 8, 9)		Experience difficulty in daily life (1, 2, 3, 4, 5, 8, 10, 12, 13, 14)
		Sleep disturbance (2, 3, 6, 8, 12, 13)		Cannot function independently in daily life (8, 9)		Cannot function independently in daily life (4, 8, 10, 12)
		Delirium (1, 3, 10, 12)		Cannot control body (8, 10)		Diagnosed with disability (10, 13, 14)
Emotional aspect	Anxiety and worry–family, work, recovery, etc. (1, 2, 3, 4, 6, 7, 8, 11, 12, 13, 14) Despair, helplessness (1, 4, 6, 11, 12) Depression (1, 4, 6, 12, 13) Self-blame, low self-esteem (1, 8, 9, 11, 13) Frustration (1, 3, 4, 10) Re-experiencing the traumatic event, flashback (1, 2, 12) Difficulty in accepting physical injury and loss (2, 6, 7, 8) Anger towards the perpetrator (5, 9, 11) Became aggressive, neurotic (8, 11)		Rejection or avoidance of situations that are reminiscent of the traumatic event (6, 7, 8) Worry about not being able to return to daily life (including economic activities) (7, 8, 9, 11) Despair, helplessness (8, 9, 11) Difficulty in accepting physical injury and loss (7, 8) Anger towards the perpetrator (9, 11)		Worry about not being able to return to daily life (including economic activities) (1, 3, 5, 8, 12, 14) Impatient with delayed physical recovery (1, 4, 10, 12, 13) Given up, loss of motivation (2, 4, 8) Re-experiencing the traumatic event, flashback (4, 5, 12) Rejection or avoidance of situations that are reminiscent of the traumatic event (10, 12, 13) Miss being healthy (1, 14) Anger toward the perpetrator (5, 12)

Trauma treatment stage

Most participants were unconscious for considerable periods after the accident. After gaining consciousness in the ICU, they were primarily shocked by extreme pain, which most of the participants ranked to be 8–10 on a scale of 1 to 10. A participant who was injured in a car accident described the severe pain and uncomfortable restraint in the ICU as follows:

“I woke up in the ICU and realized what I looked like. I was baffled because my legs and arms were bound, and all I could feel was pain. I thought I would rather die—I could not even move a finger.” (Participant 1)

For several weeks (maximum 60 days), participants were immobilized not only by the fracture caused by the accident but also by the restraints and treatment in the ICU. Intubation prevented them from communicating with healthcare professionals and family members, and they had to depend on others to take care of urine and feces. Some participants regained consciousness in the ICU and learned that they sustained severe injuries and/or underwent major surgeries, including amputation. For example, Participant 1 was told that he would wear a colostomy bag, which caused him considerable despair. Participant 8, who was hit by a truck, underwent amputation.

“I could not speak at all for about a month because I inhaled so much smoke in the fire... I felt as if I still had my legs and experienced phantom pain. I felt as if the blanket was covering my legs, but it was just folded up. It took a long time to realize that I had lost my legs.” (Participant 8)

Patients also suffered from several mental health problems, such as memory loss, sleep disturbance, and delirium, at the trauma treatment stage. Some of them still recalled the details of their delirium accurately and vividly at the time of their interview, along with the event surrounding their delirium:

“I cannot tell you how severe my delirium was after the surgery. In my dream, my attending doctor killed all my family, and I denied drinking for a week and turned my face away from the doctor when she came round to see me. I remember that I did it. I refused to take medication, drink water, and eat something for a week.” (Participant 10)

“I had severe auditory hallucinations. I saw two nurses talking to each other, and I felt as if they were conspiring to kill me. Suffering from nightmares, I wished they would just kill me rather than wake me up so that I would not have to have nightmares—I kept thinking of that.” (Participant 12)

Faced with physical pain, discomfort, and mental health problems, most participants (n=12) were anxious and worried about the consequences of injury, such as the shock of family members, returning to work, and recovery. They also felt despair, depression, self-blame, and frustration. As Participant 4 said, “I hated everything. I was anxious, depressed, and nervous.” Participants 6 and 11 described this period as follows:

“[Pointing to her legs] I had no sensation down here. ‘I cannot move, I cannot feel, and what if I never get my senses back?’ That was my biggest concern. I felt like there was nothing I could do on my own because I could not even use the bathroom whenever I wanted to. My head was filled with various kinds of thoughts. Despair, maybe? A million thoughts went through my mind.” (Participant 6)

“I went through five operations after the accident. It was so painful, and I just wanted to die until the third operation. Every day, I thought to myself that it would be better to die.” (Participant 11)

Some participants blamed themselves but simultaneously felt so much anger and resentment toward the perpetrator that they became aggressive. For example, Participant 11, who had his legs amputated after the accident, thought that the healthcare professionals in the ICU did not give him a pen because they were concerned that he might hurt himself. Six participants reported flashbacks and re-experiencing:

“Having nightmares was the most difficult. During my nightmares, I repeatedly rode the bus and entered the tunnel where the accident had occurred. I would wake up with a racing heart.” (Participant 3)

Inpatient rehabilitation

After acute treatment for traumatic injury, survivors were referred to the Department of Rehabilitation. In this study, seven participants received inpatient rehabilitation at specialized rehabilitation hospitals, and five were hospitalized for rehabilitation at the time of the interview. Three participants were readmitted to local hospitals for rehabilitation. Four participants (Participants 4, 5, 12, and 14) who did not receive rehabilitation were excluded in this stage.

During the rehabilitation phase, many aspects of the physical, psychiatric, and psychological problems that participants had encountered in the previous stage remained unresolved, and participants felt that their recovery rates were slower than what they and their family members had expected. All 11 participants still needed to take medication, and they all felt that they had not fully recovered physical function. Although many participants reported decreased pain intensity, four participants still suffered from pain. Particularly, difficulties with bowel and bladder control were conditions that made participants feel unrecovered. Incomplete recovery of mental problems such as sleep disturbances were also remarked:

“It is the most difficult when I cannot sleep at night. On sleepless nights, I feel pathetic. I feel like I got screwed. Farming was the joy of my life, and now I lost it. I am worried so much about whether I can control my bladder and bowels and whether I will need assistance with managing my hygiene for the rest of my life.” (Participant 9)

Emotional distress remained unresolved. These participants tended to suffer from despair and feelings of helplessness. Two participants had unresolved anger and resentment toward perpetrators; due to post-traumatic stress disorder (PTSD), three participants still tried to avoid any situation that might remind them of their respective traumatic event.

Participants noticeably overcame the initial shock of their traumatic events and injured bodies. However, while trying to return to everyday life, participants had difficulties accepting and adjusting to their changed bodies, selves, and socioeconomic circumstances. Particularly, in cases of severe disability, participants had difficulties with controlling their bodies and became dependent on the people around them to carry out activities in their daily lives.

“I got a prosthetic leg and still need elbow crutches or a walker to walk, which means that I cannot use both hands while walking. At work, I need to carry a lot of documents, but I cannot do that anymore. I cannot return to work. I cannot even pull a carton of milk from a shelf at a convenience store when in a wheelchair. I have to call someone and wait until they do it for me. It is miserable that I cannot even move a chair and pick up something from the floor by myself. There is nothing I can do but look on. It is really hard.” (Participant 8)

Outpatient treatment and treatment completion

Nine participants were included in this stage, and those who were hospitalized at the time of the interview were excluded. Three participants were receiving rehabilitation at outpatient rehabilitation clinics, and only one participant had completed all treatments at the time of the interview. However, all participants, including those who were diagnosed with disabilities, self-assessed that they had not fully recovered their physical and psychological functions: all participants except one mentioned persistent pain and the need to take medication. Bowel and bladder control issues were also cited. All these problems were cited during the previous stage. However, decreased body weight and strength were newly reported at this stage.

“(If I rated my current pain), it would be 5 out of 10. […] I take seven medications, including a digestive medicine, a pain killer, and psychiatric medication. […] I think my mental function has been restored by about 30%–40%.” (Participant 1)

“I believe that my cognitive function declined after the accident. It takes a long time to think of something, and I stutter a lot to think of what I want to say.” (Participant 10)

At this stage, survivors attempted to return to daily life. Participants mentioned more difficulties during this stage (n=9) than in the previous stages (n=3) as they encountered various inconveniences at home, at work, and in social activities. They remained dependent on others to carry out daily activities, which led them assess this period as the most distressing time throughout the treatment trajectory. Missing their good health, participants believed that their recovery paces were too slow; additionally, some of them became unmotivated. Moreover, sleep disturbances, re-experiencing the traumatic event, and anger toward the perpetrator remained unresolved.

“I cannot live my normal life, and I cannot speak, which is killing me. I am trying to think positively, but I do not understand why this happened to me. I feel wronged. It is like a battle against myself. It is no surprise that I was on psychiatric medication for anxiety, depression, and trauma.” (Participant 12)

“It is really stressful that I am unable to do any activities. I keep having diarrhea. If I drink water before going to bed, I have to wake up in the middle of the night to go to the bathroom. I unknowingly have diarrhea when coughing and, at times, must go behind a car because I cannot hold it. Even on my way to the toilet, I could not hold it at times and threw away my underwear countless times.” (Participant 14)

“I do not expect to return to the days before the accident occurred, but my current condition is far from what I long for. I cannot do anything now, such as eating on my own and doing the dishes. Because I cannot raise my shoulders, I can only wear baggy clothes. Nor can I take off them on my own… I heard that it will take several years to recover. I cannot even pee and have to drain urine through a catheter.” (Participant 10)

To summarize, participants experienced various physical and emotional challenges at each stage of the treatment process. Physical damage and a substantial decline/loss of function had a great impact throughout the treatment phase, which brought the participants various forms of emotional distress. Many participants responded that psychological distress became more severe in the latter half-period due to difficulties returning and adapting to daily life (Table 3).

Psychological adaptation to the changed self and life after the accident

Despite the traumatic events, multiple surgeries, treatments, remaining physical disabilities, and psychological distress that ensued from the accidents, participants strived to continue their changed lives (Table 4 and Supplementary Table 1, only online). Participants recognized that their bodily functions gradually improved even though the recovery paces were slower than they had expected. Participants 2 and 8 chose their most moving moments to be those at which they could sit in wheelchairs for the first time. Participant 4, who self-assessed that her full recovery would not be possible, said, “The wound has not improved much, but I feel better and relieved when my attending doctor tells me that it is getting better.” One participant remarked:

Table 4. Psychological Adaptation to the Changed Self and Life after the Accident.

Category	Details	Participant No.
Recognition	Recognizing gradual alleviation of psychological suffering	1, 2, 3, 5, 6, 7, 8, 9, 11, 12
	Recognizing gradual alleviation of physical suffering	1, 2, 6, 7, 9, 11, 12
	Recognizing and being satisfied with improvement in physical functioning	2, 4, 6, 8, 9, 10, 12
Acceptance	Accepting one’s condition	1, 4, 7, 8, 10, 11, 14
	Accepting limitations of the treatment process	1, 6, 14
Positivity, gratitude	Trying to have a positive mindset	1, 2, 5, 6, 7, 10, 12, 14
	Being grateful that the body is recovering	12
Willpower	Having willpower for recovery	1, 2, 3, 7, 8, 11, 12, 14
	Willingly accepting instructions from medical staff	1, 2, 3, 8
	Focusing only on recovery	1, 5
Denial	Denying current psychological suffering	7, 13

“I could not stand by the walker and now I can. I can use my smartphone with one hand while standing, which is a huge improvement. I can walk with an elbow crutch, stop with my back straight, and square my shoulders, and I feel these are a great improvement.” (Participant 8)

With time, participants have come to endure pain and accept their changed conditions, including disabilities. For example, Participants 1 and 7 remarked:

“…[A]t first, I just gave up on myself because everyone looked down on me as if I was an idiot. However, in the hospital, I told myself to accept the situation, and now I feel at peace. I asked myself, ‘What good is denial when my body is not under my control in any case?’” (Participant 1)

“My doctor explained to me how the treatment would go, how my condition would get better, and the condition of my body at the end of the treatment course… As I accepted what my doctor said, I felt better. I thought, ‘If this is the final boundary [that medicine can extend], my effort may overcome the limit a bit more.’” (Participant 7)

Moreover, participants tried to have positive attitudes toward life and the people around them. For example, Participant 14 reported anxiety and depression but also said, “I am introverted and optimistic. I think, ‘Let bygones be bygones,’ rather than have negative thoughts because I have children to support.” Having gone through times when their bodies were not controllable, participants were “very grateful for the present in which the body functions as it should” (Participant 7). Participant 12, who was stabbed and had nonfunctional vocal cords, assessed her physical recovery as less than 60%, consoled herself, and said, “I keep telling myself that at least I am alive.”

The willpower to overcome current challenges was also mentioned. Participants tried to focus on recovery and rehabilitation and shared clear treatment goals with healthcare professionals and family members. Furthermore, participants realized that their efforts to recover were crucial. Due to difficulty walking, Participant 1 despaired that he “lived under the umbrella” of his wife, but he said to himself, “it is like being a dead body if you cannot go out on your own.” He reported his gradual improvement, which progressed from “walking at home with a cane” to “walking around the yard” to “going out alone” in a span of 15 months. Another participant remarked:

“Eating was particularly difficult. My hands shook a lot [while holding a spoon], I could not chew, and I spilled food. It was really difficult. I thought with willpower that I can get better soon but only if I eat well.” (Participant 8)

However, psychological adaptation was not reported by every participant. One participant denied any emotional distress (Participant 13).

Significant family support

Trauma brought many changes to not only the participants but also their family members, and family support was crucial for the participants’ recoveries (Table 5 and Supplementary Table 1, only online). In the initial period, the family members were very shocked by the traumatic event and distraught about the participants’ conditions. In some cases, the family members were informed by the medical staff that the participants would not survive. Nonetheless, over time, the family members eventually adapted to events that occurred and eventually accepted the participants’ conditions.

Table 5. Experiences of Families of the Study Participants.

Category	Details	Participant No.
Family reaction and changes-initial	Despair at the patient’s condition	1, 2, 6, 8, 10, 11, 12, 13
	Concerned and anxious about the patient’s condition	1, 2, 5, 8, 9, 12, 14
	Shocked by the news	4, 7, 8, 9, 12, 14
Family reaction and changes-later	Accepting the patient’s condition	1, 4, 6, 7, 9, 12, 13
	Providing continuous support with attention	5, 7, 10, 14
	Concerned with realistic issues	5, 8
	Became interested in disability	7
Patient reaction and changes	Grateful for family	2, 4, 5, 7, 9, 10, 12, 13, 14
	Felt sorry for the family	4, 6, 10, 11
	Motivated for recovery	3, 14
	Felt disappointed with inadequate support	6, 8
	Relieved to meet family after the accident	12

For most of the survivors, their families were responsible for their care (n=10) (Table 2). The types of care that the family members provided for the participants varied. Family members consoled and encouraged the participants with compassion. As Participant 5 remarked:

“My family supported me a lot. I could not bear to use diapers, and my father carried me every time to the bathroom, despite being elderly himself. My mother ran a restaurant, and she asked my aunt and grandmother to take over the restaurant and came to see me. Family helped me a lot.” (Participant 5)

In addition, participants’ family members searched online and offline for diverse information related to medication, treatment procedures, well-known hospitals and doctors for the injuries, dietary needs, applicable welfare support, and legal advice for lawsuits. As participants were overwhelmed by their injuries, medical interventions, and the recovery processes after the accidents, the efforts of family members to seek, screen, and deliver various information helped the participants to concentrate on their recovery. If participants suffered from flashbacks, the family members tried to protect them by blocking out any situations or people that might evoke the accidents.

To take care of the survivors, family members shared realistic issues, including economic problems, with the participants and paid attention to issues related to disabilities. As Participant 7 said, “My family was uninterested in the disability issue, but now, all they see is legs. They keep their eyes on each other’s legs.”

Regarding family support, participants expressed overall gratitude to their family caregivers for handling the legal and economic consequences of the accidents and their dedicated support. For them, family was a source of motivation to endure challenges following the traumatic events. Moreover, some participants reported that they felt sorry for their family members due to the sacrifices that the family members made.

In some cases, participants thought that they did not receive enough support from their families. For instance, one participant thought that his family did not understand what he went through:

“It’s difficult to talk to people about my injury. I feel anger toward people who were worried about me without knowing my situation, like when they say, ‘Everything will be ok.’ I do not think that I received support. Even my family does not fully understand what I am going through, which makes me lose my temper at times. Of course, I love them, but sometimes I cannot bear them. They keep saying ‘Endure it’ and ‘You can do it,’ as if it is that simple.” (Participant 8)

In the case of Participant 14, his wife left him after the accident, and he had to raise two children by himself after their divorce (Table 5). He said, “I guess I can endure all of this only because my kids always give me a lot of support with their concerns.”

Participants’ attitudes toward friends, neighbors, and colleagues at work varied. Some participants reported that their acquaintances provided emotional support, but other participants did not. Even if participants believed that they received enough support from people around them, they simultaneously perceived the self-stigma of their disabled bodies (Participants 1, 2, 5, 8, 12, and 14) and did not want to socialize as they had done before the accident (Participants 4 and 8).

Gratitude to healthcare professionals despite inadequacies in the healthcare system

Participants’ relationships with healthcare professionals and the medical system, such as the multidisciplinary care and the hospital transfer system, also affected them. Regarding the relationship with medical staff, several participants (n=8) expressed deep gratitude and trust toward the doctors and nurses whom they met during trauma treatment and rehabilitation. As survivors of critical traumatic events, they saw the healthcare professionals as lifesavers and repeatedly expressed gratitude for them. For instance, Participant 2 assessed his relationship with the medical teams he had met as very satisfying, saying “My doctor in the trauma-care center was very dedicated. I think I would have died without him.”

In particular, participants reported that detailed explanations of their symptoms, procedures, and prognoses greatly helped them (Table 6 and Supplementary Table 1, only online):

Table 6. Experiences with Medical Staff.

Category	Details	Participant No.
Positive aspects	Provided appropriate and sufficient explanation	1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 13
	Complete trust	1, 3, 7, 10, 12, 13
	Extremely grateful	1, 2, 3, 4, 7, 10
	Received emotional support	1, 6, 7, 12
Negative aspects	Inadequate or no response to needs and/or questions	3, 8, 11, 14
	Inadequate pain management	1, 2, 3, 9
	Lack of patient-centered care	1, 4, 12
	Inappropriate warning about prognosis	4, 8
	High-handed and apathetic attitude	11

“[As laypeople,] we do not have medical knowledge. If they [healthcare professionals] help patients understand what is going on, we can fully trust them. I trust my attending doctor and feel comfortable with her so much that I look forward to my next appointment after I receive treatment and return home. I think I have a great doctor, which is quite helpful for my mental health and psychological well-being.” (Participant 1)

Given that most participants experienced loss of bodily function and disabilities either temporarily or permanently, healthcare professionals had a crucial responsibility to help them learn how to use their changed bodies, as Participant 8 described:

“[During the rehab session,] the therapists helped me adjust to my prosthetic leg. For example, they told me, ‘You did like this, and it seems that this action caused the prosthetic leg to be folded [and you fell down].’ Their comments were very useful and comforting to me and helped me develop a strategy for what to do next... They give me advice in advance before something happens [and I am embarrassed]. I think that is of utmost importance.”

In contrast, several participants related negative experiences with medical staff (Table 6 and Supplementary Table 1, only online). They relayed that doctors and nurses did not give sufficient explanations or responses to their questions. Moreover, some participants felt excluded from care-plan discussions despite their decision-making competence. Additionally, inadequate pain management, a lack of patient-centered care, strong warning that the patient may not survive, and apathetic attitudes of healthcare professionals were mentioned as negative experiences.

“It was just a job for the doctors and nurses. You never understand the suffering and bodily pain that patients are faced with every day until you put yourself in their shoes. Only patients suffer and endure it alone.” (Participant 1)

“I wish that all hospitals would always remember that patients come first. It feels unfair that I am injured and stuck here. I unexpectedly became disabled in an instant, and it makes me upset that they treat me like this. It really annoys me when they have an apathetic attitude with no regard for a patient’s feelings. Moreover, if you object to their attitude, they try to discharge you.” (Participant 11)

Some participants experienced difficulties transferring from the accident sites to regional trauma centers capable of treating patients with severe injuries, which also led to delays in treatment and repeated transfers. During treatment in the trauma centers, many participants reported difficulties they experienced, including physical restraints, inability to communicate, thirst, and separation from their families. As Participant 8 said, “In the ICU, it was hot, the light was always too bright, and everyone was lying there like a corpse. In the ICU, they focused only on cure, and I rarely got to talk to the staff, if ever.”

Repeated surgeries and examinations also distressed participants, and some of them were frustrated with the outcomes of surgery. While being hospitalized, some participants did not receive necessary rehabilitation therapy for several months.

During the rehabilitation phase, difficulties in transfers to rehabilitation hospitals were reported. Three participants could not find nearby rehabilitation hospitals, and eight participants reported that the trauma centers did not offer a transfer or provide information regarding rehabilitation hospitals, which they had to search for on their own. As the insurance type, type of injury, and legal processes were entangled, the transition to rehabilitation was not smooth.

“Even though I was a traffic accident patient, the rehabilitation hospitals refused admission because I did not have brain or spinal injuries. Surprisingly, they were more unwilling to admit me because I was only a traffic accident patient. So, I was lucky to begin my rehabilitation in this hospital. No other hospital would admit me.” (Participant 6)

After being enrolled in rehabilitation programs, some participants were dissatisfied with the lack of slots, equipment, and healthcare professionals, and their rehabilitation programs ended even though they felt they needed functional recovery. Nine participants mentioned a lack of psychiatric services during the recovery process (Table 7 and Supplementary Table 1, only online).

Table 7. Experience with the Healthcare System.

Category	Details	Participant No.
Trauma treatment process	Unpleasant environment and treatment in the ICU	4, 6, 7, 8, 12
	Did not receive rehabilitation at all in the ICU	5, 9, 11, 13
	Not connected to a trauma center where trauma treatment is available	7, 9, 12, 14
	Delayed transfer to a trauma center	7, 9, 11
	Repeated transfer to a trauma center	1, 2, 7
	Dissatisfied with treatment outcome	2, 7, 14
	Suffered from repeated surgeries and examinations	6, 7, 14
Rehabilitation treatment process	Lack/absence of psychiatric service/support	2, 3, 4, 6, 7, 10, 11, 12, 14
	Searched for a rehabilitation institution on one’s own	1, 2, 4, 6, 8, 10, 11, 13
	Difficulties in collecting treatment-related information	4, 5, 6, 8, 11
	Insufficient treatment time	1, 6, 7, 8
	Shortage of rehabilitation equipment and manpower	8, 10, 11
	Excluded from rehabilitation treatment despite functional decline	2 ,4, 6
	Absence of local specialized rehabilitation institutions	2, 4, 6
	Rehabilitation was not helpful in terms of outcome	1, 3
	Difficulty in finding time for rehabilitation while making a living	2

ICU, intensive care unit.

Legal and economic issues

Table 2 summarizes the economic and legal issues that participants encountered after injury. At the time of the interviews, 11 (78.6%) participants had not resumed economic activity, 5 (35.7%) had no income at all, and 6 (42.9%) had a substantially reduced income compared to that before their injuries.

“The industrial accident insurance compensated me the equivalent of a minimum wage for 2 years, [which was not enough to make a living], and it ended last month. I would have made more than KRW 2 million if I worked. I think that the unemployment benefit should be realistic.” (Participant 14)

For some participants, the unemployment benefit from industrial accident insurance was less than their existing incomes (Participants 3, 4, 11, and 14), and it ended before the participants could return to society (Participants 3 and 14). One of the participants had to relocate to use a wheelchair (Participant 8). The application procedure for industrial accident insurance was so cumbersome that participants often failed to be accepted or extend the support period. Participant 3 did not meet the disability criteria, and the social insurance was insufficient to support his living.

“Half of my intestines were resected, and now I have to go to the toilet five or six times a day (for defecation). However, the government agency does not recognize this as a disability. You can be recognized as disabled only if you have a third of your intestines… If you got one finger amputated, you can be recognized as disabled. With half an intestine, you cannot because, they said, the intestine is not visible. I just stopped taking medication, too…[because] the Korea Workers’ Compensation and Welfare Service supports only 20% of the total medical cost. If so, what’s the point of paying for social insurance? They should take full responsibility for severely ill patients until full recovery.” (Participant 3)

In many cases, participants had to pay for rehabilitation therapy out of their own pockets once they were discharged from the rehabilitation hospitals. Rehabilitation equipment, such as wheelchairs and prostheses, was also reimbursed only if the participants won their lawsuits.

Economic difficulties, insurance problems, and legal issues were tightly entangled in lawsuits following the accidents, and 9 patients (64.3%) were still in litigation related to their accidents. Due to the severity of the injuries, participants needed people to take care of them during hospitalization, but the cost of nursing care was unaffordable to many participants. Nursing care was not covered by car insurance policies until participants negotiated a settlement or won a lawsuit. Moreover, nursing care was not covered or only partially covered by industrial accident insurance. Hence, 10 patients did not hire caregivers and received care from their family members.

Participants reported that the economic and legal difficulties brought them anxiety, anger, and sleep disturbance:

“I can’t sleep because I am always looking up legal procedures. I took sleeping pills several times because I could not sleep. You cannot properly live your daily life if you wake up every 2 hours.” (Participant 11)

“The prosecutor dismissed it [the lawsuit]… My daughter-in-law miscarried because of the stress. We lost so much after the accident, so I can’t understand why it was just dismissed. We are still in distress and will be in the future. It has caused me great mental anguish. I lost so many things, and I can’t understand why the government dismissed it. They should have compensated me at least KRW 5 million.” (Participant 12)

“Since the accident, every moment has been hard, but now might be the most distressing time because I have no idea how to make a living from now on. I have kids to support and have to make money. I cannot work because I don’t have the physical strength and because I don’t want to cause troubles [in the workplace]. I have to go to the bathroom so often that coworkers might find it disturbing. My biggest worry is how to make a living.” (Participant 14)

Self-reported questionnaires

Table 2 shows the results of the survey that was conducted after the interview. Only one participant self-assessed that his or her psychological functioning had recovered to 100% from that before the injury. Participants had different responses to the most mentally difficult period between the moment of gaining consciousness and the present. Regarding the questionnaire, 7 participants (50.0%) scored >34 points on PCL-5 or >10 points on PHQ-9. In terms of the GAD-7 results, 10 participants (71.4%) exhibited mild anxiety (scoring between 5 and 9 points), while 1 participant (7.1%) showed moderate anxiety (scoring between 10 and 15 points). In MINI-Plus, 6 participants (45.9%) scored ≥6 points out of 33 points, which indicates moderate risk. Nine participants (64.3%) received psychiatric treatment after being injured. According to the questionnaire results, three out of 5 participants (Participants 4, 9, and 14) needed treatment intervention, but they were never recommended for psychiatric treatment. Participant 4 felt very uncomfortable recalling and relating the accident, and the interview was interrupted as she could not speak for long periods of time while crying. The severity of the injury and the scores of the medical questionnaire were not proportionate. In addition, the scores of the medical questionnaire were not associated with the duration of hospitalization and the diagnosis of disability.

DISCUSSION

To our knowledge, this is the first study to examine the experience of survivors of severe injury via a qualitative research method in South Korea. The main theme derived from the interviews was the struggle with injury, its consequences, and contributing factors. We found that physical decline/loss and mental health problems continued even after the completion of the rehabilitation treatment. This finding is consistent with that of previous studies, which were conducted in other countries and diverse ICU settings.²⁷,²⁸ For example, in Australia, one study reported that many patients still had disabilities 24 months after a traumatic injury, while 30% of them could not return to work.²⁹ Psychiatric disorder (31%),³⁰ PTSD (45%), alcoholism (26%), moderate-to-severe chronic pain (23%), and depression (18%) were commonly observed 1 year after injury.³¹ Poor health-related quality of life, such as pain or physical discomfort (72%) and difficulties in self-care (31%) were also commonly observed.³¹

Further, this study demonstrated that while the physical and psychiatric difficulties remained unresolved, the main concerns of survivors shifted from the shock, pain, and decline of physical function to the problems of returning to and adjusting to their everyday lives. As survivors were not able to return to work and found themselves depending on the care of others, psychological distress tended to worsen over time. The legal and economic challenges from lawsuits and insurances hindered survivors from concentrating on recovery. In addition, the results of the questionnaire were not proportional to the degree of injury, the duration of hospitalization, or the diagnosis of a disability of the participants. On the contrary, the participants’ psychological well-being seemed to be greatly influenced by social support, relationship with the medical staff, economic situation, insurance coverage, and legal and compensation issues. These findings indicate the necessity of continuous long-term care for trauma patients that encompasses physical, psychological, social, and economic support to reintegrate them into their communities and improve their quality of life, rather than to set a cure as a care goal.

Regarding acceptance of the consequences of injury, participants presented various types of psychological adaptation ranging from recognition, acceptance, a positive and grateful attitude, and willpower, to denial. Some participants reported that their attitudes toward life had changed since their injuries. They showed appreciation for the small things in daily life and the people around them, reset their priorities in life, and focused on meaningful relationships, such as those among family and friends. These changes after traumatic injury can be assessed as post-traumatic growth, i.e., the experience of positive change that results from the struggle with highly challenging life crises,³² which include enhanced relationships, a change in self-perception, an acceptance of limitations, and a change in life philosophy.³³ This result reveals the necessity to further study the adaptation process of trauma survivors and the causal factors. Of note, a large portion of the internal process of accepting the accident and its consequences is left to each patient themself without institutional and collective support, such as peer support³⁴ and prompt psychiatric and psychological intervention.

Drawing upon the findings of this study, we present some suggestions for promoting patient-centered care for trauma survivors, which is defined as “care that is respectful of and responsive to individual patient preferences, needs, and values while ensuring that patient values guide all clinical decisions.”³⁵ First, as revealed by the participants’ report, trauma survivors tend to depend highly on healthcare professionals with strong hope and trust, which may be due to the imminence of the critical crises that they were faced with. To build a good rapport with survivors and enhance the quality of communication and treatment outcomes,³⁶ providing sufficient and clear explanations of the patients’ current states, treatments, and prognoses with a compassionate attitude is crucial. Involvement of patients and families in decision-making; helping them to feel comfortable; speaking with a clear, friendly voice; protecting privacy; and providing help when patients are in need are critical steps.³⁵

Second, the principle of patient-centered care can be applied to the ICU where trauma treatment is delivered. Treatments in the ICU inevitably lead to experiences that are necessary for cures but unpleasant for patients, such as restraints. Nonetheless, as seen in some attempts to improve the ICU environment by family-centered ICUs,³⁷,³⁸ some efforts may be considered to alleviate discomfort more delicately, such as using applicable pain, agitation, and delirium assessment tools and management; eliminating sensory deprivation; and listening to survivors’ needs.

Third, the care for trauma survivors must include family members. Not only is family care a primary resource, but emotional and economic support is crucial for each survivor’s recovery and return to everyday life. Since family members are often exhausted while fulfilling the decision-making role of on behalf of the unconscious patient and taking care of him/her, empowerment of the survivor’s family is necessary to assist the whole family as they adjust together to the changed life of the survivor.

Fourth, a multidisciplinary treatment system needs to be established for patients with severe traumatic injuries. Studies have reported that outcomes of trauma patients can be improved through timely rehabilitation,³⁹,⁴⁰ adequate pain control,⁴¹ and relief of psychiatric sequelae³⁰ via multidisciplinary trauma care. However, the participants’ reports indicate limited access to optimal rehabilitation programs and fragmented healthcare systems. To implement such a system, awareness of its necessity, collaboration between various departments, and political commitment for financially supported infrastructure would be required.

Finally, to improve the quality of trauma treatment, it is imperative to conduct qualitative investigations on trauma patients, alongside rigorous collection of statistical data. No quantitative data are currently available on the recovery, long-term outcome, and return to society of trauma patients in South Korea, and the national databases (Korean Trauma Database) only collect data on the initial trauma treatment stage of trauma patients. As seen in the Victorian State Trauma Registry, post-discharge, patient-centered data in trauma are very useful for identifying which patients recover, when they recover, and to what extent they recover, which enables the quantification of the burden of major trauma for medical service planning.²⁹,⁴² Appropriate parameters for assessing the recovery and long-term outcomes of trauma patients should be selected, and quantitative data collection should be started in South Korea.

This study examined the struggle with injury, its consequences, and contributing factors through the experiences of severe trauma survivors throughout all stages of the treatment and recovery process. It revealed the continued prevalence of physical and psychiatric difficulties even after the completion of rehabilitation treatment. It also found that participants’ psychological well-being was influenced by social support, economic factors, and legal issues. Furthermore, it highlighted that a large portion of the process of accepting the accident and its consequences fell to the individual without institutional and collective support, thus advocating for and providing suggestions for patient-centered care approaches in trauma treatment.

This study was limited in that it addressed the experiences of severe trauma patients in a broad manner. Follow-up studies on each aspect of post-trauma survival are needed. Nonetheless, this study has great importance as similar studies on trauma survivors are scarce, and it provides valuable information and points of improvement in patient-centered care for trauma patients.

SUPPLEMENTARY MATERIAL

Supplementary Table 1

Study Participants’ Quotations