1. IntroductionTraumatic injuries affect a significant proportion of individuals worldwide. Injuries can be life changing, with many survivors experiencing long-term issues [1,2,3], placing significant burden on families. Trauma survivors often need the support of an informal carer; defined as an unpaid relative/friend who lives with and supports their physical daily living. Approximately one in eight adults (equating to around 6.5 million) in the UK are unpaid carers, with 5 million of these individuals juggling caring responsibilities alongside work [4] (carers UK). Research specific to traumatic injury indicates that the financial costs to carers are unknown [5]. The sudden and serious nature of major traumatic injury and change in life circumstances mean caregivers are often required to take time off work [6], sometimes leading to financial problems. Research suggests that as many as 61% of carers of people with a traumatic brain injury (TBI) leave their jobs [7], although UK-specific figures are unknown.Caring for someone following injury can impact on the carer’s psychological wellbeing, social life, and family and caregiver finances. Some of these areas are well researched; studies investigating the psychological or emotional consequences of being a caregiver have found that social support contributes significantly to the variance in caregiver depression [8,9]. Fewer studies have investigated carers’ response to support in the immediate aftermath of moderate to severe traumatic injury. In a study of 184 TBI carers, O’Callaghan et al. found carer anxiety to be related to a lack of information provision on discharge, which was consistent with carer reports of a lack of support and communication by the health service [10]. However, Ramazanu and Griffiths found that carers of elderly hip fracture patients were stressed resulting from pressure to abide by routines to aid the injured persons recovery [11]. Whilst O’Callaghan [10] found that uncertain prognosis inflicted anxiety for carers; denial about the future was protective for some TBI carers who were consequently optimistic.Research investigating the financial and employment impact of caregiving, particularly for people with musculoskeletal conditions, or polytrauma, is limited and has largely focused on US veterans [12,13]. Griffin, Van Houtven et al. found that carers with fewer financial resources experience greater carer burden, whilst those who are older and on lower wages are more likely to leave the labour force [12,13].In a cross-sectional survey of 564 carers of TBI and polytrauma veterans, Griffin et al. [12] found that greater social resources mitigated the caregiver intensity-caregiver burden relationship. This shows the impact that social support can have on caregiver’s experience. However, the use of structural equation modelling and cross-sectional survey data makes it difficult to be certain of the direction of this association. It is possible that caregiver burden negatively influenced perceptions of social resources amongst carers, such that those experiencing a higher carer burden perceived there to be less support available.Negative social interactions and a lack of social integration have been found to be significant independent predictors of depression in carers of a person with spinal cord injury (SCI) [8]. Despite this, research exploring the social impact of caregiving in other injury types is lacking (e.g., for orthopaedic injuries). The challenges and demands of caring for older people are well documented; however, a recent review of systematic reviews by Spiers et al. [14] stated that current evidence fails to quantify the impact of caregiving on wellbeing. Authors suggested the need for a comprehensive review to explore the impact of caring for older people on outcomes in terms of social and financial well-being. A different review by Bom et al. [15] explored the impact of caring for older adults, but compared findings across different subgroups, such as gender, marital status, type of care provided and other characteristics. The review concluded that married, female carers had poorer health outcomes than male carers, and increased intensity of caregiving generally led to worse health outcomes. However, it is still not clear why certain subgroups are impacted more than others.Research investigating the financial and employment impact of caring for people with orthopaedic injuries and SCI highlights the extent of the economic burden. Findings show that carers are required to leave work, take extensive time off, or work flexibly, in order to retain their jobs [15,16]. In a survey of 99 orthopaedic trauma carers in the USA [17], caring responsibilities were found to affect capacity to work in 53% of carers, whilst 8% quit their jobs. Research typically investigates shorter term impacts following injury, despite evidence of financial burden continuing over many years [18]. It is well known that unpaid caring for older people can lead to a loss of employment or reduction in working hours [14], with many carers having to manage employment alongside caring responsibilities. However, there is limited evidence to describe the impact of this dual role on financial and social wellbeing not only in the widely studied older person carer population [14], but also in the traumatic injury carer population.Theoretical models, such as The Roy Adaptation Model (RAM) [19,20] and the International Classification of Functioning, Disability and Health (ICF) [21] can be used to explore and describe the effects of caregiving and its impact on all aspects of life. The RAM describes humans as adaptive systems (physical, emotional, social, and functional) who respond to environmental stimuli through coping processes (adaptive modes). The model proposes that responding to stimuli via these adaptive modes influences a person’s ‘adaptation’ or adjustment to being a carer. Whilst the RAM focuses on personal psychological, and social factors, the ICF is a framework for describing and organising information on functioning and disability, recognising the impact environmental factors have on an individual’s life (Figure 1). The contextual factors (personal and environmental) can aid understanding of the impact taking on a caring role has on everyday life. Used alongside the RAM, the ICF allows for the exploration of a range different consequences of both the injury and carer giver roles (e.g., loss of job), including biopsychosocial, environmental and personal factors.Conducting qualitative research can help to understand the impact of caregiving for the wider trauma population in more depth, compared to a quantitative survey. Several studies have explored the burden on caregivers of patients with TBI, cancer, posttraumatic stress disorder and older people; however, few qualitative studies have focused on orthopaedic trauma. Newcomb and Hymes [22] also identified this gap in research and interviewed 12 carers of severely injured orthopedic trauma patients. The purpose of this study was to identify stressors and burdens experienced by these caregivers, which included turmoil of life in hospital, difficulty obtaining and understanding information, and a sense that family was not considered to be an important part of the patient’s care plan. Although authors made a valuable contribution to the evidence base, they did not fully consider the impact on financial situation and employment, noting one limitation as recruiting all carers from a wealthy area of the country.

There is a clear lack of qualitative studies involving carers outside the two most prevalently researched injury types (SCI and TBI), and research investigating employment and financial impacts across injury types. Caregivers of trauma survivors are likely to be younger, income-producing individuals compared to often older carers of those with other conditions such Alzheimer’s disease, cancer, stroke. Therefore, there is a timely need to understand the perspective of carers, particularly given the uniqueness of each injury and its consequences. Therefore, to address the research gap, this study aimed to explore the impact of being a traumatic injury carer on finances, employment, social life and psychological wellbeing.

4. DiscussionThis study provides some insight into the impact of being a caregiver for a person with a traumatic injury, on family finances and carer’s employment, and social life and psychological wellbeing. Findings suggest that individuals step into the role of primary care provider and for many injured people, caregivers were not supported by healthcare services post-discharge. They also felt solely responsible for looking after the trauma survivor despite offers of support from friends and family. This counters evidence which suggests greater social resources mitigate the caregiving intensity-caregiver burden relationship [12].Several findings related to support were noted which have important implications, such as limited psychological support for carers across injury types, and inconsistent care and communication in hospitals. Support was especially limited for carers supporting a person without a TBI, particularly regarding the provision of rehabilitative care; whereas in the case of TBI, professional care in the community was given, this corroborates existing evidence [26].Carers viewed offers of help from friends and family as temporary and peripheral to the trauma survivors’ recovery. This stemmed from challenges navigating the hospital environment and carers finding it easiest to take sole responsibility for interactions with hospital staff. Reluctance to share caring responsibilities is consistent with others’ findings, indicating poor involvement of families in post-injury care plans [27]. In this qualitative study, carers found the hospital environment confusing and challenging to obtain information in, whilst the family were not considered important in care planning. The findings of our research expand on this as carers consequently experienced close relationships with trauma survivors whilst others suffered, resulting in family tensions.Carers who were also healthcare professionals were given more information about the injured person’s recovery trajectory and were able to build rapport with doctors. Thus, enabling them to access more long-term support. This contrasted other carers who received minimal or unprofessional communication from hospital staff [28,29]. Furthermore, whilst research indicates that TBI carers look to the future once the trauma survivor has returned home, and experience anxiety at a lack of information provision [28]; our findings captured a mixed response with some TBI carers initially struggling to come to terms with the injury. This is in line with research indicating changes in information needs during the transfer from primary to secondary care [29]. Such changes along with the unequal treatment of carers who are healthcare professionals highlight the need for standard information provision across different recovery stages, and consistency in carer communication. Interventions should seek to increase carers’ sense of self efficacy to forge relationships with hospital staff to access greater support.The impact of the injury on carer employment as well as financial consequences is consistent with the literature [13,16]. Employers responded supportively, meaning that carers were able to keep their jobs, and prioritise caring responsibilities; although differences were present for those not employed in the public sector. Whilst older carers prioritised work less, this was partly related to their employment status (e.g., part time) rather than solely the employer’s response. However, they did not all leave the workforce [13].Although literature highlights the link between financial concerns and depression among carers [30], in this study, such impact appeared more of a concern for less financially stable families (i.e., lower socioeconomic status). In line with studies which have identified financial stress experienced by carers [31], this was associated with difficulties receiving benefits. Difficulty accessing financial support was universal across carers. A lack of help in completing applications for state benefits and compensation increased carers’ sense of isolation and burden. This corroborates research which identifies a need for compensation advice at major trauma centres [32]. Caregivers of individuals with more complex injuries and those with TBI appeared to be affected more financially than those caring for individuals with less complex injuries and shorter recovery periods. For individuals with longer recovery trajectories, the greater the financial impact on caregivers as they were forced to reconsider their employment and ability to stay in work. The healthcare service should provide information and assistance to families regarding financial support following injuries. This may reduce unnecessary burden from carers and match the support that was offered by employers.Many carers struggled to accept the injury, particularly when this was associated with severe physical and in some cases mental disability [2,3]. This contributed to negative emotions. However, in some cases denial about the long-term prognosis helped carers to be upbeat and motivated regarding rehabilitation. Findings suggested that carers of those with less severe injuries, such as single limb fractures and shorter recovery trajectories were less psychologically affected than those who cared for individuals with more severe and/or long-term injuries, such as complex polytrauma and TBI. Perhaps negative psychological impact was linked to not knowing when the person they care for would recover, or if they ever will recover, and a lack of education around the impact of injury. Our findings align with research involving informal carers of stroke survivors [33], suggesting that psychosocial and educational support (e.g., ensuring the caregiver understands individual needs) should be provided for stroke caregivers to reduce daily caregiver burden and improve psychological wellbeing. Considering our findings, healthcare workers should seek to communicate the recovery trajectory of injuries gradually to help carers process and respond to the injury in the present tense, along with educating them about impairments and potential long-term needs. This would improve information provision regarding prognosis, which is currently lacking [34]. Future research should seek to investigate the relationship between carer attitude and the impact on emotions at different stages of the recovery trajectory.

This study had several strengths. The broad sample enabled some comparison to be drawn between well researched conditions such as carers of people with TBI and under researched groups. Many of those interviewed were carers of people who had sustained multiple injuries (polytrauma) where no head injury had been sustained. We recruited a sample of carers whose lives had changed dramatically, with 50% having to reduce their working hours or relinquish work altogether. This addresses a gap in research regarding the impact of caregiving for the trauma population on work. Additionally, using two theoretical frameworks enhanced the scientific rigour of analysis and allowed different areas of the research question to be addressed in relation to theory. However, there were some limitations. The sample was small and almost all female, which limits the generalisability of conclusions. It also limits the ability to make strong comparisons between caregivers of different injury types. Our sample size included a number of older women, some of whom were retired, which again limits findings. Future research should therefore attempt to recruit more male carers and carers of working age.

Due to the COVID-19 pandemic, we had to conduct interviews remotely via telephone, which may have introduced recruitment bias. We understand that limiting the interview to telephone may have excluded carers that do not have a phone or may be less able to communicate remotely in comparison to a face-to-face interview. However, we feel we were still able to recruit a diverse sample of carers with a range of experience despite this. Another limitation was not using a specific definition of a carer (including tasks links to advanced activities of daily living, personal activities of daily living and intensity of care provided) as part of the inclusion criteria. This would have enabled us to provide a clearer description of the sample. We did not collect data on ethnicity and while the intention was not to focus on Caucasian carers, the methods of recruitment did not attract an ethnically diverse sample. This is an unrepresented sample and we recognise it as a limitation. Further research should adopt different recruitment methods to better understand the impact of caregiving from the perspective of people from a broader range of ethnicities and socioeconomic backgrounds.

Our interviews only provided a snapshot of the carers’ situation and experience at one point in time and while both theoretical models assume an interaction between the patient or carer and the context, they do not necessarily account for interactions with others or changes in the context over time [35]. Therefore, further research is needed to explore these interactions, along with the expectations for the future of these trauma survivors. Research is required to better understand the longer-term impact of caring for someone with serious injury, in terms of the in length, intensity, and type of care, but also in terms of the socioeconomic impact on work, income, family finances and the wider economy. Given that the majority of admissions to UK major trauma centres are people aged over 65 and the known association between care giving and negative health effects particularly in older women, research should explore the longer-term impact of caregiving following serious injury and its relationship with ageing in carers, thus building on existing evidence [15].