Selection of Studies

Once the search strategies were applied, 1,140 studies were found. Duplicate records were excluded, and after applying the eligibility criteria, 31 studies were included for the systematic review (Figure 1).

Figure 1. Selection of Articles.

Characteristics of the Included Studies

In the studies analyzed, a total of 3,012 firefighters, 2,876 paramedics, and 161 rescuers were presented, with ages ranging from 20 to 62 years, with a significant percentage of males, and with an average seniority in the position of 9.7 years. Of the 31 articles, 14 included firefighters, 13 included paramedics, and four included both populations.

The articles by Witczak-Błoszyk, et al;^{Reference Witczak-Błoszyk, Krysińska, Andriessen, Stańdo and Czabański17} Miller, et al;^{Reference Miller and Brown18} and Almutairi, et al^{Reference Almutairi and Azza19} sought the relationship between burnout and coping mechanisms. Alghamdi, et al;^{Reference Alghamdi, Hunt and Thomas20} Meyer, et al;^{Reference Meyer, Zimering, Daly, Knight, Kamholz and Gulliver21} Soravia, et al;^{Reference Soravia, Schwab, Walther and Müller22} Lee, et al;^{Reference Lee, Park and Sim23} Witt, et al;^{Reference Witt, Stelcer and Czarnecka-Iwańczuk24} Kucmin, et al;^{Reference Kucmin, Kucmin, Turska, Turski and Nogalski25} Theleritis, et al;^{Reference Theleritis, Psarros and Mantonakis26} Clohessy, et al;^{Reference Clohessy and Ehlers27} Durham, et al;^{Reference Durham, McCammon and Allison28} Huang, et al;^{Reference Huang, Li and An29} and Tomaka, et al^{Reference Tomaka, Magoc, Morales-Monks and Reyes30} established the relationship between symptoms of PTSD and coping styles and how these can be protective or risk factors. Regarding the workplace and exposure to traumatic events, Moskola, et al;^{Reference Moskola, Sándor and Susánszky31} Minnie, et al;^{Reference Minnie, Goodman and Wallis32} Boland, et al;^{Reference Boland, Mink, Kamrud, Jeruzal and Stevens33} Dowdall-Thomae, et al;^{Reference Dowdall-Thomae, Gilkey, Larson and Arend-Hicks34} Pisarski, et al;^{Reference Pisarski, Bohle and Callan35} Shakespeare-Finch, et al;^{Reference Shakespeare-Finch, Smith and Trauma36} and Halpern, et al^{Reference Halpern, Maunder, Schwartz and Gurevich37} presented the coping strategies used by this population after these events. Fonseca, et al;^{Reference Fonseca, Cunha, Faria, Campos and Queirós38} Iwasaki, et al;^{Reference Iwasaki, Mannell, Smale and Butcher39} Piñar-Navarro, et al;^{Reference Piñar-Navarro, Fuente, González-Jiménez and Hueso-Montoro40} and Völker, et al^{Reference Völker and Flohr-Devaud41} examined coping strategies related to stress. Sattler, et al^{Reference Sattler, Boyd and Kirsch42} and Yang, et al^{Reference Yang and Ha43} evaluated how coping strategies contributed to posttraumatic growth in these professionals. The articles of Chang, et al^{Reference Chang, Lee, Connor, Davidson, Jeffries and Lai44,Reference Chang, Lee, Connor, Davidson and Lai45} evaluated the association between coping strategies and psychiatric morbidity. Oginska-Bulik, et al^{Reference Oginska-Bulik and Langer46} investigated the relationship between personality traits and coping strategies. In addition, Vaulerin, et al^{Reference Vaulerin, D’Arripe-Longueville, Emile and Colson47} identified the relationship between musculoskeletal injuries and coping strategies (Table 1).

Table 1. Characteristics of the Included Studies

Abbreviations: COPE, Coping Orientation to Problems Experienced scale; PTSD, posttraumatic stress disorder; EMS, Emergency Medical Services.

Five studies presented events that first responders considered traumatic experiences that they had difficulty processing and influenced their emotions, such as accidents or events involving children, accidents with multiple victims, injury or death related to a coworker, dealing with violent people, or suffering from direct physical or verbal threats at the scene of an incident, and witnessing suicides or the death of a patient in their care.^{Reference Soravia, Schwab, Walther and Müller22,Reference Kucmin, Kucmin, Turska, Turski and Nogalski25,Reference Moskola, Sándor and Susánszky31,Reference Minnie, Goodman and Wallis32,Reference Sattler, Boyd and Kirsch42}

In relation to the studies reviewed, there are different instruments to evaluate coping strategies in the face of stress, mostly derived from the theory of Lazarus and Folkman, 1984.^{Reference Lazarus and Folkman7} In the present review, it was found that the most commonly used instruments were the coping scale COPE (Coping Orientation to Problems Experienced) with 55% of studies, the Ways of Coping Questionnaire (WCQ) with 13% of studies, the Ways of Coping Checklist (WCCL) with 13% of studies, the Coping Inventory for Stressful Situations (CISS) with seven percent of studies, and four different instruments with a total of 12%.

Characteristics of the Excluded Studies

Articles were excluded because they did not measure coping strategies through any instrument, the population was voluntary or had other health training different from that evaluated in this study, or the studies were qualitative. Regarding the type of study, no systematic reviews, topic reviews, protocols, or action plans were included.

Assessment of Risk of Bias

Thirty cross-sectional studies were included, of which six studies were unsatisfactory, mainly due to the lack of comparability,^{Reference Witczak-Błoszyk, Krysińska, Andriessen, Stańdo and Czabański17,Reference Miller and Brown18,Reference Kucmin, Kucmin, Turska, Turski and Nogalski25,Reference Clohessy and Ehlers27,Reference Iwasaki, Mannell, Smale and Butcher39,Reference Sattler, Boyd and Kirsch42} and three were good studies^{Reference Almutairi and Azza19,Reference Moskola, Sándor and Susánszky31,Reference Chang, Lee, Connor, Davidson and Lai45} (Table 2).

Table 2. Newcastle–Ottawa Scale (Modified) for Cross-Sectional Studies

In addition, the only clinical trial included^{Reference Alghamdi, Hunt and Thomas20} had an unclear risk of bias for the random sequence, allocation concealment, and other biases. Additionally, there was a high risk of bias for blinding, since it was open, and the result could have been evaluated subjectively (Figure 2A and 2B).

Figure 2. (A) Risk of Bias among Studies. (B) Risk of Bias within Studies.

Results of Individual Studies

First responders to emergencies are frequently at risk of presenting symptoms of PTSD due to the characteristics of their work, where they are exposed to highly stressful events and severe trauma. Of the studies reviewed in this study, 13 reported the presence of PTSD in the populations analyzed. Of these, two studies (Lee, et al^{Reference Lee, Park and Sim23} and Huang, et al^{Reference Huang, Li and An29}) despite reporting the evaluation of this condition, did not report the data obtained in terms of PTSD. The study by Meyer, et al^{Reference Meyer, Zimering, Daly, Knight, Kamholz and Gulliver21} reported a prevalence of four percent. The other ten studies reported a prevalence of PTSD between eight percent and 51%.

Nonadaptive Coping Strategies

The studies of Witczak-Błoszyk, et al;^{Reference Witczak-Błoszyk, Krysińska, Andriessen, Stańdo and Czabański17} Soravia, et al;^{Reference Soravia, Schwab, Walther and Müller22} Völker, et al;^{Reference Völker and Flohr-Devaud41} Theleritis, et al;^{Reference Theleritis, Psarros and Mantonakis26} Chang, et al;^{Reference Chang, Lee, Connor, Davidson, Jeffries and Lai44} Dowdall-Thomae, et al;^{Reference Dowdall-Thomae, Gilkey, Larson and Arend-Hicks34} and Meyer, et al^{Reference Meyer, Zimering, Daly, Knight, Kamholz and Gulliver21} showed a frequent use of nonadaptive coping strategies, with avoidance or disconnection as a strategy to avoid difficult situations and to downplay the perceived stressful event to prevent experiencing or re-experiencing the stressful situation. The mechanisms of distraction and social fun, as strategies to avoid thinking about situations, and denial as an absence of acceptance of the situation, enable individuals to tolerate or support the emotional state generated by trauma and self-blame while avoiding the real problem. Huang, et al^{Reference Huang, Li and An29} found that the cognition and negative evaluation caused by traumatic events can make people use avoidant coping more frequently.

Another avoidance strategy used by emergency personnel is to escape through the consumption of substances such as alcohol and drugs to generate emotional disconnection and alleviate symptoms of stress.^{Reference Tomaka, Magoc, Morales-Monks and Reyes30,Reference Halpern, Maunder, Schwartz and Gurevich37} According to Kucmin, et al,^{Reference Kucmin, Kucmin, Turska, Turski and Nogalski25} the coping style focused on emotions is also a maladaptive strategy that emergency personnel resort to due to the tendency to try to eliminate thoughts, images, or memories, resulting in greater accessibility to them and the activation of emotional memory, which in turn stimulates anxiety.

Miller, et al^{Reference Miller and Brown18} found that humor was not a positive factor as a coping strategy in these personnel, since they resorted to this tool to try to downplay stressful situations.

Dysfunctional coping was explained by perceived stress after exposure to critical incidents, increasing the level of threat and cancelling the protective role of self-acceptance and life.^{Reference Fonseca, Cunha, Faria, Campos and Queirós38}

According to Alghamdi, et al,^{Reference Alghamdi, Hunt and Thomas20} emergency personnel presented passive coping strategies such as behavioral disconnection, substance abuse, and self-blame, but showed significant positive changes after the use of narrative exposure therapy.

Additionally, it was reported that nonadaptive strategies that are related to a behavioral disconnection from stressful situations and a feeling of loss of control do not allow people to resort to active strategies to cope with problems.^{Reference Clohessy and Ehlers27,Reference Moskola, Sándor and Susánszky31}

The nonadaptive coping strategies used by these personnel showed a strong relationship with PTSD symptoms, burnout syndrome, psychiatric morbidity, and chronic stress, specifically avoidance coping. The importance of these studies performing correlations with psychiatric symptoms was conclusive evidence with respect to the adaptability of these coping styles.

Adaptive Coping Strategies

These types of strategies were presented less frequently among these personnel, but they are significant in cushioning the adverse effects of continuous exposure to trauma. Strategies that involve active coping as behaviors aimed at resolving such situations can minimize the negative effects of the experience. Among these active coping strategies, the authors reported acceptance as a strategy in which both the situation faced and the emotions generated from it are recognized and accepted, solutions to resolve them are sought, and the stressful event is interpreted in a positive way based on the deliberate reflection of trying to understand the trauma, reflective and constructive thoughts, valuing the traumatic event as an experience of growth and learning, and interpreting it as rewarding.^{Reference Miller and Brown18,Reference Iwasaki, Mannell, Smale and Butcher39–Reference Völker and Flohr-Devaud41} Acceptance is an important component in building resilience.^{Reference Demiroz and Haase48} In this sense, Chang, et al^{Reference Chang, Lee, Connor, Davidson and Lai45} and Clohessy, et al^{Reference Clohessy and Ehlers27} reported positive reinterpretation as another important strategy that seeks the positive in the situation to improve and grow from it, promote well-being, and decrease anxiety and stress.

For Moskola, et al;^{Reference Moskola, Sándor and Susánszky31} Sattler, et al;^{Reference Sattler, Boyd and Kirsch42} Yang, et al;^{Reference Yang and Ha43} Durham, et al;^{Reference Durham, McCammon and Allison28} Vaulerin, et al;^{Reference Vaulerin, D’Arripe-Longueville, Emile and Colson47} Oginska-Bulik, et al;^{Reference Oginska-Bulik and Langer46} and Witt, et al,^{Reference Witt, Stelcer and Czarnecka-Iwańczuk24} coping focused on addressing situation and seeking to resolve the internal or environmental demands that were generated by the stressful event. This is accomplished through meetings in which staff are exposed to psychological debriefing, impressions are explored, facts, thoughts, and emotions are reviewed, and education is provided on how to deal with stress, with the objective of taking action and making an effort to resolve the situation through cognitive transformation.^{Reference Scott, O’Curry and Mastroyannopoulou49} Establishing this type of coping is a protective factor for staff.

Self-efficacy, as a coping strategy, determined by the competence and personal capacity to face stressful situations and regulate one’s own functioning, is another of the protective strategies that help control thoughts and regulate emotions in these staff.^{Reference Soravia, Schwab, Walther and Müller22}

Other strategies that alleviate the symptoms were emotional support either as social support given by coworkers, bosses, or institutions and the instrumental support given by specialized mental health personnel. This support from peers, family, friends, or experts and talking about what happened after the incidents was associated with a key mechanism for the management of emotions and the ability to cope with trauma.^{Reference Almutairi and Azza19,Reference Lee, Park and Sim23,Reference Minnie, Goodman and Wallis32,Reference Boland, Mink, Kamrud, Jeruzal and Stevens33,Reference Pisarski, Bohle and Callan35,Reference Shakespeare-Finch, Smith and Trauma36,Reference Chang, Lee, Connor, Davidson and Lai45}